Legionnaires Disease Deserves More Attention

Often, a new disease breaks out that has doctors and pubic health professionals

Legionella Under the Microscope. U.S. Centers for Disease Control (CDC).Public Domain.

Legionella Under the Microscope. U.S. Centers for Disease Control (CDC).Public Domain.

puzzled and worried. In 2014, it was Ebola. This year, it is the Zika Virus.

There are also potentially fatal illnesses that are preventable and yet, the Centers for Disease Control and Prevention is seeing cases on the rise. One such example is Legionnaires Disease.

My article, Insurance Implications of Legionnaires Disease, published by the AmWins Group’s The Edge, provides an update on illnesses related to legionella bacteria, along with prevention tips, symptoms and the liability concerns. I hope you find it helpful.


Doctors More Likely to Dispense Unnecessary, Stronger Opioids For Profit

When doctors prescribe strong opioids to injured workers, the assumption is the workers need them.

But when Florida banned physicians from selling strong opioids to injured workers, this did not translate into more scripts for pharmacies to fill.

Instead, doctors distributed weaker pain medications, according to a Workers Compensation Research Institute (WCRI) study, The Impact of Physician Dispensing on Opioid Use released today.

“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,” Richard Victor, WCRI’s executive director, said in a statement.

“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,” he added.


The WCRI study is important because it confirms what many of us
in Comp Land have been suspecting all along.

Specifically, patients receiving physician-dispensed weaker pain medications – non-steroidal anti-inflammatory medications such as Ibuprofen — went up from 24.1 to 25.8 percent. The percentage of injured workers who received weaker but legal opioids increased from 9.1 to 10.1 percent. 

The study defines “strong” opioids as those on the U. S. Drug Enforcement Administration’s Schedule II ( i.e. CodeineHydrocodone) and Schedule III opioids, (i.e. products containing no more than 90 milligrams of codeine per dosage unit such as Tylenol with Codeine® and buprenorphine (Suboxone®). “Weaker” opioids are Schedule IV drugs that include carisoprodol (Soma®) and diazepam (Valium®).

Only two percent of injured workers taking weaker physician-dispensed pain medications in the first six months received stronger opioids from the pharmacy afterwards.

Physician dispensing of medication is a huge workers’ comp pet peeve of mine, as I covered in previous blogs.

This WCRI study is important because it confirms what many of us in Comp Land have been suspecting all along. When doctors can make money on stronger opioids, they will dispense them to injured workers even when safer alternatives work just as well.

Given the danger of opioid use and our nation’s opioid epidemic, I can only hope that this study gets the attention of lawmakers who have the guts to put injured workers before physician profits.

Oh, and here’s the fine print. The study is based on data concerning the medications dispensed for injured workers under the Florida workers’ compensation program. The claims were divided into two groups: pre-reform, with dates of injury from January 1, 2010 to June 30, 2010 (prior to the July 1, 2011, effective date of the ban) and post-reform, with dates of injury from July 1, 2011 to December 30, 2011 (immediately after the ban). The data included 24,567 claims with 59,564 prescriptions in the pre-reform group and 21,625 claims with 52,747 prescriptions in the post-reform group.

For more information about this study or to purchase a copy, visit http://www.wcrinet.org/result/PD_opioid_result.html

Yeah! Employers Are Keeping Employee Health Care Coverage

Most organizations are continuing to offer health care coverage for their employees, according to a survey by Society for Human Resource Management (SHRM) and the Employee Benefit Research Institute (EBRI) released last month.

It’s obviously a good sign for employees who fear finding insurance as individuals through state exchange programs (ObamaCare). Those of us who have avoided the bumps in the road during ObamaCare implementation are sympathetic to Americans who have gone through the arduous process.

And sure, it also means employers recognize that offering employee benefits is still key to attracting and retaining employees.

But I am hoping there is another important reason why employers will be compelled to continue offering coverage even in 2018 — when a 40 percent excise tax will apply to the value of more expensive health care plans.

