Take-Home Exposure a Widespread Problem
More than 1.5 million workers are potentially at risk of lead exposure. The problem can lead to contamination of others unless proper steps are taken, according to the government.
A routine, well child exam showed that a 2-year-old girl had a blood lead level that was nearly three times the amount the Centers for Disease Control and Prevention recommends as a reference level.
“This serves as a warning the child may be exposed to lead at home or in the environment and may require case management,” according to the National Institute for Occupational Safety and Health. “It also allows parents, doctors, public health officials, and communities to take action earlier to reduce the child’s future exposure to lead.”
In this case, the exposure was work-related. A post on the NIOSH science blog explained that the agency has found so-called take-home exposure to be a widespread problem.
Investigators conducted a lead risk assessment of the girl’s home but found no lead-based paint. However, there was lead dust on the floor of the family’s laundry room.
“Upon further testing of the family, [the father] was found to have a BLL of 25 micrograms per deciliter (µg/dL). NIOSH defines an elevated BLL for those over age 16 to be 10 µg/dL or more,” according to the post. The father “told the lead risk assessor that he typically came home from work at the e-scrap recycling facility with dust in his hair and on his clothes. He routinely picked up and played with his 2-year-old daughter Sarah when he arrived home, then would take a shower and throw his clothes in the laundry before sitting down for dinner.”
The agency determined that the father and his coworkers were exposed to lead as they performed various tasks at the e-scrap recycling facility such as crushing cathode ray tubes from discarded televisions and computer monitors.
“Without access to showers at work or uniforms that could be left at work for laundering, employees of the e-scrap recycling facility risked contaminating their personal clothes, vehicles, and homes with lead,” the post said. “The Occupational Safety and Health Administration estimates that approximately 804,000 workers in general industry and an additional 838,000 workers in construction are potentially exposed to lead as a result of the production, use, maintenance, recycling, and disposal of lead material and products.”
The government recommends employers help prevent take-home exposure by:
- Reducing exposure in the workplace.
- Having employees shower and change clothes before going home and leaving soiled clothing at work for laundering. They should also store street clothes in areas separate from work clothes.
- Prohibiting removal of toxic substances or contaminated items from the workplace.
“Preventing take-home exposure is critical because decontaminating homes and vehicles is not always effective,” according to the post. “Normal house cleaning and laundry methods are inadequate, and decontamination can expose the people doing the cleaning and laundry.”
In the case above, the father quit his job at the e-scrap recycling facility. Three months later, his daughter’s BLL had decreased substantially.
Drug Trend Report: Costs Up, Usage Down
The introduction of new specialty medications, rising costs of compound medications, and an increase in the average wholesale price of oxycodone with acetaminophen are among the key drivers of pharmacy costs in the past year, according to Healthcare Solutions. The pharmacy benefit management company is the latest to issue a drug trend report based on in-network paid pharmacy transactions in a comparison of 2014 and 2013.
“In 2014, Healthcare Solutions’ book of business saw a 4.1 percent increase in the total pharmacy spend,” the company said. “This is attributable to an increase in the cost of prescription medications.”
The company reported an overall 8.6 percent price increase of prescription medications, including average wholesale price (AWP) increases of 12.5 percent for brand name drugs and 7.9 percent for generics. The increase in prices for generic drugs was “unexpected” following years of flat levels and the authors expect the increases to continue as newer medications come off patent.
“There were some significant inflationary factors regarding generic product pricing,” the report said. “One of the main contributors to the overall increase in spend was the AWP increase in hydrocodone with acetaminophen combination products.”
“The introduction of higher cost specialty medications will need to be monitored closely, as with the Hepatitis C medications” which came into the arena during 2014.
Last fall, the federal government changed hydrocodone combination products (HCPs) from a Schedule III to the more restrictive Schedule II, the authors noted. While the change has resulted in a “20 percent reduction” in the use of HCPs, “the manufacturers are now required to follow stricter guidance, management and label changes which resulted in an increase to the AWP for the medication.”
Utilization of pharmaceuticals among injured workers decreased by more than 3 percent, according to the report. Included was a reduction in the use of opioids.
“In relation to cost management, HCP price increases were offset by the gains in decreased utilization,” the report said. “The introduction of higher cost specialty medications will need to be monitored closely, as with the Hepatitis C medications” which came into the arena during 2014.
Payers who provide workers’ comp benefits to health care workers have been especially impacted by the rising costs of medications to treat hepatitis C, the authors reported. Each treatment can cost $100,000, and the trend is expected to continue.
Specialty medications that target large claimant populations are being developed. For example, Pfizer Inc. and Eli Lilly and Company are creating Tanezumab. Described as a “new, non-narcotic medication to treat chronic pain,” the drug “has the potential to offer an innovative treatment to help millions suffering from painful conditions.” However, the medication “may add a significant cost to payers who cover chronic pain claimants.”
