In the course of claim and medical management in workers’ compensation, adjusters can and should take advantage of available clinical resources, if and when necessary.

The first line of assistance is generally provided by registered nurses who have prominent roles in utilization review and case management, the latter performed either telephonically, or in the ‘field’ in direct contact with claimants and treating physicians.

However, a resource that is often underutilized is physician expertise which can be provided in various ways. This article discusses the options and optimal avenues of physician review based on the circumstances and requirements of the request.

File (Peer) Review:

Physician review consists of a review of the medical records and is often supplemented with a telephone call between a reviewing and treating physician (peer-to-peer conference).

In this scenario, there is no contact (i.e., physical examination) between the peer reviewer and the claimant. All the information required for the decision is obtained via:

• medical records
• imaging reports
• claim records
• data obtained by the reviewer’s conversations, if any, with one or more treating physicians.

There should be an attempt to match the expertise of the reviewing physician with that of the treating physician, referred to as specialty-matching. This ensures that treating physicians cannot assert their cases have been evaluated by physicians with a lesser degree of training and experience than they possess.

Peer review physicians may be “medical directors” of payer organizations (carriers, TPAs, managed care companies,) but more commonly they are practicing physicians independently-contracted by these organizations to perform peer reviews.

It is important to credential all peer reviewers to ensure that they are board-certified, have active and unrestricted state licensure, and have no record of significant sanctions that would present a credibility obstacle if a determination were to be challenged. Many payers establish relationships with vendors providing national networks of credentialed peer review physicians in all specialties, and this may be a convenient and effective approach that eliminates the need of the payer to “build” a panel of reviewers from scratch.

When is a peer review appropriate?

• Utilization Review

If a medical service subject to prior authorization is deemed questionable by an R.N., then peer review is required to make a final decision. Note that some states require the reviewing physician to be licensed in the jurisdiction where the claim occurs; most states do not have this requirement. This review process can also be applied to the review of non-formulary drugs.

• Causation

Peer review physicians can be helpful in advising a claim adjuster as to whether an alleged injury or illness is occupationally-related, and therefore compensable.

• Appropriateness of a Treatment Plan

When a claim adjuster or case manager is faced with a case that is not progressing well towards resolution, a peer review of the entire course of evaluation and treatment may yield suggestions for a reassessment of the diagnosis, and/or alternative therapeutic interventions that might be more successful.

• Return-to-Work (RTW) Determinations

Reviewers can indicate whether, based on objective findings in the file or reported by a treating physician, a claimant is functionally able to RTW, either at full-duty or modified by specific restrictions or limitations. Reviewers may also be able to opine on the face-validity of impairment ratings assigned by treating physicians.

Independent Medical Examinations (IMEs):

IMEs entail a referral to a physician for a comprehensive physical examination and responses to specific questions posed by claim adjusters.

As with file reviewers, the right specialty should be selected for the exam, and the qualifications and standing of IME physicians must be established via a thorough credentialing process. Casual referrals to local physicians are often not the best approach; the use of vendors with established networks of IME physicians subject to careful quality control is recommended.

When is an IME appropriate?

• IMEs are not useful for:
  • utilization review of services and drugs, except in a few exceptional circumstances.
  • causation determinations, or treatment planning, both of which are relatively easy to accomplish based on a review of medical files and current familiarity with evidence-based medical practice guidelines.

• IMEs may be useful when a physical examination by the responding physician is important
  • determinations of maximum medical improvement (MMI) status;
  • definitive impairment ratings based on the impairment guide mandated in the jurisdiction of the claim.

• IMEs will hold greater weight in litigated claims, particularly when an appearance at a state board hearing is scheduled or anticipated.

Peer Reviews Should be First Option

In general, peer reviews should be considered the first option for obtaining physician expertise, unless an IME is strongly indicated by the above criteria.

Speed

• Peer reviews can be obtained very quickly. Depending on the nature of the review, decisions are typically available from the same-day up to 5 days from referral.
• IMEs require advance scheduling, and usually reports are not available for 10-14 days. Therefore, the handling of a claim can be expedited via peer review.

Cost

Given the great cost disparity, a peer review is often a reasonable and cost-effective initial tool, even if one ultimately may need to resort to an IME.

• From a cost perspective, peer reviews range in price from $75- $300, again varying based on the type of review.
• IMEs, on the other hand, tend to range between $300-$2000, based on provider specialty and location, and the negotiating leverage that is applied.

Collaboration

In addition to access and cost factors, a peer review with a peer-to-peer conversation also has the advantage of facilitating a constructive and collegial dialog between the peer reviewer and the treating physician.

• When the peer review is well-handled, one can often engage the treater as a partner in the effective management of a claim, rather than as an adversary, and this can result in timely recovery and resolution of the claim.
• IMEs do not offer this opportunity for collaboration.

Jacob Lazarovic MD, Medical Advisor at Amaxx LLC, has considerable experience in managed care, including 18 years as chief medical officer at Broadspire , a leading TPA. His department produced clinical guidelines and criteria to support sound medical claim and case management practices; participated in analysis, reporting and benchmarking of outcomes and quality improvement initiatives; developed educational and training programs that updated the clinical knowledge and skills of claim professionals and nurses; provided expertise to enhances the medical bill review process; and operated a comprehensive and unique in-house physician review (peer review) service. He has been published extensively in industry journals and has held several senior medical management positions at companies including HealthAmerica, Blue Cross/Blue Shield of Florida and Vivra Specialty Partners

Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of current best scientific evidence in making decisions about the care of individual patients.