My hope is that employers will see health care coverage as more than employee benefit, but as an integral part of investing in employee health to encourage productivity and presenteeism (or absence management.) By integrating medical insurance with wellness, safety, disease management and return-to-work programs — along with other initiatives — employers will see a return on their investment. Just think about how much it costs to pay a temporary worker or the stress it causes the rest of the team to share a person’s job, not to mention loss of morale.

We’ve known this for a while. Even back in 2002, when I wrote a 16-page booklet for Business & Health magazine, there was evidence that investing in employee health and productivity saves more than double the costs of absence.

The challenge is to educate employees
about the costs of health care and absence
in their own personal lives.


In the booklet, the estimates were that the total cost of employee absence equals revenue capacity (assuming employee contribution is worth 150 percent of daily income for organizational profitability) plus wage replacement. So for a worker getting paid $20 per hour, using the formula and assumptions, it would be: ($20 X 1.50) + $15, which would make lost productivity cost about $45 hourly. (To see the article, “Selling the CFO,” click here and go to page 7. Warning: it takes a while to load.) The formulas today are undoubtedly more detailed and complex, but this equation makes the point.

That said, health care costs are ever-increasing at a time when Americans are becoming more unhealthy. The trick is cracking the code of how to motivate people to live safer and healthier lives.

I believe part of the code is educating employees about the costs of health care and absence in their own personal lives. I don’t think employers or insurers, for that matter, do this enough.

People need to see differences in annual claims costs. One comparison, for example, would be looking at a claims for two people of the same age and comparing the cost of individual co-morbidities. They need to understand that preventable contributors to health care costs make it difficult for employers to hire more people or offer additional benefits.

They also need to understand what obesity, for example, will do to their quality of life in the short and long-term. One obvious result is getting Type 2 Diabetes. People hear about the risk of diabetes, but do they know what it means in real life? My school-aged daughter, who has had Type 1 (non-preventable) Diabetes for nearly eight years, can tell you.

The diabetic lifestyle not only means pricking fingers and the risk of insulin dependency (which requires poking an insulin pump tube into the body every three days) but can also lead to organ failure (kidney dialysis anyone?) pain when walking (how about those diabetic nerve drug commercials?) and more difficult recoveries. Sure, this approach will not help everyone, but it at least a start.

They also need to understand that getting back to work as soon as medically possible is the best for them. Stay off too long and long-term income potential decreases.

Finally, I am thrilled that employers are continuing to offer health care. The real key in reducing the costs of health care, however, are up to us. And I say, the less we need health care the better off we are.


Eliminating Physician Drug Selling is a Workers’ Comp Necessity

Physician-dispensed drug prices in Connecticut dropped about 30 percent, yet stayed 30 to 60 percent higher than pharmacy prices, according to study by the Workers Compensation Research Institute (WCRI) announced today.

This study points to a nagging issue in workers’ comp. That is, doctors in many workers’ compensation systems are able to make significant profits selling drugs.

As I covered in a previous blog, doctors should not be playing the role of pharmacist. Period.

The issue as gained a lot of attention in the past three years or so and for good reason. Why is it, when our nation has opioid epidemic, that doctors can sell drugs without oversight?

To make matters worse, as another WCRI study revealed, doctors still have a long way to go in monitoring their patients on opioids, which is contributing to addiction, abuse and death. Put these two realities together and there are still states that allow doctors to sell opioids to patients when chances are, there is little or no patient monitoring.


Why is it, when our nation has opioid epidemic,
that doctors can sell drugs without oversight?

Why it is even legal for doctors to sell drugs directly to patients is beyond my comprehension. Doctors generally charge much more than the local pharmacy. And since injured workers (which the exception of Washington state) do not pay any of the tab, they do not have an incentive to obtain drugs at competitive prices.

The argument in favor of physician dispensing is patient accessibility to medication. This is not a concern in most localities.

