Closed Formulary, Coming Soon to Your State?

There's little doubt that the Texas closed formulary rules (instituted for new injuries as of 9/1/11 and forthcoming for all claims as of 9/1/13) is having it's intended impact.  Opioid scripts have dropped, spending on medication therapy has dropped, and prescription habits are clearly changing.  Washington State and Ohio, both monopolistic work comp systems, have also implemented closed formularies with apparent benefit (both clinical and financial). 

This morning's article in WorkCompCentral on California's forthcoming efforts around prescription drug management opens the door for the concept in California as well.  CA Insurance Commissioner Dave Jones explicitly suggested that a closed formulary concept should be explored.  This would make California only the second non-monopolistic state to adopt such an approach.

Obviously, we're a long way from the state legislature passing and the governor signing any such bill, not to mention the time it would take for DWC to implement such a measure.  In Texas, House Bill 7 - which called for the closed formulary to be implemented - was passed and signed in 2005; the rules went into effect in September of 2011.  Nonetheless, the notion isn't as far-reaching in California as it might appear. 

When plotting the potential geographic adoption of closed formulary concepts around the country, my view is that we're most likely to see such rules adopted in states that share several characteristics.

First, closed formularies will be particularly attractive in states that have a significant opioid issue.  California certainly fits this criteria.

Second, states that already have medical treatment guidelines with which the provider community is used to complying will find the concept of a closed formulary easier to swallow.  When Texas opted to use Appendix A of the Official Disability Guidelines, there was little push back.  ODG has been the guideline set governing care for Texas work comp patients for several years now.  California has its own Medical Treatment Utilization Schedule, but these guidelines are weak on opioids.  Interestingly, Department of Industrial Relations Director Christine Baker admitted as much to a panel of California lawmakers yesterday.  She noted that updating these guidelines is a "top priority" for DWC's panel of medical advisers.

Third, closed formularies will be most easily negotiated in states that already have clearly supportive utilization review (UR) statutes and regulations.  I recently reviewed the Texas rules as part of an education session in a non-UR state and suggested that I thought it might be a good idea for this particular state to give it a try.  Several audience members reacted quite negatively with one particular gentleman suggesting that all of the state's doctors would immediately cease taking work comp patients.  If your state doesn't have experience with UR, jumping right to a closed formulary is a tough sell to the provider community.  In California, UR is nothing new, though it's not a mandate like it is in Texas.  Nevertheless, I believe it's still a good leading indicator that adoption is possible.

Fourth, the state's politicians must exhibit the political will to adopt measures that are clinically and financially necessary, but not necessarily popular - particularly among physicians.  There are others in our industry who know far more about California politics than I, but I'm not convinced that a closed formulary concept wouldn't be changed beyond all recognition as it worked it's way through the deal making, negotiating, and bargaining that is a matter of course in Sacramento (and in many other state capitals around the country). 

California lines up well with respect to recognizing the opioid issue, moving toward more effective guidelines, and having plenty of experience with utilization review.  The open question: will the politics allow it to happen? 

Michael
On Twitter @PRIUM1

Addiction, Patient Rights, and Law Suits

The text of Nevada Senate Bill 75, authored by State Senator Tick Segerblom, is simple.  Here it is in it's entirety:

1.  Notwithstanding any provision of law, a person who suffers injuries as a result of an addiction to a prescription drug may bring and maintain an action for damages against:
a) The manufacturer of the prescription drug.
b) The provider of medical care who prescribed the prescription drug, if the provider of medical care knew or should have known of the person's addiction to the prescription drug. 
2. A person who prevails in an action brought pursuant to this section may recover his or her actual damages, including, without limitation, any costs associated with rehabilitation for the addiction, attorney's fees and costs of any punitive damages that the facts may warrant.
3. [definitions]

That's it.  Pretty straightforward.  But at the same time, incredibly complicated. 

To be clear, I'm in favor of the concept.  Patients that suffer the consequences of iatrogenic disease (including addiction... perhaps especially addiction) should have recourse against the responsible physician.  Addiction is a well-defined and legitimate diagnosis.  If a patient exhibits symptoms of addiction and the physician misses them or refuses to acknowledge them, that physician should bear responsibility for the consequences to the patient. 

That said, such broad language as included in Senate Bill 75 leaves lots of unanswered questions.  If the doctor is to blame, where does the liability of the drug manufacturer come into play?  How does such legislative language align with work comp's exclusive remedy?  What would passage of such a bill do to malpractice insurance?  I'm sure the plaintiff's bar loves this idea, but how do we separate the wheat from the chaff? (There will be no shortage of frivolous suits driven by this law).  Plus the hudreds of other questions you're thinking of right now as you read this...

I'm not sure that Senate Bill 75 is the panacea some hope that it will be.  But it's a bold suggestion in the face of a major public health issue. 

Michael
On Twitter @PRIUM1

Opioid Abuse: Is there a Role for Self Management?

Today brings a guest post from PRIUM's Founder and CEO, Jim Pritchard. 

There is little argument with the statement that injured workers are suffering from a high incidence of opioid abuse.

With such widespread recognition of the problem, why is it so hard to correct?  A partial explanation is reflected in the erosion of the “no fault” intent of workers' compensation.  We want the problem to be fixed back to the pre-incident status without cost to the injured worker (which is reasonable) and without effort (which is not).