Hierarchy of Scientific Evidence

While we would like to think that scientific evidence has always been the basis of modern medical practice, over the last few decades there has been an exponential improvement in research study design and rigorous data analytics such that clinicians and administrators have been the beneficiaries of increasingly valid and actionable study results and conclusions.

With respect to study design, this is often depicted as a hierarchical pyramid in which, for example, single case reports are at the lowest tier and are the least persuasive, whereas randomized, blinded, controlled studies (RCTs) and systematic reviews/meta-analyses are at the peak of the pyramid, and constitute the “gold standard” of research methodology. So we have moved from a reliance on small, uncontrolled studies to large-scale (and often geographically widespread) studies in which matched patient populations are prospectively given one treatment or another  (or no treatment at all in the form of a placebo or sham procedure) and outcomes are measured over many years.

Furthermore, the results of multiple RCTs may be aggregated to produce sophisticated meta-analyses which have greater statistical power than any single RCT in isolation.

Critical Evaluation by Expert Panel

However, the process does not end there. There next needs to be a sifting and critical evaluation of the evidence produced through a myriad of studies on any single topic. This is the task of specially-constituted expert panels of physicians. These editorial advisory boards,(assembled by various clinical specialty societies, medical universities, government entities, medical publishers, and similar organizations), translate the research described above into treatment guidelines to be applied by medical practitioners in the course of clinical care. Of course, these same guidelines are equally useful for those evaluating the medical necessity and appropriateness of treatment being proposed or delivered by physicians, and also helpful for any other interested stakeholder in the medical management arena.

Let’s illustrate this using a procedure (one which I fabricated) called electromagnetic plasma fusion, or EPF, which is being promoted for various soft tissue injuries. The advisory panel (likely consisting of orthopedists, physiatrists, occupational medicine physicians, Ph.D. statisticians, etc.) gathers and reviews all the available research evidence about EPF, eliminating studies from the bottom of the pyramid, and placing greater weight on studies at its apex. After considerable discussion and the use of group consensus techniques, the panel may decide that EPF has not met the threshold to be deemed a scientifically beneficial technology, and it will publish a guideline with a “not recommended” determination, and its rationale for this decision.

On the other hand, the panel may feel that EPF has a place in the toolbox of treatment for certain conditions, and it will produce a clinical guideline that documents under what circumstances it should be offered, e.g. which patients may benefit; when to use it in addition to, or in place of, alternative therapies; how frequently it should be used, etc. All of this may be summarized in a graphical algorithm for ease of use by clinicians.

Free Resource for Published Guidelines

There are now thousands of published guidelines from many sources on multiple topics, and many are publicly available at the National Guideline Clearinghouse site:

• https://www.guidelines.gov/

Evidence-Based Medicine Guidelines for Workers’ Compensation

Particular sets of national guidelines have been uniquely developed for the workers’ compensation/disability market.

• Treatment guidelines encompass best practice treatment for all musculoskeletal conditions, as well as other common conditions encountered as occupational injuries and illnesses
• Duration guidelines include the expected and optimal return-to-work durations post-injury.
• Drug guidelines (formularies) typically consist of all common classifications of drugs including opioids, muscle relaxants, anti-depressants, etc., and will indicate which drugs are, and are not recommended for use.

The guidelines below are available electronically via paid subscriptions.

• ACOEM guidelines: produced by the American College of Occupational and Environmental Medicine, and distributed through MDGuidlines/Reed Group.
• ODG (Official Disability Guidelines): produced by the Work Loss Data Institute.

Studies confirm that the use of clinical/duration guidelines results in measurable impact:

• Medical cost-savings of 25%-60% (by state, payer, TPA, and health plan)
• Average disability duration down 34%-66%, median duration down 30%

It should be noted that many states endorse or mandate specific guidelines to be used for formal utilization review and related medical management purposes, and typically either ACOEM or ODG have been selected by these states’ regulatory bodies. However, several states have developed their own sets of guidelines, which are freely available on state websites. Finally, some states are entirely silent on the subject of guideline selection. Consequently, it is important that guideline users be aware of the relevant regulations state-by-state, i.e. claim adjusters, utilization review and case management nurses, and physician reviewers.

Summary

• Evidence-based medicine is based on high quality, peer-reviewed research.
• Expert panels translate scientific data into applicable guidelines and update them regularly.
• Clinical AND duration guidelines should be integrated into WC medical management to the greatest extent possible

Jacob Lazarovic MD, Medical Advisor at Amaxx LLC, has considerable experience in managed care, including 18 years as chief medical officer at Broadspire , a leading TPA. His department produced clinical guidelines and criteria to support sound medical claim and case management practices; participated in analysis, reporting and benchmarking of outcomes and quality improvement initiatives; developed educational and training programs that updated the clinical knowledge and skills of claim professionals and nurses; provided expertise to enhances the medical bill review process; and operated a comprehensive and unique in-house physician review (peer review) service. He has been published extensively in industry journals and has held several senior medical management positions at companies including HealthAmerica, Blue Cross/Blue Shield of Florida and Vivra Specialty Partners

By Jacob Lazarovic, MD, FAAFP Senior Vice President and Chief Medical Officer, Broadspire

REVISITING SOME CONTROVERSIAL TOPICS

TAKING OUR PULSE

Practicing medicine, or making decisions about the appropriateness of treatment, and the presence and extent of disability, is not always a straightforward issue. How many times have you heard the “experts” change their minds about whether a certain vitamin is useful, or whether eggs and coffee are good or bad for you?