In California, doctors were forced to accept prices very close to pharmacy prices. WCRI studied that too. It turned out doctors continued to sell drugs – and patients continued to buy them.

The insurance industry is saving money from this change, but when doctors are pressured to make patient visits shorter, how can they monitor drug use, especially of multiple medications?

To learn more about WCRI’s latest study, check out http://www.wcrinet.org/media_info.html.

That’s my two cents. Please share your opinion in the comments section below.  

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Carpal Tunnel Syndrome Often Misdiagnosed; Not Work-Related

By Daniel R. Miller, MPH, Senior Consultant, ClaimDocs

Carpal tunnel syndrome (CTS) has caused a firestorm of controversy in recent years.  CTS is a perfect example of how popular beliefs are not supported by overwhelming medical evidence.

It is time to set the record straight.

Considerable misinformation continues to surround the etiology, definition, diagnosis and treatment of CTS. Even its popular name is incorrect. The correct clinical name is Median Nerve Compression Neuropathy. According to the AMA Physicians Guide to Return to Work, “CTS is actually a condition with a known pathology and not a syndrome, but the name carpal tunnel syndrome has become so well known that CTS is used rather than median nerve compression neuropathy.”

Although the popular belief is that keyboard use causes CTS, the science shows otherwise. Nine studies have reviewed this relationship, including the Mayo Clinic, Harvard Medical School, and a Swedish study reported in Orthopedics Today, demonstrate that, “there is not a causal relationship between CTS and computer keyboarding.” The scientific research shows that keyboards are safe to use and do not cause CTS. Furthermore, keyboard design had no effect on the incidence of CTS. Symptoms may increase with many activities, including the use of keyboards, but keyboards do not cause CTS.

According to the AMA Guides to the Evaluation of Disease and Injury Causation, “85% of patients who meet the National Institute of Occupational Safety and Health (NIOSH) guidelines and requirements for a diagnosis of CTS would not have a true CTS confirmed by nerve conduction testing.”

What complicates the diagnosis and treatment of CTS is that there are multiple causes. These include: diabetes, pregnancy, use of birth control pills, menopause, various vitamin deficiencies, insufficient water consumption, exposure to cold temperatures, incorrect sleeping positions, smoking, knitting, playing musical instruments, recreational sporting activities and other non-work-related activities.

Medical studies have shown that up to 85% of patients
who are told they have CTS are misdiagnosed.

What complicates the diagnosis and treatment of CTS even further is that there are literally dozens of other diseases and conditions that mimic CTS-like symptoms. These include: tendonitis, bursitis, sprains, fractures, dislocations, gout, rheumatoid arthritis, osteoarthritis, thoracic outlet syndrome, myofacial trigger points, as well as an array of neck, shoulder, back and cervical conditions. In fact, there are 59 medical conditions that have been identified to be associated with CTS-like symptoms.

A common error in diagnosis and treatment is the tendency of physicians to treat a case as if there were a single physical site causing all the problems. In fact, it would be extremely rare for only one nerve location to be involved. This means that pain in the wrist may be the result of nerve entrapment in the neck or shoulder. This is referred to as the “whole-nerve syndrome.”

Medical studies have shown that up to 85 percent of patients who are told they have CTS are misdiagnosed. Yet in the workers compensation industry the overwhelming number of cases are determined to be work-related and it has been reported that up to 70 percent go on to receive CTS surgery.

Currently 250,000 people per year in the U.S. have CTS release surgery. Not only has this been a major problem in the workers’ compensation industry for the past two decades but it is also the fifth most common surgical procedure performed among Medicare patients.

According to a University of Maryland Medical Center study, “CTS surgery does not cure all patients and because it permanently cuts the carpal tunnel ligament some wrist strength is often lost. A number of experts believe that CTS release is performed too often.”

