Y doesn’t necessarily mean Yes

As readers of this blog know, I am keenly interested in the Texas Closed Formulary (TCF) and the effect those rules have on treatment and prescription behavior.  My January 2012 whitepaper documented a more than 50% reduction in the use of “N” drugs (as classified by ODG’s Work Comp Drug Formulary) for claims requiring preauthorization on dates of injury on or after 9/1/11.  Other sources subsequently documented similar or even greater reduction in the use of “N” drugs for new injuries.

Since February I have been seeking input as to what is happening with that 50% not using “N” drugs.  There is no consensus but many theories, including:

1. Switching to more conservative therapy
2. Switching to “Y” drugs
3. Switching to interventional methods like injections or nerve blocks
4. Cost shifting to the injured worker’s group health policy or Medicare/Medicaid
5. Injured worker paying for the drugs themselves
6. It was a statistical anomaly that will even out over time

After attending two conferences last week, I get the feeling that option 2 (switching to “Y” drugs) is largely misunderstood by non-clinical people in Work Comp.  I have even heard of physicians asking the DWC to tell them what “Y” drugs they can prescribe instead of the “N” drugs.  In this particular case, “Y’ does not equal “Yes”.

The ODG drug formulary applied a Status of “N” if the drug is not recommended as first-line treatment and preauthorization is recommended to assess their appropriateness and necessity.  A drug with a status of “Y” is a preferred drug for first-line therapy.

For example, all benzodiazepines (alprazolam, clonazepam, diazepam, lorazepam, temazepam, etc.) have an “N” status.  All non-prescription analgesics (acetaminophen, ibuprofen, naproxen) have a “Y” status.  For oxycodone opioids, OxyIR is a “Y” while Oxecta (recommended for patients with risk of abuse but not as first-line therapy for other patients) and OxyContin (second-line therapy due to issues of abuse and Black Box FDA warnings) are “N”.  But just because OxyIR is “Y” doesn’t mean it is medically appropriate as it still needs to meet the criteria of opioid treatment (conservative therapies and less potent analgesics were unsuccessful in controlling pain, risk management pre-screening has been completed for opioid use, etc.).

Other opioids that are “Y” include Suboxone (Buprenorphine), Codeine, Duragesic (Fentanyl) patches, Vicodin and Lortab (Hydrocodone/APAP), Dilaudid (Hydromorphone), Levo-Dromoran (Levorphanol), Morphine, Embeda (Morphine ER), Percocet (Oxycodone/APAP), Ultram (Tramadol), Ultracet (Tramadol/APAP).  If you have been involved in Work Comp, you probably recognize many of these drugs, and probably question their use in cases.  And that is my point.  Just because the drug is a “Y” in ODG, or not included in ODG’s formulary (i.e. non-FDA approved), does not mean they are automatically medically appropriate.

In this together – Mark

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