In our world, we also must confront controversial issues and ensure that we are adopting “best practices” based on the most current evidence-based medical research.

So today we will revisit a few ongoing issues, see what the prevailing wisdom is, and review our current approaches.

JUST WHAT THE DOCTOR ORDERED

1. Fibromyalgia

Fibromyalgia is not quite a disease, but rather a syndrome of various complaints involving fatigue, pains in muscles and other soft-tissues, and sleep disturbances. It doesn’t qualify as a disease because, to this point, there is really no firm evidence of any objective physical findings (that can be seen in lab tests, x- rays, tissue biopsies, etc.). It remains a largely subjective phenomenon.

There is debate about its cause, with proponents disputing whether it is a “brain” condition or a musculoskeletal one. Some scientists claim to have noted abnormalities on central nervous testing, such as MRIs. Others feel that is a psychological state akin to depression, which is why anti-depressants are often successfully used to treat it.

In 2013, one laboratory claimed to have discovered a blood test that can diagnose fibromyalgia, which would be a breakthrough. However, even though some insurance carriers now reimburse the test, many others consider it to be of unproven value, as do many researchers.

From our perspective the most important fact is that, regardless of what stance one takes on the above, there is certainly no evidence of an occupational causation. Consequently, our policy remains as follows, per our medical advisory on the subject:

FIBROMYALGIA MEDICAL ADVISORY

Medical Advisory:

Based on the above considerations, fibromyalgia, chronic fatigue syndrome (FM/CFS) and other related conditions, and treatments for such conditions, cannot be considered work-related. There is no evidence at all to substantiate any occupational factors or injuries as causative. The current best hypothesis is that FM/CFS, to the extent that it has “legitimacy as a discrete entity” represents a genetic pain sensitization phenomenon due to dysregulation of pain pathways related to atypical neurotransmitter levels. 

With respect to disability (functional impairment), this needs to be carefully evaluated based on objective evidence of physical and cognitive deficits. 

B)  Viscosupplementation (hyaluronic acid, HA) injections to the knee

These injections have been used for a long time to reduce the pain and stiffness of arthritic knees. They can be thought of as a “lubricant” that cushions the knee as the joint is in motion. However, there have always been skeptics questioning the effectiveness of this therapy.

Several recent studies, one of which is excerpted below, now validate this skepticism, demonstrating that there is no, or minimal, benefit from HA injections.

However, the Official Disability Guidelines (ODG) continue to recommend this therapy, although a very long list of utilization criteria must be met prior to approval. As further evidence is published, ODG may reconsider its stance on viscosupplementation.

Of course causality is also an important consideration. Knee osteoarthritis is a degenerative condition which, unfortunately, many of us will get, and not necessarily related to occupational activities. It typically affects multiple joints in the body and is thought to have a genetic predisposition as well. A careful analysis to determine whether the condition is genuinely causally related to an individual’s occupation is recommended.

ODG:

Recommended as an option for severe knee osteoarthritis (OA) for patients who have not responded adequately to conservative treatment (exercise, NSAIDs, corticosteroid injections), in order to potentially delay total joint replacement. Higher quality studies have shown the magnitude of improvement to be modest at best. While medial and/or lateral compartment OA is a recommended indication, there is insufficient evidence for other conditions including patella-femoral arthritis, chondromalacia patella, patella-femoral syndrome (kneecap pain), or osteochondritis dissecans. 

C)  Platelet Rich Plasma (PRP)

PRP is one of several blood products that can be extracted from a patient’s own blood, and then injected into a painful body part. In the case of PRP, the blood is concentrated to achieve a high number of platelets, which contain growth factors that, theoretically, when injected into damaged tissue, can help to heal and strengthen the involved area. It is commonly used for soft tissue injuries, although you may have noticed local newspaper ads in which medical entrepreneurs advertise its use for myriad conditions. Similar claims are being made for stem cell therapy.

Despite all the fuss, there remains no consensus that PRP or related therapies have meaningful benefit. Broadspire’s medical advisory, as well as the ODG, reinforce this view. The prevailing recommendation is that this therapy should be confined to rigorous clinical studies, and not used in the general population.

Medical advisory:

Blood product injection therapies are not recommended for certification/ authorization due to an absence of high-grade medical evidence permitting an evaluation or confirmation of the efficacy of this modality. There is currently insufficient evidence to support the use of these injection therapies.  Rigorous studies of sufficient sample size, using validated clinical, radiological and biomechanical measures and tissue injury healing response biomarkers are needed to determine long-term effectiveness and safety. 

