The June 28, 2012 decision by the United States Supreme Court on the Affordable Care Act may go down as one of those “Where were you when the ruling was announced?” type of moments. As both a self-proclaimed C-SPAN and political junkie, I followed the debate from the beginning, when President Obama signed into law the Patient Protection and Affordability Care Act of 2010 (PPACA) and the Healthcare and Education Reconciliation Act of 2010 (HCERA), including reading the transcripts of the oral arguments made to the U.S. Supreme Court a few months back.

The reason for my interest was a key provision pertaining to prescription drug plans which, if enacted, will have an affect on Medicare Part-D and, therefore, on Workers’ Compensation Medicare Set-Asides (WCMSA). PPACA § 2502 pertains to the elimination of the exclusion of coverage of certain drugs that traditionally have not been compensable under Medicare Part-D.

Now that the healthcare law has been upheld, beginning in 2013 Medicare Part-D will begin to cover Benzodiazepines and barbiturates used for certain conditions such as epilepsy, cancer, or a chronic mental disorder. Currently, these medications are excluded from Medicare Part-D prescription drug plans.

Benzodiazepines are those medications such as Diazepam (Valium), Clonazepam (Klonopin), Alprazolam (Xanax), and barbiturates and include the commonly used medication Phenobarbital. Although we do not see use of Phenobarbital often in the WC arena, Benzodiazepines are utilized for many conditions in WC, such as anxiety, sleep, and muscle relaxation.

Normally, these medications would not generate any concern as they are typically dispensed as generic and are relatively inexpensive. However, the expansion of Medicare to cover them will have a direct impact on WCMSAs in two ways.

First, individuals may request the brand name Benzodiazepines in lieu of a generic at the time of fill. Average Wholesale Price (AWP) of brand name Valium costs about $3 per tablet and averages 15 times higher than the price of the generic equivalent Diazepam.

Second, although Benzodiazepines are abused less than opioids, there is now the potential for an increase in prescriptions for these medications. Benzodiazepines abuse is commonly seen when there is an established pattern of opioid abuse or with an illicit substance. Therefore, the potential for increased rates of abuse may rise. The WC community is already struggling with overuse of opioid medications and, conceivably, the new coverage could compound the problems the workers’ compensation community is seeing with the abuse of opioids.

These changes are certainly something to keep any eye on. They provide a strong argument for both early intervention strategies and prescription management and requires further close scrutiny on how it may affect the bottom line.

Further information on these and other changes can be found at:

http://www.medicareadvocacy.org/InfoByTopic/Reform/10_04.08.MAandPDChanges.htm

About the Author: William F. Bell, Jr. is the Senior Clinical Pharmacy Specialist for Gould & Lamb, LLC. His primary responsibility is the review of a claimant’s pharmacotherapy regimen and the identification of off-label medications in a Medicare Set Aside Allocation. He has given numerous presentations on the subject of medication management and how it relates to Workers’ Compensation and Medicare Set Aside Claims. Bill has also authored two continuing education articles for the Pharmacist’s Letter, a nationally known education resource for practicing pharmacists.

Gould & Lamb is a global leader of MSA/MSP Compliance Services in the country, serving domestic and international insurance companies, third-party administrators and self-insured entities.

Continuing Short Term and Long Term Financial Difficulties

The Medicare program has two components. Hospital Insurance (HI) and Supplementary Medical Insurance (SMI).  HI, otherwise known as Medicare Part A, helps pay for hospital, home health, skilled nursing facility, and hospice care for the aged and disabled. SMI consists of Medicare Part B and Part D. Part B helps pay for physician, outpatient hospital, home health, and other services for the aged and disabled who have voluntarily enrolled. Part D provides subsidized access to drug insurance coverage on a voluntary basis for all beneficiaries and premium and cost-sharing subsidies for low-income enrollees. Medicare also has a Part C, which serves as an alternative to traditional Part A and Part B coverage. Under this option, beneficiaries can choose to enroll in and receive care from private “Medicare Advantage” and certain other health insurance plans that contract with Medicare. These plans receive prospective, capitated payments for such beneficiaries from the HI and SMI Part B trust fund accounts.