Perhaps this is reflected by society’s perception of health.  Our society has tacitly defined health as indemnification against cost of health care procedures as well as our own poor personal choices, not just being of “sound mind, body and spirit”.  In my view, this is patently false.  Real health is a personal responsibility not a physician responsibility.  There is so much money (public and private) in this system with so many stakeholders continually attempting to gain their share of that money that we are encouraged and many times required to abdicate responsibility for our own health.

In workers' compensation, this is reflected by the attitude that the injured worker is indemnified against not only cost but also any pain, discomfort or effort in the recovery from incident or injury.  There are just too many perverse incentives at play.  Secondary gain, a busted legal system and little motivation to get back to work are just a few of such conflicting incentives. 

We at PRIUM have seen thousands of narcotics abuse cases.  Of these cases, obesity is the number one co-morbidity.  Psychological and other issues are frequently seen and mismanaged as part of the work incident, but obesity is still number one.  We all know that obesity brings with it a myriad of other co-morbid conditions such as hypertension, hyperlipidemia, diabetes, reduced level of activity, etc.  All of these issues tend to create a set of confounding variables that seriously complicate management of the case. Both narcotics and obesity tend to reduce desire for mobility which is probably the single best therapy for typical musculoskeletal workers' compensation injuries.

Instead of addressing this co-morbid condition (which admittedly requires an uncomfortable conversation), too many physicians increase dosage and medications to the detriment of the patient’s overall health.  We hear all too often “the patient is stable with a reduced pain score” as sole rationale for long term prescription of opioids.  We lose focus on function thereby creating a vicious cycle of reduced activity, increased caloric intake, feeling less well about one’s self, increased hypertension, potential onset of diabetes and more pain.  Removing these confounding variables should be pre-requisite to considering long term use of opioids for chronic pain.

In order to address this pandemic of prescription opioid abuse we must educate the patient as to the high risk and questionable benefit of long term opioid therapy in chronic pain treatment.  Patients must have sufficient information in order to exercise a responsible role in the decision making process for their own health.  Unfortunately, many in the physician community have displayed poor performance in addressing opioid abuse without such shared responsibility.

So, to answer the original question (why is opioid abuse so hard to fix?), not only should there be a role for self management in addressing opioid abuse, it should be a requirement.

JAP
On Twitter @PRIUM1

Medical Bills Are Killing Us

Normally, I find that Time Magazine isn't worth the paper on which it's printed.  Pretty cheap paper, too.  But the cover story of the February 20th issue caught my eye: Bitter Pill - Why Medical Bills are Killing Us. 

As I began to read the piece, I realized that this wasn't a typical, four-page, gloss-over-the-subject cover story.  This was 30 pages of in-dept analysis that took the author, Steven Brill, seven months to research, analyze, and synthesize.  The article balances the power of the anecdote with the realities of the data.  The conclusions are alarming.  For those of us that have spent a career in health care, the data, the stories, and the intricacies of the system are not news.  But Brill's cover story shines a light in a heretofore dark space for the vast majority of health care consumers in this country. 

This is the first mainstream piece of journalism I've read in which the concept of the illusive "chargemaster" is discussed in great detail.  The utter lack of logic on which the chargemaster is based is just the beginning of the problem.  The real issue is that a great deal of the negotiating that goes on between hospitals and insurance companies revolve around this massive database of fundamentally arbitrary codes and prices.   This isn't a fact most of us have to worry about - unless you are uninsured or underinsured.  Brill sums it up this way: "If you are confused by the notion that those least able to pay are the ones singled out to pay the highest rates, welcome to the American medical marketplace." 

Of particular interest to most regular readers of this blog will be the story of the $49,237 spinal cord stimulator from Medtronic.  Not a typo.  The patient was actually charged nearly $50k for a SCS (and this was for the device itself and did not include the outpatient surgery charges, the physician charges, or the blankets and surgical gown for which the patient was also charged).  And for those of you paying bills in the work comp space based on fee schedules driven off of Medicare rates, there's a lot of discussion about how CMS sets those rates and what it means for providers. 

We've spent a lot of time in this country over the last several years arguing about how to pay for growing medical costs.  I'm not going to weigh in on that debate.  But I do appreciate Brill's view on the subject: "When we debate health care policy, we seem to jump right to the issue of who should pay the bills, blowing past what should be the first question: Why exactly are the bills so high?"

Worth a read. 

Michael
On Twitter @PRIUM1

Patient Education: Opioid Basics

PRIUM has put together a simple, one-page (front and back), graphically intensive, easy-to-understand education piece aimed at patients on opioid therapy for chronic pain.  We're offering this resource absolutely free of charge to anyone who wishes to use it: injured workers, adjusters, nurses, physicians, attorneys, etc.  While the PRIUM logo is shown on the page, we'd be happy to share an alternative version that doesn't contain our logo - just ask and we'll send it your way. 

You can find our patient education brochure here.

We spend a lot of our time here at PRIUM on the concept of education.  We conduct continuing education for claims professionals and clinicians.  We deliver informal education within the context of every peer-to-peer intervention we perform.  One of the purposes of this very blog is general industry education.  But we hadn't yet developed anything to engage the injured worker.  And that wasn't for lack of trying.  We had grand ideas about web sites, interactive tools, self-assessment techniques, etc. 

Then Dr. Pamella Thomas, our Medical Director, shared a glaring and critical insight about the need to create patient education that is simple.  Her rule: if the patient can't get through it while sitting on the toilet, it's probably not going to help.

Special thanks to Dr. Thomas for developing the content and to Marketing Works for turning the content into an engaging infographic. 

If this leads to even a single patient asking a single question that leads to better treatment of chronic pain, the effort will have been worth it.

Michael
On Twitter @PRIUM1