BLOOD PRODUCT INJECTIONS MEDICAL ADVISORY 

ODG:  Platelet-rich plasma (PRP)

Not recommended for chronic pain except in a research setting. PRP therapies are more complicated than previously acknowledged, and an understanding of the fundamental processes and pivotal molecules involved will need to be elucidated. PRP therapies in clinical trials await assessment. Platelet-rich plasma (PRP) therapy is a recently developed technique that uses a concentrated portion of autologous blood to try to improve and accelerate the healing of various tissues. There is considerable interest in using PRP for the treatment of musculoskeletal disorders, particularly athletic injuries. Because PRP products are safe and easy to prepare and administer, there has been increased attention toward using PRP in numerous clinical settings. Platelet-rich plasma has been used to treat conditions such as lateral epicondylitis, ligament and muscle strains, and tears of the rotator cuff, anterior cruciate ligament, Achilles tendon, plastic surgery and other conditions. Platelet-rich plasma can be applied at the site of injury either during surgery or through an injection performed in the physician’s office. However, there is little published clinical evidence that proves its efficacy in treating the multitude of injuries/disorders that are thought to benefit from PRP. 

 
CIRCULATING IN THE PRESS 

More Insurance Companies Now Paying for Fibromyalgia Blood Test

“In 2013, Los Angeles-based biomedical company EpicGenetics made international headlines when it introduced FM/a, the first ever fibromyalgia blood test.

While FM/a hasn’t caught on in most doctors’ offices, more insurance companies are now paying for the test.

Dr. Bruce Gillis, EpicGenetics’ CEO, says the No. 1 reason patients get the test is to prove to family members and others that they are really sick.

He believes physician bias is the main reason why the test is not more widely used.

The legitimacy of fibromyalgia has been complicated for decades because of the lack of a diagnostic test to prove its existence. It’s typically a diagnosis of exclusion – meaning illnesses with similar symptoms have been ruled out through extensive (i.e. often expensive) medical testing.

We believe [the term] fibromyalgia is a misnomer, he says. These people aren’t suffering with anything that’s affecting the muscles, per say. What they are suffering with is their immune system cannot produce normal quantities of protective proteins. There are cells in the immune system called peripheral blood mononuclear cells. They are not producing normal quantities of the protective proteins called chemokines and cytokines.

EpicGenetics’ research and the FM/a test aren’t without critics. Fibromyalgia expert Dr. Daniel Clauw has said EpicGenetics’ studies contradict other research, which has shown normal or elevated cytokine levels in fibromyalgia sufferers.

Researcher and rheumatologist Dr. Fred Wolfe called one of EpicGenetics’ studies “junk science”, saying it didn’t meet minimal scientific standards.”

Viscosupplementation for Osteoarthritis of the Knee

“Knee osteoarthritis is responsible for a large burden of care and cost within health care. Osteoarthritis results from an imbalance between the breakdown and repair of articular cartilage in any joint and occurs as a result of multiple risk factors including mechanical overload (obesity, heavy lifting), trauma, overuse (repetitive knee bending), and genetic predisposition.

The CDC (U.S. Centers for Disease control and Prevention) reports that one in two individuals may develop symptoms of osteoarthritis in at least one knee by eighty five years of age.

In conclusion, this best-evidence systematic review assessing the clinical significance of outcomes involving pain relief and functional improvement does not support the routine use of intra-articular HA. In contrast to previous reviews, we found no significant evidence of publication bias in the studies that we selected for analysis. The patient benefit of intra-articular HA was not clinically important when compared with intra-articular saline solution injections used as a placebo. Subdividing HA preparations by molecular weight did not change the results of the analyses. Selecting the best evidence resulted in significantly reduced heterogeneity but did not change the outcome; no clinically important improvement in pain and other outcomes from a patient’s perspective was found.”

How effective are platelet rich plasma injections in treating musculoskeletal soft tissue injuries?

“Platelet-rich plasma (PRP) has become increasingly popular in sports medicine and orthopaedic practice as treatment for muscle, tendon, and ligament injuries, and has received media attention because of its promise as a regenerative therapy.

We argue that patients should only be offered PRP for musculoskeletal soft tissue injuries within the context of well-designed clinical trials, with informed consent, high quality verbal explanations, and supporting written information. Advise patients that there is currently insufficient evidence to show that it is effective treatment for musculoskeletal soft tissue injuries. Clinicians offering PRP should ask manufacturers for the evidence of the platelet and growth factor concentrations, the constitution, and the viability of their PRP product (platelet activation levels).”

Efficacy of Autologous Platelet-Rich Plasma Use for Orthopaedic Indications: A Meta-Analysis4

“The recent emergence of autologous blood concentrates, such as platelet-rich plasma, as a treatment option for patients with orthopaedic injuries has led to an extensive debate about their clinical benefit. We conducted a systematic review and meta-analysis to determine the efficacy of autologous blood concentrates in decreasing pain and improving healing and function in patients with orthopaedic bone and soft-tissue injuries.

The current literature is complicated by a lack of standardization of study protocols, platelet- separation techniques, and outcome measures. As a result, there is uncertainty about the evidence to support the increasing clinical use of platelet-rich plasma and autologous blood concentrates as a treatment modality for orthopaedic bone and soft-tissue injuries.”