Compound medications increased in terms of the “number, complexity and cost” in 2014, the report said. “In the past 4 years the average cost of compounds has escalated 225 percent.”
Study Validates California’s UR Process
A relatively small number of physicians and attorneys are involved in independent medical review disputes in California’s workers’ comp system. A new report also finds that denials of requests for compounded medications are nearly always upheld by IMR physicians.
The findings stem from a study of California’s utilization review and IMR system. It suggests that, contrary to what critics have said, the process is working well to ensure injured workers get high-quality medical care and are protected from unnecessary medical procedures.
“Amid continuing debate over whether UR and IMR improve the California workers’ compensation medical dispute process, a new CWCI analysis of IMR decisions from 2014 finds that 91 percent of physician-level UR modifications or denials of treatment reviewed by an IMR physician were upheld, while 9 percent were overturned,” the report said, “suggesting that UR and IMR not only work to assure that the care rendered to injured workers is appropriate, but also provide a needed check against pharmaceuticals, diagnostic tests, surgeries and other procedures that fail to meet evidence-based medicine standards and that could delay recovery or lead to further impairment or disability.”
IMR was implemented in the state’s workers’ comp system after enactment of Senate Bill 863 in 2012. Under the system, medical doctors rely on evidence-based treatment guidelines to resolve disputes over the necessity of recommended medical treatment. It replaced the previous system whereby judges had the final say in the disputes.
The role of the IMR physician is not to perform additional tests on the injured worker. Instead, they review the treating physician’s reports as well as other documentation leading to the UR decision. Once the IMR physician has considered the case, he issues a determination letter stating whether the disputed service is medically necessary.
Medication requests top the list of those included in the IMR process, according to the California Workers’ Compensation Institute. Durable medical equipment, physical therapy, injections, and diagnostic tests and measurement requests comprise the bulk of the remaining services in the IMR process.
CWCI researchers reviewed data from all final IMR decision letters issued in 2014. The 137,781 cases involved 76,718 injured workers — many with requests for multiple services. In all, there were 260,889 individual medical services involved.
The authors examined the data to determine a variety of factors, including:
- The volume and timeliness of IMRs.
- The number, mix, and uphold rates for medical services that were reviewed.
- The impact that high-volume attorneys and physicians have on IMR.
- The guidelines and other information that independent medical reviewers use to make their decisions.
“Although the volume of requests for IMR has far exceeded original projections, the study reveals that a relatively small number of physicians are responsible for the vast majority of requested medical services that result in IMR disputes,” the report said.
Most injured workers who requested IMR were represented by attorneys. The researchers used the addressee information on each IMR determination letter to identify the specific individual to whom the decision was sent. They found a small percentage of attorneys are involved in the process.
“The vast majority of 2014 IMR decisions addressed to someone other than the employee were addressed to only a small number of representatives, with the top 1 percent of representatives named on 18 percent of the decision letters last year, and the top 10 percent of representatives named on 65 percent of the letters,” the report said.
With prescription drug requests involved in 45 percent of all treatment disputes that went through the IMR, the authors found 92 percent of the UR decisions involving them were upheld. They then drilled down to determine the types of medications involved and the overturn rates.
“A closer look at the pharmaceutical IMRs found that compound drugs, which have been the focus of controversy both in workers’ compensation and in other health systems, accounted for 12 percent of the pharmaceutical requests, and that less than 2 percent of the compound drug requests were found to be medically necessary by the IMR physician,” the authors wrote. “Among requests for non-compound drugs, opioids accounted for 29 percent of the IMRs, with the UR denials or modifications upheld 91 percent of the time.”
Requests for antidepressants had the highest overturn rate among the top 10 non-compound prescriptions. IMR physicians found they were medically necessary in 23 percent of the cases. Anti-convulsants — sometimes prescribed for off-label use as mood stabilizers or neuropathic pain — had the second-highest overturn rate at 16 percent. The overturn rate for diagnostic tests was 12 percent.
Future. “The UR/IMR process was improved when the requesting physician clearly outlined the reasons for the requested goods and services and backed them up with clinical findings as that helped assure that the ultimate decision on the requested medical service was firmly supported by evidence-based medicine,” the report noted. “Given the small number of providers who generated such a high percentage of the disputed treatment requests, and how few of the treatment requests denied by a UR physician were overturned, it may make sense to engage these physicians directly in conversations about their treatment choices.”
For services that had higher than average overturn rates, the authors suggested they may indicate “areas of medical controversy” that are not fully addressed in California’s Medical Treatment Utilization Schedule. “As pointed out in recent studies, consideration of a drug formulary may be the linchpin needed to reduce workers’ compensation pharmaceutical disputes and control costs.”