Texas Closed Formulary: So Far, So Good... But What About the Legacy Claims?

Warning: anecdotal evidence only contained in this post.  I’m as data-driven a professional as you’ll come across, so it pains me a bit to share a thought or two not entirely supported by a spreadsheet, but…

Many of the work comp PBM professionals I talk with on a regular basis have indicated that the new “closed formulary” rules in Texas appear to be stemming the flow of prescription narcotics to newly injured workers.  The number of pre-authorization requests being processed is less than was expected (in some cases, far less than what was expected).  Too early to draw conclusions, but leading indicators point to a potentially disappointing (though not terribly surprising) fact:  the mere adoption of the new rules appears to have altered physician prescribing habits. 

Not that the nature of industrial injuries has changed.  Not that the disposition of the individual patients is different.  Not that new medical evidence has emerged.  No, the state of Texas said, “you have to ask first” and the docs have quietly acquiesced, silently acknowledging that the care being rendered prior to the adoption of the rules was inappropriate. 

So kudos to Texas.  This is a rare example of effective formulation and implementation of public policy to begin addressing a major issue in the work comp space. 

Emphasis in that last sentence should be on the word “begin.” While the new rules appear to be having an effect on new injuries, little attention has been paid to the parts of the new rules addressing legacy claims.  Employers and carriers have to begin addressing those legacy claims no later than March of 2013 in preparation for the application of the closed formulary to those claims starting in September of 2013.  Smart payers won’t wait that long. 

The rules specifically outline a procedure that facilitates payers proactively reaching out to treating providers to discuss these legacy cases, rationalize the pharmaceutical regimen in light of evidence-based guidelines, and document the agreed-upon treatment plan to ensure no interruption of therapy in September of 2013.  Given the number of claimants in Texas currently being prescribed N drugs, I think that NOW is the time to start addressing those claims.

Look for a forthcoming white paper on this topic from my colleague and co-blogger, Mark Pew. 

- Michael
On Twitter @PRIUM1