****************

REFERENCES:

1. “More Insurance Companies Now Paying for Fibromyalgia Blood Test”, Donna Gregory Burch, http://nationalpainreport.com.
2. “Viscosupplementation for Osteoarthritis of the Knee”, David Jevsevar, MD, MBA, et al, J Bone Joint Surg Am. 2015;97:2057-60.
3. “How effective are platelet rich plasma injections in treating musculoskeletal soft tissue injuries?”, David Keene, et al, BMJ 2016;352:i517 doi: 10.1136/bmj.i517 (Published 17 February 2016).
4. “Efficacy of Autologous Platelet-Rich Plasma Use for Orthopaedic Indications: A Meta-Analysis”, Ujash Sheth, et al, J Bone Joint Surg Am. 2012;94:298-307.

About Broadspire®

Broadspire (www.choosebroadspire.com), a global third party administrator, offers casualty claim, medical management, disability and absence management solutions, and risk management information services, helping increase employee productivity and reducing the cost of risk through early  intervention, professional expertise and data analytics. As a Crawford Company, Broadspire is based in Atlanta; Ga. Services are offered by Crawford & Company under the Broadspire brand in countries outside the U.S.

By Jacob Lazarovic, MD, FAAFP Senior Vice President and Chief Medical Officer, Broadspire

TAKING OUR PULSE

The current measles outbreak in California, now rapidly spreading to at least 16 other states, is a reminder that infectious diseases still require vigilance, that vaccine-preventable infections may reappear if our compliance levels decrease, and that attention to adult immunization guidelines remains a priority in order to help prevent workplace disability.

First, let’s catch up on measles.

Measles is a highly contagious disease, transmitted by respiratory aerosols when an infected person coughs or sneezes. The virus can live for up to two hours on surfaces or in an airspace where the infected person coughed or sneezed. The incubation period ranges from 7-21 (average 10-12) days and an individual can pass the virus to others before feeling ill. The signs and symptoms of measles include: fever, malaise, runny nose, cough and conjunctivitis (“pink eye”). A raised, red rash typically appears ~3 days after onset of illness and the ill person continues to be infectious for about 4 days after the rash appears. The rash initially appears behind the ears and on the forehead, spreading down the neck, upper extremities, trunks, and lower extremities (including palms and soles). It may last for 5-7 days before fading. Complications from measles may include: middle ear infection, bronchopneumonia, croup, diarrhea, acute encephalitis, and death.
All suspected measles cases should be reported to county health departments immediately.

JUST WHAT THE DOCTOR ORDERED

The Centers for Disease Control and Prevention (CDC) has developed a comprehensive workplace health model containing several health promotion building blocks.

Adult immunization programs constitute one element of a systematic approach to workplace health.

Vaccine-preventable diseases are infectious diseases that can be prevented by immunization (vaccination). Traditionally, vaccines have been associated with protecting young children, but far too many adults become ill, are disabled, and die each year from diseases that could easily have been prevented by vaccines. Vaccines not only prevent disease in the people who receive them but often create “herd immunity,” meaning that even unvaccinated individuals are at lower risk of disease if most of their community is immunized. Everyone from young adults to older adults can benefit from immunizations.

Among vaccine-preventable diseases in adults, influenza has the greatest impact in the U.S. population.

• An average of 36,000 deaths and over 200,000 hospitalizations associated with influenza occur each year in the United States.
• The combination of influenza and pneumonia was the eighth leading cause of death among all persons in the United States in 2005, accounting for 63,000 deaths.
• The overall national economic burden of influenza-attributable illness for adults, age 18 years and above is $83.3 billion. Direct medical costs for influenza in adults totaled $8.7 billion including $4.5 billion for adult hospitalizations resulting from influenza-attributable illness.
• Influenza is also responsible for substantial indirect costs ($6.2 billion annually), mainly from lost productivity. Each year, among adults age 18 to 64 years, 17 million workdays are lost to influenza-related illness.

However, influenza is certainly not the only condition that is addressed in an adult immunization program. Based on recommendations from the National Advisory Committee on Immunization Practices (ACIP), current guidelines include:

• Diphtheria and tetanus (Td) booster every 10 years for persons younger than 65 years. One of the Td boosters should be replaced with tetanus/diphtheria/acellular pertussis (Tdap) to provide protection against pertussis (whooping cough).
• Influenza (annually for adults age 50 years and older)
• Human papillomavirus (HPV) for women ≤ 26 years of age
• Varicella (chickenpox) immunization (2 doses) for people with no evidence of immunity such as a history of varicella infection. Very few adults actually need the varicella vaccine because most adults had chickenpox as children
• Zoster (shingles) for adults age 60 years and older. Shingles can be extremely painful and debilitating.
• Pneumococcal (for adults age 65 years and older). One major change in the 2015 schedule is that it is now recommended that two types of pneumococcal vaccines be administered: the traditional PPSV23, as well as the newer conjugate vaccine, PVC13.
• Other immunizations, such as hepatitis A and B; pneumococcal (for persons younger than 65 years based on high risk conditions such as diabetes); measles, mumps, and rubella (1-2 doses for persons born after 1957); and meningococcal vaccines

http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule-easy-read.pdf

Business travelers going abroad should be aware of destination-specific initial vaccinations and boosters, as recommended by the CDC, to maximize protection from locally prevalent infections, e.g. hepatitis A and B, typhoid, rabies, polio, yellow fever, meningitis, encephalitis and others.

