The Brady Bunch

Thursday, December 20, 2012 | 0

California's Commission on Health and Safety and Workers' Compensation met on Dec. 14 in Oakland.

New CHSWC appointee Martin Brady was elected CHSWC chair for 2013.

Brady has served as executive director of Schools Insurance Authority since 1988, so to say he knows his way around the California comp system is an understatement. Brady succeeds outgoing chair Angie Wei of the California Labor Federation.

What's up at CHSWC? That's always worth noting, as CHSWC has been ground zero for reform ideas in California's workers' comp system.

Christine Baker, director of the Department of Industrial Relations (and former CHSWC executive officer), gave the first presentation. She stated that SB 863 had helped "avert a crisis" in California workers' comp and asserted that the bill is a "balanced tradeoff" between increasing benefits and controlling costs.

Baker also noted that the Brown administration will monitor the law as the law and regulations take effect and that they "stand ready to make adjustments" if need be.

Of particular interest was Baker's comments on Labor Code 139.48, the new $120 million return-to-work fund that was added to the bill during the final negotiations over SB 863 after Teamsters, Machinists, Los Angeles Firefighters and a few other unions insisted on further changes in the bill.

Baker indicated that she is working with Rand on ideas about how the fund should be allocated and administered. She indicated that the goal is to target payments to workers who don't return to work and whose actual percentage of wage loss is more severe than expected losses for workers with similar injuries.

She noted that Rand had been contracted to do an analysis of this and that the study is due mid-2013, with proposed regs coming sometime thereafter and then time for public comment. Baker observed that there was ample time to develop this since the DIR is taking the position that the fund under 139.48 applies only to post-1/13 injuries and that it would be a while before earnings losses will be determined for those injuries.

Baker also noted that the fund will probably require workers to document both pre and post injury earnings data. However, Baker did not reveal any other significant details about how the fund might be administered or exactly what periods of post earnings losses would be required.

The focus then shifted to opioids.

Concern about opioids has been growing nationally and the issue is clearly on the CHSWC radar. The concern is threefold: opioid deaths and non-fatal overdoses, opioid costs and opioid diversion.

CHSWC has been looking at the issue and in this session heard a presentation on how opioid guidelines might be adopted. The topic was outlined in a Powerpoint presentation by Dr. Teryl Nuckols.

Nuckols is co-author with Allison L. Diamant, MD; Ioana Popescu, MD; Laura Anderson and Roger Chou, MD, of a study "Identifying Risky Opioid Prescribing Practices" that has now been posted on the CHSWC website (see bottom of this post).

CHSWC has also posted an Aug. 30, 2012, memo that summarizes the evaluation of guidelines for the use of opioids to treat chronic pain.

In her presentation, Nuckols, who is an associate professor of internal medicine at the University of California, Los Angeles and a Health Services Researcher at the Rand Corp., concluded that the most rigorously developed guidelines available on the use of opioids to treat chronic pain are the guidelines of the American Pain Society and the American Academy of Pain Medicine (AP-AAPM) and the Canadian guidelines for safe and effective use of opioids for chronic non-cancer pain, developed by the National Opioid Use Guideline Group.

What is on the minds of the CHSWC members? Here's a rough summary (not verbatim quotes) of some of the issues that were raised:

Member Sean McNally of Grimmway Farms asked about the possibility of restricting which physicians could prescribe opioids to make sure that those medications are distributed appropriately.

Nuckols noted that providers could be selected and profiled but acknowledged some concerns about making sure patients were not penalized on access issues.

Doug Bloch of the Teamsters Union asked why opioids are prescribed more frequently in workers' comp than in group health settings. Nuckols noted that this is complicated and may be in part due to when the treatment occurs, or as a result of some variations in geographic regions, where physicians trained, and so on, as well as some secondary gain issues.

Martin Brady noted concern about opioids appearing in schools if they are diverted.

CHSWC member Faith Cuthbertson raised questions about the effects of urinary drug testing.

Doug Bloch queried how California tracks drug diversions and overprescribing.

Angie Wei asked whether opioid use results where there is a failure to address and treat the underlying cause, with Nuckols noting that there are lots of chronic pain conditions where there is no easily identifiable cause.

Among those who testified in response was Mike Nolan of the California Workers' Compensation Institute, who noted the work that CWCI's Alex Swedlow has done on the issue. Nolan, who mentioned the issue of creating a drug formulary, challenged the notion that opioids are used more frequently in workers' comp because they are "sicker patients," noting that there are several studies which challenge that notion.

Representatives from the California Medical Association and the California Chiropractic Association testified. The CMA's message is that any reform should be carefully done so that patients are not denied access to care.

The chiropractors argue that opioid use has expanded because the system now has a bias in favor of pharma. More workers now rely on meds to control their pain and limitations on chiropractic and physical therapy has resulted in more workers with medication-related gastrointestinal problems, ulcers, and kidney and liver failure.

Another presentation to the commission was from Frank Neuhauser of UC Berkeley. Neuhauser, a frequent consultant for CHSWC, summarized a draft experience modification study done in conjunction with Rand Corporation's Center for Health and Safety in the Workplace. The study, co-authored by Seth Seabury of RAND and John Mendeloff, is titled "The Impact of Experience Rating on Small Employers: Would Lowering the Threshold for Experience Rating Improve Safety?"

The X-mod study has been posted online for public comment.

The opioid study can be found here.

The memo on evaluation of opioid prescribing guidelines can be found here.

Julius Young is a claimants' attorney with the Boxer & Gerson law firm in Oakland. This column was reprinted with his permission from his Workers' Comp Zone blog.