A medical director at a leading insurance company told me, “I recommend that all CTS cases go on have surgery because that is where all the cases end up anyway.” Needless to say, I will not recommend that insurer to my clients.

The good news is that CTS can be diagnosed accurately. In many cases, it can be treated successfully with conservative treatment in a matter of weeks and is easily prevented. The bad news is that primary care physicians more often than not misdiagnose CTS. This results in incorrect treatment and unnecessary surgery, which leads to chronic unresolved conditions, no relief to the patient and staggering costs to U.S. employers and insurers

Leading medical experts such as Peter Tsairis, MD, retired chairman of neurology at the Hospital for Special Surgery in New York, said the biggest concern is the automatic assumption that the clinical problem is work-related. “It is a significant problem, since many of these patients do not have CTS,” he added. Yet, he has often seen patients already scheduled for surgery whose primary care physicians did not perform a thorough physical exam or conduct any electrical diagnostic testing to confirm the CTS diagnosis.

Dr. Ron Safko, a New York-based, board-certified chiropractic orthopedist, has also seen many cases of misdiagnosis by primary care physicians. “It boggles my mind how physicians do not even consider other underlying conditions and do not even examine other areas, such as the neck, back, shoulder or cervical spine,” he said.

Just because it has become a widely accepted urban myth that CTS is caused by keyboarding and, therefore, a work-related injury, should not give treating physicians the liberty to avoid performing a thorough patient history, physical examination and appropriate diagnostic testing based on widely accepted and evidenced-based medical protocols.

Isn’t it about time the workers’ compensation industry got it right?

What do you think? Please offer your comments below. To contact Dan directly, write dan@claimdocs.com

Tips for Workers’ Comp Independent Med Exams

Independent medical exams (IMEs) can be an effective way to determine an injured worker’s medical status. But too often, they turn out to be a waste of money.

I asked my colleague, Daniel R. Miller, senior consultant for ClaimDocs, to give me some quick tips. I’ve known Dan for nearly 20 years and his career background includes national consulting firms.

Here are Dan’s tips:

1)   Before scheduling an IME, the claims manager and exam doc must know its purpose. Be specific about the details. Whether the issue is misdiagnosis, causation or degree of disability, provide medical reports, witness and injured worker statements, and other supporting materials.

2)   Find out the state’s laws and applicable treatment guidelines. Make a checklist of what needs to be done, how and when. Follow it to the letter. Some states dictate timing and conditions of the IME. More often than not, IMEs occur too late in the process. Therefore, starts considering an IME when the medical pieces of a claim are not fitting together and/or “red flags” are showing up.

3)   To ensure credibility, hire well qualified and highly respected doctors. Those with a relevant specialty tend to get more weight than generalists. Docs with successful private practices, are affiliated with teaching hospitals or are involved in research are generally given more credence.

4)   IMEs related to returning an injured worker to the job should include specific job requirements according to the employer, physician input and the employer’s efforts to assure return to work. Providing the job requirements on video is generally very helpful.

5)   Communicate clearly to appropriate parties throughout the claims process. No matter how much you follow the other steps, miscommunication can cause something to go wrong.

For more information, you can contact Dan directly by writing dan@claimdocs.com.

If you have other good tips or feedback, please add a comment.

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Surprise! ObamaCare Needs More of the Young and Healthy

Sometimes the news just makes me laugh.

Apparently, the young and healthy are not clamoring for ObamaCare. The U.S. Department of Health and Human Services reported today that only one quarter of 18 to 34 year olds who need to sign up for ObamaCare are actually doing it. (To see the news release, click here.)

This 25 percent only meets 18 percent necessary to make ObamaCare work. Meanwhile, one-third of the 2.2 million who signed up are 55 to 64 years old.

In other words and to no surprise, high risk people who will cost more to cover are signing up faster than the “low risk” younger crowd. The younger generation is also smaller than this age group, which represents part of the heavily populated baby boomer generation.