Health care workers also have special needs with respect to their immunization schedules, related to potential blood-borne exposures.

Employees should encourage and facilitate employees’ compliance with the ACIP immunization guidelines, and employees should discuss this with their primary care physicians to ensure a safe and effective vaccination protocol.

CIRCULATING IN THE PRESS

“Anti-Vaccine Movement Causes Worst Measles Epidemic in 20 Years”

by Steven Salzberg, Contributor, Pharma & Healthcare, 2/1/15, Forbes.com.

Measles is now spreading outward from Disneyland in California, in the worst outbreak in years. The epidemic is fueled by growing enclaves of unvaccinated people.

The CDC reports that in just the past month, 84 people from 14 states contracted measles, a number that is certainly an under-estimate, because the CDC doesn’t record every case. California alone has 59 confirmed cases, most of them linked to an initial exposure in Disneyland. A majority of people who have gotten sick were not vaccinated.

For years, scientists (including myself) have warned that the anti-vaccination movement was going to cause epidemics of disease. Two years ago I wrote that the anti-vaccine movement had caused the worst whooping cough epidemic in 70 years. And now it’s happening with measles.

Finally, though, the public seems to be pushing back. Parents are starting to wake up to the danger that the anti-vax movement represents to their children and themselves.

What’s sad about this – tragic, really – is that we eliminated measles from the U.S. in the year 2000, thanks to the measles vaccine.

But we had 644 cases in 27 states in 2014, the most in 20 years. And 2015 is already on track to be worse. Measles may become endemic in the U.S., circulating continually, thanks to the increasing numbers of unvaccinated people. Until now, each outbreak was caused by someone traveling from abroad and bringing measles to us. The anti-vaccine movement has turned this public health victory into defeat.

Anti-vaxxers have been relentless in the efforts to spread misinformation. Despite overwhelming scientific evidence that vaccines are beneficial, they endlessly repeat a variety false claims, such as:

• Vaccines cause autism. They don’t.
• The preservative thimerosal in vaccines causes autism. It doesn’t.
• Natural immunity is all you need. It isn’t. Measles infects 90% of people exposed to it unless they are vaccinated.
• A healthy lifestyle will protect you from measles. It won’t.

Where does this breathtaking science denialism come from? It’s been building for years, as I and many others have written. The wave began with a 1998 paper published in The Lancet by Andrew Wakefield, claiming that the MMR vaccine was linked to autism. Wakefield’s work was later shown to be fraudulent, and his claims about the vaccine “dishonest and irresponsible.” After lengthy investigations, the paper was retracted and Wakefield lost his medical license. Despite this very public repudiation, Wakefield has stuck to his claims, though, and has spent much of the past 15 years speaking (or perhaps “preaching” would be a better term) to anti-vaccine groups, to whom he is a kind of folk hero.

Make no mistake, measles is a very dangerous infection. In the current outbreak, 25% of victims have ended up in the hospital. And it is extremely infectious: the CDC’s Schucha explained that: “You can catch it [measles] just by being in the same room as a person with measles even if that person left the room because the virus can hang around for a couple of hours.”

About Broadspire®

Broadspire (www.choosebroadspire.com), a global third party administrator, offers casualty claim, medical management, disability and absence management solutions, and risk management information services, helping increase employee productivity and reducing the cost of risk through early  intervention, professional expertise and data analytics. As a Crawford Company, Broadspire is based in Atlanta; Ga. Services are offered by Crawford & Company under the Broadspire brand in countries outside the U.S.

By Jacob Lazarovic, MD, FAAFP Senior Vice President and Chief Medical Officer, Broadspire

First let’s review the acronym glossary. Accountable Care Organizations (ACOs) were stimulated by the Patient Protection and Affordable Care Act (PPACA). A cousin of the ACO model is the patient‐centered medical home (PCMH) model. And these, and similar delivery systems, are often described as value‐ based healthcare (VBH) models.

While similar to managed care models of yesteryear, VBH models comprise three critical elements:

1. The medical entity bears financial responsibility for the health care needs of a defined population, employing shared savings and risk arrangements that “align the incentives” among all stakeholders.
2. The entity coordinates and oversees the clinical provision of care across the continuum of all services required for the population being served.
3. The entity provides measured outcomes relating to both cost and health, ideally achieving both medical expense reductions and superior clinical results.

It is recognized that successful ACOs require both a sophisticated administrative infrastructure to manage care effectively, as well as robust information technology systems that collect data seamlessly across the system and deliver meaningful reporting and analytics.

In the inaugural issue of the American Journal of Accountable Care, the authors describe their mission as follows:

“In this time of contention, there seems to be a growing consensus among stakeholders that the traditional, volume‐based, fee‐for‐service (FFS) care is an untenable strategy to deliver evidence‐based care that is both fiscally sustainable and able to meet the clinical needs of Americans. As we look for a solution to an overspending, underachieving system, the concept of “accountable care” has received much attention as a potential mechanism to better align provider financial incentives with high‐quality care.”

