The latest study from CWCI suggests that implementation of a Texas-like or Washington-like formulary could produce substantial savings in the CA work comp system on the order of $124-$420 million. I was extremely impressed with the detailed methodology CWCI developed. Not only did they dig into the formularies at the NDC level and build the analysis from the bottom up, Alex Swedlow and team also created a model that incorporates the effects of drug substitution in light of formulary implementation. And it's not an overly simplistic approach, either. They use the Medispan GPI number to assess the likelihood of substitution for drugs not included on the formulary. The reader of this report learns more than just dollars and cents in CA; some of the key take-aways relate to the vast differences between the TX and WA approaches. Bottom line: the report is educational and insightful and should be required reading.
There's just one major variable the report doesn't include: politics.
That's not a shot at CWCI - that's not their role, their mandate, or their mission. But I couldn't help look at the numbers and think, "there's no way a closed formulary concept survives a fight in Sacramento." I'm always encouraging people to avoid cynicism and here I am dishing it out. But it's hard to imagine a politically diverse state like CA (was that diplomatic enough?) implementing something remotely close to what Texas did (a much more politically homogeneous state) or what Washington did (a monopolistic work comp system). Keep in mind that even in Texas, the legislation that called for the creation of a closed formulary was signed into law in 2005. Full implementation of that closed formulary finally occurred in 2013. That's 8 years of regulatory wrangling in a state where less than 10 percent of injured workers are represented by attorneys and employers need not bother with work comp at all if they so choose.
On the other hand, we learned this morning from the Oregon Workers' Compensation Premium Rate Ranking Summary that California is the most expensive state in the country. While there has always been a lot of debate about the methodology of this annual report, perhaps it's enough to create the burning platform CA so desperately needs to get a handle on medical costs.
Michael
On Twitter @PRIUM1
Michael:
ReplyDeleteThanks for the post. There is no question that politics can sometimes get in the way of real solutions. PBMs have been using formularies to identify and alert payers of potentially dangerous medications but oftentimes confusing or complex regulations can get in the way of using that information to better influence the care received by injured workers. In defense of Texas, it wasn't politics that delayed the implementation of the closed formulary. It was really a matter of practical reality. The reform bill passed in 2005 had a host of new initiatives, many of which, like treatment guidelines, needed to be completed before the closed formulary could be implemented. And, to the Texas DWC's credit, they spent a year traveling around their state educating physicians on the closed formulary in an effort to change prescribing patterns. They also engaged stakeholders at every step of the reform process. Texas leveraged the politics to accomplish positive change with broad support of the stakeholders. That, I believe, is the key reason the closed formulary in Texas has been so successful. In the case of Texas, the politics actually worked to bring people together to solve critical problems.