From the insurance perspective, this is just another “I told you” moment. Convincing the young and healthy to buy health care coverage has always been tough. Meanwhile, the “adverse risk” group continues to grow as the American waistline expands.

When I look back to my own experience, I know there was no way
I could have afforded the Affordable Care Act when I was 22…

Insurance experts pointed to past experience and actuarial charts to show the costs of coverage. They knew it would cost Americans more – both collectively and individually – in taxes and fees. So it is no surprise that 79 percent of the nearly 2.2 million who managed to get signed up requested financial assistance, according to the HHS news release.

I think about today’s young adults. Many are burdened with student loans that mirror the cost of a car payment. They are having a hard time finding work, even if they earn advanced degrees. They face the highest taxes in U.S. history and, without a mortgage, lack much relief from tax deductions.

When I look back to my own experience, I know there was no way I could have afforded the Affordable Care Act when I was 22 and fresh out of college. I came from a lower middle working class background. My dad loaded trucks for a living. Mom was a sales clerk at Sears. To get through college, I worked and borrowed. I was the first in my family to earn a college degree.

My first job was with the state of Ohio’s Bureau of Workers’ Compensation, which Thank God, provided very affordable health care. It was hard enough for me to pay the pre-25 year-old premium for car insurance or pay taxes without deductions. I was driving a beater (well, actually a cool one –a ’77 Cutlass 442 with a 350-V8 engine, but I am digressing…oh, I still miss that car!)– paying for a modest one-bedroom apartment in German Village alone with my 8 percent interest student loans and the costs of just getting started in life. I didn’t live with my parents and they really did not have money to help. In my day, successful people did not sponge off their parents or the government.

But now I laugh until I cry, realizing that the Obama behind the care never really faced the financial struggles that most of us do. And he will probably never have to get ObamaCare either.

ObamaCare is Our Own Dang Fault

“Ask not what your country can do for you, but what you can do for your country,” — President John F. Kennedy, inaugural address, 1961

I have been thinking a lot about Kennedy’s admonition as Americans are waking up and smelling the ObamaCare coffee. I am wondering why are Americans so shocked.

Americans had been warned by health insurance experts. They told us such promises were impossible to achieve. The experts told us that you could not socialize medicine and extend the same level of health care for all. The resources do not exist. If nothing else, there are not enough doctors.

But you didn’t have to be a healthcare expert to know this. Even common sense would dictate that expanding healthcare coverage for more people would cost everyone more. Of course employers would rather pay a fine that is cheaper than paying ever-rising health insurance premiums. You like to save money too, don’t you?

ObamaCare would have never gotten off the ground in Kennedy’s day. Americans were still too much against anything that smacked of socialism.

But we are a different America now. Kennedy’s 1961 audience was made up mostly of those who had lived through the depression and at least one world war. If they were young enough to have no memory of such trying events, they had parents who did — and they talked about it. Such collective experience has been buried in our nation’s cemeteries.

We have forgotten that those who lived through those events sacrificed more than most of us have. My Grandmother Webbe, who was born 104 years ago, was coming of age during the depression. It left an indelible mark on her and her peers. They never took prosperity for granted. They saved everything because they never knew when a time of need would happen again.

Even common sense would dictate that expanding healthcare coverage
for more people would cost everyone more.

Kennedy’s statement was offered to a people who understood that individual rights meant individual responsibilities. These were a people who believed in the Judeo-Christian God to whom they were accountable. They did not see jobs as a right but a privilege they worked hard to achieve and maintain. They did not rely on government but the strength of family and community. Some people fell through the cracks, so government got involved. Some will fall through the ObamaCare cracks as well.

But the audience is different now. Our rights do not stem from a creator to whom we owe an account of our lives. That presumed creator in the Declaration of Independence’s who endowed us with rights of life, liberty and the pursuit of happiness has been substituted by the government. The freedom of assembly, religion and expression now extends to the right to personal offense and lawsuits that censor Americans from speaking truth.

