Study ‘Raises Concerns’ About Unnecessary Drugs
Reforms addressing physician dispensing might need to target specific drugs in addition to prices, suggests a new study.
A review of workers’ comp claims in Florida points to evidence that physicians allowed to dispense medications prescribed unnecessarily strong opioids.
The Workers Compensation Research Institute looked at claims both pre- and post-reforms to curb physician dispensing in Florida. The results surprised the researchers.
“If the pre-ban strong opioids were necessary, researchers would expect that workers who received weaker physician-dispensed pain medications after the ban would later need strong opioids (that can be dispensed only at a pharmacy).
But only 2 percent of those with weaker physician-dispensed pain medications in the first six months after the ban received strong opioids at a pharmacy in the next six months,” the report said.
“This raises concerns that a significant proportion of pre-reform physician-dispensed strong opioids were not necessary, which means injured workers in Florida were put at greater risk for addiction, disability or work loss, and even death.”
The researchers looked at the prescribing behaviors of physicians after Florida banned physician dispensing of strong opioids.
They found no material increase in pharmacy-dispensed strong opioids but instead an increase in the rate of patients receiving physician-dispensed weaker pain medications — nonsteroidal anti-inflammatory medications such as ibuprofen.
The percentage receiving weaker opioids increased from 9.1 to 10.1 percent.
The study comes as policymakers in several states focus on the prices charged by physician dispensers compared to pharmacies for the same medications.
But increasingly there is speculation that economic incentives associated with physician dispensing lead to unnecessary medications prescribed for injured workers.
“When we compare pre- and post-reform prescribing practices, it appears that physician-dispensers not only reduced their dispensing of strong opioids but also reduced prescribing of strong opioids,” said Richard Victor, WCRI’s executive director.
“Since Florida has banned physician dispensing of strong opioids, the lessons of this study are relevant for the other states concerned about eliminating unnecessary costs in their system while protecting injured workers from unnecessary medical care.”
Report Sparks NH Commissioner’s Call for Fee Schedule
A new report looking at the high workers’ comp costs in New Hampshire calls for creation of a database, implementation of a pharmacy benefit management program, and continuing the commission’s work. But several members of the gubernatorial task force rejected the majority report and said a medical fee schedule is needed.
Gov. Maggie Hassan received the report in December after the panel’s nearly three-month review of the system. She created the commission from insurance, business, health care, and labor to recommend ways to reduce workers’ comp medical costs.
The report’s first recommendation would require legislative approval to develop a database of workers’ comp charges and costs for collection, analysis, and a transparency tool to allow public access. But the three members opposing the report said rather than reducing costs, the database would “add substantial costs to the carriers that operate in NH since most do not track the claims in the manner expected by the commission.”
Insurance Commissioner Roger Sevigny, who chaired the commission, disagreed with the minority report’s assertion. “While the creation of such a database would be time-consuming, the information it eventually would generate would be invaluable to the ongoing examination of workers’ compensation costs in New Hampshire.” However, Sevigny admitted it would take some time.
“Until such a database is constructed, however, we cannot afford to do nothing,” he said. “Work should begin immediately on the creation of a fee schedule that is fair and based on the real costs of health care in New Hampshire.”
The minority report recommended adoption of a fee schedule using group health as a benchmark of appropriate medical charges. “This fee schedule would be fair to medical providers and not difficult or expensive to implement,” the minority report said. “If medical providers are accepting group health payments for non-work related injuries, what is the rationale for requiring workers’ compensation payers to pay upwards of 200 percent or 300 percent more for the same treatment?”
Sevigny said he “agreed in principle” with the idea but said a fee schedule must be “well thought out and carefully crafted.”
The full report’s recommendation to implement a mandatory PBM program was approved by all 15 members. However, the minority report said pharmacy “represents a very small percentage of the overall medical pie,” and a PBM program “will not impact the cost burden in any meaningful way.”
The full report’s recommendation to continue the commission’s work was opposed by both Sevigny and the minority members. “While I agree that more work needs to be done, I am concerned that the many methodologies and possibilities the group has committed to examining in this recommendation will make any future effort on the Commission’s part unduly diffuse,” the commissioner said. “Thoughtfully limiting any future Commission’s scope is necessary if anything is to be accomplished.”
From Coast to Coast
The 3,920-ton Left Coast Lifter, originally built by Fluor Construction to help build the new Bay Bridge in San Francisco, will be integral in rebuilding the Tappan Zee Bridge by 2018.
The Lifter and the Statue of Liberty
When he got the news, Scot Burford could see it as clearly as if somebody handed him an 8 by 11 color photograph.