ACOs have proliferated rapidly since their inception in 2010. As of June 2014, there are said to be 626 ACOs across the country, of which 329 have government contracts, 210 have commercial contracts, 74 have both, and 13 are in development. It is estimated that 20 million Americans are currently covered by ACO agreements. There is considerable variation in these statistics, as reported by multiple sources.

A recent article documents furious activity in this sector, involving major health payers such as Aetna, Cigna, United Healthcare, multiple Blues plans, and Humana, among others.

Humana also reports that its ACO business, as broadly defined, is taking off. “Today we have well over 900 relationships with provider entities that we call ‘accountable,’ ” says Renee Buckingham, enterprise vice president for the provider development center of excellence within Humana’s healthcare services segment. That includes joint ventures, medical homes and integrated delivery systems. Of the total, approximately 100 or so relationships are commercial, according to Buckingham.

Structurally ACOs come in many configurations: “if you’ve seen one ACO, you’ve seen one ACO”. They may be owned by hospitals, physician groups, or integrated systems. They may provide all services internally, or outsource some services to affiliated entities. The risk/savings may be shouldered by the entity as a whole, or flow downward to some or all participating providers.

Generally, ACOs and similar VBH arrangements are intended to provide comprehensive medical services, “population‐based care”. However, there are also initiatives underway which apply this approach to  more granular sets of services, referred to as “bundles” or “episodes of care”. Bundled care is sometimes considered to be a stepping stone toward fully accountable care for a defined population, i.e., a way station on the continuum from fee for service, to pay for performance, to shared savings and bundling, then ultimately arriving at the goal of full capitation.

“Bundled payments encourage providers to collaborate on improving the efficiency and quality of individual care episodes, honing in on the unit cost of care. Two key features of the bundled payment create these incentives. First the lump sum payment is shared among participating providers, establishing mutual accountability. Second, the bundled payment is typically smaller than the sum of historic individual payments, generating upfront savings for the payer. As a result, providers can only succeed under bundled payments by reducing input costs and growing volumes to offset the reimbursement cut per case.

In a bundled payment program, providers ultimately succeed by reducing input costs and improving quality during individual episodes of care. As a result, hospitals will develop gainsharing models to reward physicians for standardizing high‐cost implantable device and care protocols. If readmissions are included in the bundle, hospitals will work to streamline patient handoffs across the care continuum and engage patients post‐discharge to reduce readmission risk.”

The Centers for Medicare & Medicaid Services (CMS) has taken the lead in establishing a program of this type:

“On January 31, 2013, the Centers for Medicare & Medicaid Services (CMS) announced the health care organizations selected to participate in the Bundled Payments for Care Improvement initiative, an innovative new payment model. Under the Bundled Payments for Care Improvement initiative, organizations will enter into payment arrangements that include financial and performance accountability for episodes of care. These models may lead to higher quality, more coordinated care at a lower cost to Medicare.

Traditionally, Medicare makes separate payments to providers for each of the individual services they furnish to beneficiaries for a single illness or course of treatment. This approach can result in fragmented care with minimal coordination across providers and health care settings. Payment rewards the quantity of services offered by providers rather than the quality of care furnished. Research has shown that bundled payments can align incentives for providers – hospital, post‐acute care providers, physicians and other practitioners – allowing them to work closely together across all specialties and settings.”

Of the 48 bundled packages established by CMS to date, 14 of these deal with orthopedic procedures commonly required in workers compensation settings. For example one package is entitled “cervical spine fusion” which encompasses DRG groups 471‐473, and could include all hospital services as well as all related physicians (surgeon, anesthesiologist, radiologist, etc.).

The drawback of episodic arrangements is that while they can favorably impact the quality and cost metrics of each specific bundle, they do not per se address the utilization/frequency of these services, i.e., how many cervical fusions are being performed in the population.

Early results of VBH arrangements are promising, though not consistently so, both within CMS shared savings programs, and as reported by commercial payers. Total medical expenses have been reduced, as well as the rate of hospital admissions and emergency room visits.

“A March 2013 Commonwealth Fund report, exploring the experiences of seven ACOs, found that the most advanced ACOs saw reductions or slower growth in health care costs and had anecdotal evidence of care improvements. The ACOs in the report that had been at financial risk long enough to see results have cut costs, primarily from reduced hospitalizations, lower spending per hospitalization and reduced spending on specialty and ancillary care. Newer ACOs lacked enough financial data to cite concrete results, but some saw improvements in utilization rates, such as fewer inpatient days, lower length of stay and greater patient engagement.”

An exhaustive Rand Corporation research report evaluated the success of three types of VBH models: pay for performance, ACOs, and bundled programs, and concluded that definitive results are simply not available at this time.

“VBP programs are natural experiments and inherently difficult to evaluate because program sponsors rarely withhold the VBP intervention from a matched group of providers to see what would have occurred absent the intervention. There are many weaknesses in the methods often used to evaluate P4P (and now the broader class of VBP programs), including reliance on pre‐post comparisons with populations of providers that are substantially different from the treatment group, and failure to account for other factors that may be contributing to the observed results.