The Social Security Act established the Medicare Board of Trustees to oversee the financial operations of the HI and SMI trust funds. The Social Security Act requires that the Board, among other duties, report annually to the Congress on the financial and actuarial status of the HI and SMI trust funds. A complete copy of the 2012 report submitted by the Board can be found on the CMS website.

In summary, total Medicare expenditures were $549 billion in 2011. The Board projects that, under current law, expenditures will increase in future years at a somewhat faster pace than either aggregate workers’ earnings or the economy overall and that, as a percentage of GDP, they will increase from 3.7 percent in 2011 to 6.7 percent by 2086 (based on the Trustees’ intermediate set of assumptions). If lawmakers continue to override the statutory decreases in physician fees, and if the reduced price increases for other health services under Medicare are not sustained and do not take full effect in the long range, then Medicare spending would instead represent roughly 10.4 percent of GDP in 2086. Growth of this magnitude, if realized, would substantially increase the strain on the nation’s workers, the economy, Medicare beneficiaries, and the federal budget.

The Trustees project that HI tax income and other dedicated revenues will fall short of HI expenditures in all future years under current law. The HI trust fund does not meet either the Trustees’ test of short-range test of financial adequacy or their test of long-range close actuarial balance.

The Part B and Part D accounts in the SMI trust fund are adequately financed under current law, since premium and general revenue income are reset each year to match expected costs. Such financing, however, would have to increase faster than the economy to match expected expenditure growth under current law.

The financial projections in this report indicate a need for additional steps to address Medicare’s remaining financial challenges. Consideration of further reforms should occur in the near future. The sooner solutions are enacted, the more flexible and gradual they can be. Moreover, the early introduction of reforms increases the time available for affected individuals and organizations—including health care providers, beneficiaries, and taxpayers—to adjust their expectations. Congress and the executive branch must work closely together with a sense of urgency to address the exhaustion of the HI trust fund and the growth in HI, SMI Part B, and SMI Part D expenditures.

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About the Author: Rafael Gonzalez is Director of Medicare Compliance & Post-Settlement Administration. He brings over 20 years of experience in the Workers’ Compensation and Liability insurance industries with a specific focus on Medicare Compliance. Rafael has been responsible for all areas of Medicare Set Aside Allocations (MSAs) including the preparation of MSAs and their approval by the Center for Medicare & Medicaid Services.  At Gould & Lamb, Rafael’s duties include assisting clients with Medicare Compliance issues, specifically on Post-Settlement Administration and client education.

Gould & Lamb is a global leader of MSA/MSP Compliance Services in the country, serving domestic and international insurance companies, third-party administrators and self-insured entities.

The word Epidemic is defined as “a case of a certain disease exceeding what is expected”. When we hear the word epidemic, we typically think of an influenza outbreak or the West Nile Virus. Unfortunately, we can now officially add the Prescription Drug Abuse Crisis as an epidemic as was recently confirmed by the Centers for Disease Control and Prevention (CDC) at the inaugural National Rx Drug Abuse Summit held in Orlando, FL.

The Summit was very successful in gathering and sharing of information, establishing that we all have something at stake in this epidemic. Whether you are a physician, pharmacist, nurse, claims adjuster, or third party payer, we must all agree that it is our problem and work in order to bring a solution.

Telling statistics from this Summit include:

• 1 death occurs in the United States every 19 minutes which is attributable to prescription medication abuse
• 7 deaths occur in Florida each month from abuse of prescription medications, namely opioids
• Those who abuse opioids will generate costs 8.5 times greater on the US Healthcare system than those who do not
• Prescription drug abuse costs close to $73 billion annually in unnecessary expenses
• Pharmacy robberies are up 86% over the last decade in part due to OxyContin
• 48 states now have some sort of Prescription Drug Monitoring Program (PDMP) in place

In the workers’ compensation arena, I cannot stress enough how education is paramount to fight the problem. Awareness and recognition by adjusters, claims examiners, nurses, pharmacists, physicians, and third party payers can lead to intervention and prevention.