On January 30, the Left Coast Lifter, a massive crane originally built by Fluor Construction to help build the new Bay Bridge in San Francisco, steamed past the Statue of Liberty. Excited observers, who saw the crane entering New York Harbor, dubbed it the “The Hudson River Hoister,” honoring its new role in rebuilding the Tappan Zee Bridge over the Hudson River.
Powered by two stout-hearted tug boats, the Lauren Foss and the Iver Foss, it took more than five weeks for the huge crane to complete the 6,000 mile ocean journey from San Francisco to New York via the Panama Canal.
Scot took a deep breath and reflected on all the work needed to plan every aspect of the crane’s complicated journey.
A risk engineer at Liberty International Underwriters (LIU), Burford worked with a specialized team of marine insurance and risk management professionals which included John Phillips, LIU’s Hull Product Line Leader, Sean Dollahon, an LIU Marine underwriter, and Rick Falcinelli, LIU’s Marine Risk Engineering Manager, to complete a detailed analysis of the crane’s proposed route. Based on a multitude of factors, the LIU team confirmed the safety of the route, produced clear guidelines for the tug captains that included weather restrictions, predetermined ports of refuge in the case of bad weather as well as specifying the ballast conditions and rigging of tow gear on the tugs.
Of equal importance, the deep expertise and extensive experience of the LIU team ensured that the most knowledgeable local surveyors and tugboat captains with the best safety records were selected for the project. After all, the most careful of plans will only be as effective as the people who execute them.
The tremendous size of the Left Coast Lifter presented some unique challenges in preparing for its voyage.
The original intention was to dry tow the crane by loading and securing it on a semi-submersible vessel. However, the lack of an American-flagged vessel that could accommodate the Left Coast Lifter created many logistical complexities and it was decided that the crane would be towed on its own barge.
At first, the LIU team was concerned since the barge was not intended for ocean travel and therefore lacked towing skegs and other structural components typically found on oceangoing barges.
But a detailed review of the plan with the client and contractors gave the LIU team confidence. In this instance, the sheer weight and size of the crane provided sufficient stability, and with the addition of a second tug on the barge’s stern, the LIU team, with its knowledge of barges and tugs, was confident the configuration was seaworthy and the barge would travel in a straight line. The team approved the plan and the crane began its successful voyage.
As impressive as the crane and its voyage were, it was just one piece in hundreds that needed to be underwritten and put in place for the Tappan Zee Bridge project to come off.
The rebuilding of the Tappan Zee Bridge, due to be completed in 2018, is the largest bridge construction project in the modern history of New York. The bridge is 3.1 miles long and will cost more than $3 billion to construct. The twin-span, cable-stayed bridge will be anchored to four mid-river towers.
When veteran contractors American Bridge, Fluor Corp., Granite Construction Northeast and Traylor Bros. formed a joint venture and won the contract to rebuild the Tappan Zee, one of the first things the consortium needed to do was find an insurance partner with the right coverages and technical expertise.
The Marsh broker, Ali Rizvi, Senior Vice President, working with the consortium, was well known to the LIU underwriting and engineering teams. In addition, Burford and the broker had worked on many projects in the past and had a strong relationship. These existing relationships were vital in facilitating efficient communication and data gathering, particularly given the scope and complexity of a project like the Tappan Zee.
And the scope of the project was indeed immense – more than 200 vessels, coming from all over the United States, would be moving construction equipment up the Hudson River.
An integrated team of LIU underwriters and risk engineers (including Burford, Phillips, Dollahon and Falcinelli) got to work evaluating the risk and the proper controls that the project required. Given the global scope of the project, the team’s ability to tap into their tight-knit global network of fellow LIU marine underwriters and engineers with deep industry relationships and expertise was invaluable.
In addition to the large number of vessels, the underwriting process was further complicated by many aspects of the project still being finalized.
“Because the consortium had just won this account, they were still working on contracts and contractors to finalize the deal and were unsure as to where most of the equipment and materials would be coming from,” Burford said.
Despite the massive size of the project and large number of stakeholders, LIU quickly turned around a quote involving three lines of marine coverage, Marine Liability, Project Cargo and Marine Hull & Machinery.
How could LIU produce such a complicated quote in a short period of time? It comes down to integrating risk engineers into the underwriting process, possessing deep industry experience on a global scale and having strong relationships that facilitate communication and trust.
Photo Credit: New York State Thruway Authority
When completed in 2018, the Tappan Zee will be eight lanes, with four emergency pullover lanes. Commuters sailing across it in their sedans and SUVs might appreciate the view of the Hudson, but they might never grasp the complexity of insuring three marine lines, covering the movements of hundreds of marine vessels carrying very expensive cargo.
Not to mention ferrying a 3,920-ton crane from coast to coast without a hitch.
But that’s what insurance does, in its quiet profundity.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Liberty International Underwriters. The editorial staff of Risk & Insurance had no role in its preparation.