The application of performance‐based payment models represents a work in progress regarding how best to design VBP programs to achieve desired goals, the optimal conditions that support successful implementation, and provider response to the incentives. We believe that continued innovation is desired at this early stage of VBP development and implementation. Concerted efforts will be required to ensure that the lessons learned from these experiments are identified and disseminated to advance the use of VBP as a strategy for improving federal and private health care programs.”

Do these alternative medical models offer opportunities to redesign the prevailing model of delivery and financing in workers compensation? It would seem that bundled arrangements would be easier to implement than population‐based models, and furthermore they would more closely match the nature  of WC events which are inherently episodic, not holistic.

Several barriers to WC application of these models exist. Historically, WC has been a volume‐driven, fee‐ for‐service model, and expectations and attitudes would need to be reformed. A pattern of micromanagement of all medical services would need to be altered, by increased delegation to provider entities. And the plethora of state regulations, dealing with reimbursement and direction of care, among others, would need to be overhauled to facilitate these approaches.

Specific recommendations offered include:

Providers/ACOs: Be receptive to closer partnership with workers compensation and group health insurers. Be prepared to embrace additional risk sharing and the occupational medicine expertise that will be required to maintain fast return‐to‐work.

Workers compensation insurers: Set up the proper risk sharing models, reduce the administrative burden, stop micromanaging physicians, and instead build networks that include only physicians who have proven they can support good health outcomes. Evaluate closer partnerships with healthcare insurers and employers, especially those that have integrated.

Regulators: Consider accelerating adoption of outcome‐based arrangements in workers compensation by providing legislative incentives for these programs.

Despite the bumps along the way, many observers feel that the future shape of medical care delivery and financing is inevitable.

“The development of the accountable care movement will be determined by early results. The majority of ACOs are using shared savings models, and most are committed to evaluating their financial returns for 2 to 3 years before moving away from these payment arrangements. ACO leaders speak of a desire to improve the value they provide, but they are hesitant to adopt any wholesale movement away from FFS‐based billing as they are not fully convinced that full provider risk and capitation/bundling is the inevitable conclusion of the accountable care movement. In the short term, however, providers are continuing to experiment with new payment models and new approaches to providing and coordinating care. The end result of the ACO movement, particularly relating to provider risk and reimbursement, is still undecided, but the consensus among these organizations is that the value‐based focus of accountable care is here to stay.”

Interesting times lie ahead.

Jacob Lazarovic, MD, FAAFP

Dr. Lazarovic is Senior Vice President and Chief Medical Officer for Broadspire, a Crawford Company, and a leading global third party administrator of workers compensation and disability claims. Dr. Lazarovic is a board‐certified family physician, and experienced medical administrator. He completed his medical training and residency at McGill University in Montreal, and subsequently practiced family, emergency, and geriatric medicine while teaching in a residency program.

At Broadspire, Dr. Lazarovic directs the Medical Department which produces clinical guidelines and criteria that support sound medical claim and case management practices; participates in analysis, reporting and benchmarking of outcomes, and quality improvement initiatives; develops educational and training programs that update adjusters’ and nurses’ clinical knowledge and skills; and provides expertise which enhances the medical bill review process. Additionally, the Medical Department operates a comprehensive in‐house physician review (peer review) unit that contributes to effective utilization and case management decisions, promotes the appropriate use of medical services, and facilitates timely return‐to‐work through communication with treating physicians.

The Medical Department also carries out and publishes original research and development on issues relevant to workers compensation and disability.

About Broadspire®

Broadspire (www.choosebroadspire.com), a global third party administrator, offers casualty claim, medical management, disability and absence management solutions, and risk management information services, helping increase employee productivity and reducing the cost of risk through early  intervention, professional expertise and data analytics. As a Crawford Company, Broadspire is based in Atlanta; Ga. Services are offered by Crawford & Company under the Broadspire brand in countries outside the U.S.

References:

• The Accountable Care Paradigm: More than Just Managed Care 0. David Muhlestein, et al., Leavitt Partners, 2013

• “Accountable Care Organizations: Looking for Answers to an Overspending, Underachieving System”. American Journal of Accountable Care, Mark Fendrick, MD, et al., December 12, 2013.

• Growth and Dispersion of Accountable Care Organizations: Matthew Petersen, et al, Leavitt Partners, June

• “ACO squeeze: How much can they really save?” Judy Packer‐Tursman, Managed Healthcare Executive, August 5, 2014

• “Bundled payment a stepping ‐stone for ACOs? I don’t buy ” Rob Lazerow, The Advisory Board Company, www.advisory.com

• Bundled Payments for Care Improvement (BPCI) Initiative: General Information. Centers for Medicare and Medicaid Services, http://innovation.cms.gov/initiatives/Bundled‐Payments/

• Succeeding as an ACO: A 6‐Step Guide for Health Care Organizations, Athenahealth, July 2013

• Measuring Success in Health Care Value‐Based Purchasing Programs. Cheryl L Damberg, et , 2014 Rand Corporation

• Bringing Value‐Based Healthcare to Workers Compensation. Prashanth Gangu, et , Oliver Wyman, January 2014

• “Risk Bearing and Use of Fee‐for‐Service Billing Among Accountable Care Organizations”. David Muhlestein, JD, MHA; et al., American Journal of Managed Care, 2013, Vol. 19, No. 7