One way all of us can participate is through DEA annual “take-back” day program. This program is designed to allow consumers to properly dispose of unused medication safely and without fear of it falling into the wrong hands. Nearly 900,000 pounds of unwanted or expired medications have been collected at various sites throughout the country as part of this initiative. This year’s event removed a record 176 tons of medication from circulation. More information can be found at:

National Take-Back Initiative

As stated in my last blog, recognition of this problem is a good first step to achieving long-term goals and solutions. Action is required by all of us if we are to curb the rising use of prescription opioids in workers’ compensation. Time will tell if we will be successful in our efforts.

About the Author: William F. Bell, Jr. is the Senior Clinical Pharmacy Specialist for Gould & Lamb, LLC. His primary responsibility is the review of a claimant’s pharmacotherapy regimen and the identification of off-label medications in a Medicare Set Aside Allocation. He has given numerous presentations on the subject of medication management and how it relates to Workers’ Compensation and Medicare Set Aside Claims. Bill has also authored two continuing education articles for the Pharmacist’s Letter, a nationally known education resource for practicing pharmacists.

Gould & Lamb is a global leader of MSA/MSP Compliance Services in the country, serving domestic and international insurance companies, third-party administrators and self-insured entities.

Nearly15,000 people die each year from overdose of prescription medications (CDC Vital signs 2011). Deaths attributed to prescription drug overdoses are America’s fastest growing drug-related problem and outnumber deaths from both heroin and cocaine, combined. The problem has no boundaries.  Each day, it seems, we hear about another celebrity death from prescription medications. We may even have family and/or friends who have been personally affected by the abuse of prescription medications, especially opioids.

One sobering statistic is that the United States of America represents only 4% of the total world’s population; however, the U.S. consumes close to 80% of the world’s opioid supply. To put that into perspective, the CDC report states that “Enough prescription pain killers were prescribed in 2010 to medicate every American adult around the clock for a month.” Hydrocodone/APAP is routinely in the top five of medications dispensed yearly by pharmacies, accounting for 132 million prescriptions annually. The workers’ compensation arena is not immune to this epidemic, as the use of opioid medications is at an all-time high in the industry.

There have been many blog postings and articles on effective ways to reduce opioid use in workers’ compensation cases advocating education, along with prescription drug monitoring and control. This is a good first step. We have seen REMS introduced as a way to educate physicians, patients, and other healthcare providers on the risks and benefits with these types of medications. Many states have now adopted prescription drug monitoring programs to electronically track prescriptions with the goal to decrease “Doctor shopping” and filling at multiple pharmacies. Recently, the DEA suspended the licenses of a major wholesaler and pharmacy chain due to the excessive quantities of opioids dispensed. As a practicing pharmacist, I applaud states that decide to develop comprehensive prescription drug monitoring programs (PDMPs). This is long-overdue and should prove beneficial moving forward.

Last year the White House released a paper entitled, “Epidemic: Responding to America’s Prescription Drug Abuse Crisis.” The report cited more statistics quantifying the problem and offered four main areas that could help to solve it: Education, Tracking and Monitoring, Proper Disposal of Medications, and Enforcement.  I recommend that you read the report.

Healthcare professionals must be held accountable during this crisis, as well. Physicians have a responsibility to properly prescribe medications and pharmacists have the duty to properly fill those prescriptions, while ensuring that a patient’s health is not compromised and the physician order is appropriate.

The inaugural National Rx Drug Abuse Summit will be held in Orlando, Florida next month. The purpose of this summit is to bring together experts in the healthcare field to discuss this problem and effective ways to solve it.  My next blog posting will report on this conference and the results of it.

