Tuesday, April 30, 2013

On My Desk: A Litany of Legislation

The past couple of weeks have seen a significant number of legislative and regulatory efforts that warrant the attention of anyone working in our industry.  I couldn't decide which one to dig deeply into first, so here's an overview of what's sitting on my desk.  Look for deeper dives into each one over the next couple of weeks.

Florida has managed once again to snatch defeat from the jaws of victory in the battle over repackaged medications.  Senate Bill 662 (and companion House Bill 605) stipulate a compromise approach to pricing for repackaged drugs - 112.5% of the original manufacturer's AWP plus an $8 dispensing fee.  Setting aside for a moment the lack of logic behind differential pricing models for pharmacies and physicians, the larger impact of the legislation will be felt from the repeal of 440.13(12)(c) which smart payers were using to re-price these repackaged medications.  Senator Alan Hays is celebrating the compromise and while I give him credit for leading the fight over the last several years, the outcome is not a victory for Florida payers. 

Minnesota is attempting to update its approach to long term use of opioids.  Senate Bill 1603 (and its companion House Bill 1799) call for the adoption of "rules establishing standards for health care provider treatment."  Such rules are already in draft form and could quickly follow the adoption of the legislation.  Rules could govern such practices as opioid agreements between doctors and patients, frequency and content of follow up visits, and referrals to pain management specialists.

New York is asking for comment on newly proposed medical treatment guidelines for non-acute pain.  Comments are due by June 10.  At first glance, the guidelines appear comprehensive (the document is 90 pages with a sole focus on non-acute pain management).  The question will be: are they sufficiently specific to actually make an impact in prescribing behavior. 

Last, but certainly not least, is Oklahoma's Senate Bill 1062 (all 556 pages of it).  While I do not believe the adoption of this bill will lead to either widespread "opting out" within Oklahoma or widespread adoption of similar legislation in other states, it's nonetheless indicative of broader systemic issues and frustration around the workers' compensation. 

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Monday, April 15, 2013

Medical Treatment Guidelines: Evidence vs. Consensus

Senate Bill 200 is all but signed into law in Tennessee.  The bill brings broad reform measures to the state, some of which were desperately needed (e.g., the creation of an administrative dispute resolution system that will largely relieve the civil courts of the burden of work comp fights) and some of which will be deeply contentious (e.g., the revised definition of AOE/COE that will surely shift a material number of injuries that might have been covered by work comp historically into the commercial/group health insurance market). 

One seemingly minor point caught my eye.  The law gives the newly created position of Administrator of Division of Workers' Compensation, appointed by the governor, the charge to adopt medical treatment guidelines for the diagnosis and treatment of workplace injuries.  These guidelines need to be in place by January 1, 2016.  Assisting the Administrator in this task will be a medical advisory committee which will be assembled as soon as the law goes into effect and will expire on July 1, 2015.  Assuming the committee is formed over the next several months, it appears they'll have approximately two years to adopt medical treatment guidelines.

Two years? 

If Tennessee isn't careful, they'll end up with a Louisiana-like approach to the development and adoption of medical treatment guidelines - a process so fraught with lobbying, special interests, law suits, and covering of tracks that sections of the resulting guidelines more closely resemble instructions for Medtronic spinal implants than actual medical treatment guides. 

The choice for Tennessee's medical advisory committee is simple: they can choose evidence-based guidelines or consensus-based guidelines.  While it sounds reasonable that a group of Tennessee-based medical experts should assemble themselves and consider all stakeholder views to develop a set of guidelines for which there exists broad acceptance... the reality is that good politics often leads to bad medicine.  Before the citizens of Tennessee realize what's happening, lobbyists from pharma, medical device, and physician constituencies will take pen to paper to write sections of the guidelines - as a service, of course, to the very busy committee members. 

Instead, the role of the medical advisory committee should be to debate which set of existing, off-the-shelf, evidence-based, nationally recognized, constantly updated guidelines should be adopted by the state in their entirety with no edits, additions, or subtractions driven by special interests.  This will be tougher to accomplish politically, but will lead to the best, most consistent, most credible, and most reliable clinical and financial outcomes for the work comp system. 

(Note: See Texas.  This works.) 

On Twitter @PRIUM1