And we don’t ask ourselves what we can do for our country. We expect more from others than we do ourselves.

As a result, the question of what we can do for our country has been answered for us. Doing for our country means paying higher taxes and accepting a lower standard of living. These are taxes necessary to finance our high expectations from governmental programs promised by politicians to get elected.

And this is our fault. Rising health care costs is a direct result of Americans having greater expectations to live unhealthy lives without having to pay much of the health care tab.

Kennedy’s statement was offered to a people
who understood that individual rights meant individual responsibilities.

ObamaCare is also the result of a civil war taking place in this country, but of a different kind.

It is not one being fought with guns, but something less obvious and perhaps more sinister: propaganda. We are surprised by the effects of ObamaCare because we wanted to believe the promises it made to us.

Recently I gained new perspective on the War Between the States by reading the southern states’ perspective. It turns out my great, great grandfather, Henry H. Gill, fought in the civil war for the Confederacy. I felt I owed it to Henry H. Gill of the 1st Northern Virginia Infantry to see the war through his eyes.

Growing up in Cleveland, I already knew the north’s perspective. Of proud Yankee blood, I felt great that my ancestors were on the right side of history. Another ancestral line is made up of Quakers who left Virginia in 1799 to live in the slave-free Northwest Territory.

When it came to slavery, the north was right. But when it came to state’s rights, the Confederacy was right.

From their perspective, their own country went to war against them. Many Americans who are being forced into ObamaCare feel their government is imposing on them. ObamaCare won political support even though about half of Americans were against it. We are a country divided about health care.

The confederacy fought back. Most soldiers were not fighting to maintain slavery. Frankly, most of them could not afford slaves anyway.

The confederate states wanted liberty from the federal government forcing its agenda on them. This is no different than the genesis of the Declaration of Independence, which came about because Mother England was doing the same. My ancestors fought in the Revolutionary war as well.

But we are a different people now. Our expectations are different. We ask what our country to do for us instead of the other way around. Such expectancy paved the way for ObamaCare. This is our own dang fault.

This is no longer the country for which my ancestors fought. I don’t think they would have felt comfortable here anyway.

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DMEC Legislative Updates

The Internal Revenue Service, Employee Benefits Security Administration and the Centers for Medicare & Medicaid Services have released final regulations regarding incentives for nondiscriminatory wellness programs in group health plans.  These final regulations increase the maximum permissible reward under a health-contingent wellness program offered in connection with a group health plan (and any related health insurance coverage) from 20% to 30% of the cost of coverage. 

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Opening A Window Into Health Care’s Future

Cover of Leader's Edge magazine, May 2013

Cover of Leader’s Edge magazine, May 2013

Technology promises amazing innovations that can support longer and healthier lives. But what will it cost us as individuals and as a society?

I gave these issues a look for the award-winning Leader’s Edge magazine. It is the cover story for the May issue.

Called “Fully Exposed,” my article walks readers through exciting technological innovations including body monitoring, telemedicine, DNA sequencing, and even growing replacement organs. Taking a view into the future is really exciting.

These technologies are evolving just as the nation’s health care system is being turned upside down. ObamaCare, sources say, will lead to a two-tier health care system that will place high-tech, cutting edge medicine out of reach for more of the middle class. Americans are just beginning to find out how ObamaCare will really affect them.

Truly, our society has some soul searching to do.

Americans will also find out how much health care really costs. We have been getting a bargain, paying less in co-payments than the cost of taking the family out for dinner. We can expect to pay much more out of pocket for our own care and higher taxes for everyone else’s.

Then there are ethical questions. Just because science provides new opportunities does not mean it is good for society to take them. A genetic family tree can help prevent and cure diseases, but even U.S. history has examples of eugenics. Truly, our society has some soul searching to do.

I intend to explore these issues in greater detail in future blogs. In the meantime, I hope you enjoy my article! Please feel free to comment on it as well.

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