There is a long ways to go in workers’ compensation with the prescription drug issue. Recognition of this problem is a good first step to achieving long-term goals and solutions. It is my hope that both awareness and education are instrumental in curbing inappropriate opioid usage which can lead to preventable death.

About the Author: William F. Bell, Jr. is the Senior Clinical Pharmacy Specialist for Gould & Lamb, LLC.  His primary responsibility is the review of a claimant’s pharmacotherapy regimen and the identification of off-label medications in a Medicare Set Aside Allocation.  He has given numerous presentations on the subject of medication management and how it relates to Workers’ Compensation and Medicare Set Aside Claims.  Bill has also authored two continuing education articles for the Pharmacist’s Letter, a nationally known education resource for practicing pharmacists.

Gould & Lamb is a global leader of MSA/MSP Compliance Services in the country, serving domestic and international insurance companies, third-party administrators and self-insured entities.

Two strategies are routinely sought after in healthcare: positive clinical outcomes for the patient and controlling the costs.  The proper use of generic medications is one way to manage costs. Another way costs can be controlled, while simultaneously achieving positive clinical outcomes, is through the use of Over-the-Counter (OTC) medications.

Controlling Costs with OTC Medications

Because OTC medications do not require visiting a physician or a physician’s prescription, the cost of going to a doctor’s office is eliminated and there is greater and easier access to the medications. Over the last two decades, the notion of “self-care”, a program where the patient can treat conditions they normally would not due to perceived barriers, such as socio-economic factors or the inability to see a physician, has increased. The greater access to OTC medications to treat conditions prevents unnecessary ER or hospital visits, thereby allowing physicians to focus their time and energy on more serious conditions.

A recent study released by the Consumers Healthcare Products Association (CHPA) concluded that for every $1 spent on an OTC medication, a $7 in savings to the overall healthcare system is realized.

Potential Savings Recognized in Workers’ Compensation Cases

In the Workers’ Compensation insurance sector, use of OTC medications is an under utilized standard of care and makes good sense. Factors such as the lack of formulary management allow for the prescription version of OTC medications to continue to be prescribed with the payer ultimately absorbing the costs. As an example, the chart below illustrates the AWP for two common GI medications and the potential savings as measured against the OTC version. We see these medications commonly prescribed in the Workers’ Compensation industry secondary to NSAID usage (Meloxicam, Ibuprofen) or with opioids (Hydrocodone/APAP) to alleviate upset stomach or other GI effects.

*AWP based on 30 day supply. BC/BS Michigan Pharmacy Sheet.

Although this may not seem significant or substantial, use of an OTC medication to take the place of a prescription can yield substantial savings to a Workers’ Compensation Medicare Set-Aside and could make the difference between settling the file or having to keep it open.  Keep in mind, both Omeprazole and Lansoprazole are not indicated to be utilized for chronic periods. Thus, it makes sense to utilize OTC versions of these products once or twice yearly as opposed to funding a Workers’ Compensation Medicare Set-Aside monthly for the prescription versions.

In today’s Workers’ Compensation claims handling setting, each and every dollar must be managed appropriately. OTC medication utilization is one way that Part-D allocations can be significantly reduced and properly funded in a Workers’ Compensation Medicare Set-Aside, providing both positive outcomes while being cost effective as well.

About the Author: William F. Bell, Jr. is the Senior Clinical Pharmacy Specialist for Gould & Lamb, LLC.  His primary responsibility is the review of a claimant’s pharmacotherapy regimen and the identification of off-label medications in a Medicare Set Aside Allocation.  He has given numerous presentations on the subject of medication management and how it relates to Workers’ Compensation and Medicare Set Aside Claims.  Bill has also authored two continuing education articles for the Pharmacist’s Letter, a nationally known education resource for practicing pharmacists.

Gould & Lamb is a global leader of MSA/MSP Compliance Services in the country, serving domestic and international insurance companies, third-party administrators and self-insured entities.