What the New CDC Opioid Guidelines Will Mean to Work Comp

Not much, I fear.  Allow me to explain...

What the CDC has done here is critically important to addressing the public health crisis that is opioid misuse and abuse.  While the CDC's process came under scrutiny (from, among others, me), the resulting guidelines are evidence-based, well-written, and carry the imprimatur of the preeminent public health agency in this country.  That's groundbreaking.  But I'm not sure we're going to see a significant impact in workers' compensation for three reasons.

Before we dive in, here's a link to the guidelines.
Here's a link to Dr. Tom Frieden's (CDC Director) letter regarding the guidelines in NEJM.
And here's perhaps the most practically valuable thing the CDC published earlier this week - a checklist for primary care physicians who prescribe opioids (this is excellent).

Reason #1 we're unlikely to see a significant impact in work comp: It takes a long time for new medical evidence to penetrate actual physician practice.  The guidelines have received a lot of press coverage over the last few days, but busy primary care physicians may not be immediately responsive to new medical evidence even if they see it on the front page of the local newspaper. First, not all physicians have the same faith in an agency of the federal government that I possess.  In fact, for some, the notion that the federal government published these guidelines may be the primary source of skepticism.  Second, there will armies of pharma reps to gently, diplomatically, but firmly push back, find holes, work arounds, etc. to increase the likelihood that current prescribing practices remain intact.  Third, there are obviously no enforcement mechanisms in connection with these guidelines.  A primary care doc who chooses not to follow them will face no immediate consequences (though, we should be clear, the long term consequences to the patients of such a doctor could be catastrophic).

Reason #2: Our primary cost drivers in work comp are long term, chronic pain cases.  The new guidelines offer precious little guidance for these types of cases.  Most of the guidelines focus on opioid initiation and to the extent chronic opioid therapy is addressed, the guidelines suggest avoiding it.  Well... what if we have an injured worker who has been on opioids for that past 10 years?  Whose dose has escalated regularly and dangerously over that period?  The guidelines suggest those opioids should be weaned.  Right.  Telling a primary care doc to simply wean a patient off of opioids in the midst of a long term, complicated, polypharmacy drug regimen is perhaps expecting too much.  I would have liked to have seen more detailed guidance on how to deal with such complex patients.  So why didn't the CDC go there?  Because it's really complicated, that's why.

Reason #3: Primary care docs, by and large, didn't create most of our pain management issues in work comp.  Granted, I'm dealing with a very skewed subset of cases here at PRIUM.  I recognize we suffer from adverse selection, so this might not be accurate for the entirety of the work comp universe.  But what we see is that surgeons and pain management specialists tend to initiate complex pain management drug regimens (after the profitable procedural work is done) and then, in perhaps the most unkindest cut of all, the patient is discharged back to the primary care doc... who is now overwhelmed by a monster of a drug regimen that he did not create.  Yes, primary care docs write almost 10 times more opioid scripts per year (28 million) than pain management and interventional pain management doctors combined (3 million), but will these new guidelines - aimed at primary care docs - help them much if they're not the ones making the initial prescribing decision?

I'm thrilled the CDC published these guidelines.  I think they represent useful, cogent, and practical thinking.  And I hope I'm wrong that we won't see a material impact in work comp.

Michael
On Twitter @PRIUM1 (just click the link to follow!)

The Judge, The Doctor, The Patient: Who Should Decide?

Why is it that we have such a hard time in workers' compensation breaking free of the concept that judges shouldn't be making medical decisions?  And why do the judges making these decisions fail to recognize the unintended (and negative) consequences of their actions?

Enter Judge Donald Johnson of the 19th District Court in Louisiana.  Judge Johnson recently ruled that the state's approach to dispute resolution surrounding injured worker treatment requests is unconstitutional based on the fact that patients are being deprived of due process rights.  Since 2011, treatment requests from workers injured in Louisiana that are denied by utilization review are ultimately adjudicated by the medical director at the Louisiana Office of Workers' Compensation (OWC).  This way, a physician ultimately decides the applicability of the guidelines given the individual injured worker's clinical circumstances.

Judge Johnson has now suggested we go back to judges making these decisions instead.  I call it a "suggestion" because his decision isn't being enforced until the Supreme Court weighs in (likely some time in the next year).

And the usual suspects have taken their usual positions:

Payers are obviously displeased.  Medical costs had decreased and disability benefits had stabilized in the last few years in Louisiana.  The medical treatment guidelines and dispute resolution process put in place in 2011 appeared to be working.  

Plaintiff's attorneys are celebrating the decision.  Now that they have a shot at going back to the old way of resolving treatment disputes (i.e., requesting a hearing with an administrative law judge at the OWC), there's increased likelihood of care being delivered that's not in alignment with evidence based medicine.  Forget that several defense attorneys have observed that the new process actually resolves disputes faster than the hearing/ALJ approach.

This happens again and again as reforms are enacted to move medical decisions away from judges and back with doctors (where they belong).  Judges routinely attempt to take that power back.  Recall this same debate in California over the Dubon decision?  

Injured workers are best served by medical doctors making medical decisions.  Sometimes, that will involve multiple medical doctors: the treating physician, a peer reviewer, and perhaps the medical director of OWC.  And those doctors may not agree with one another.

But isn't an informed dialog and exchange of information among a group of physicians a vastly superior way to reach the right medical decision than relying on a judge to collect medical opinions, and with no medical expertise, decide which opinion should prevail?  

Michael
On Twitter @PRIUM1

Fear Not, Be Smart: How to Deal with Medical Marijuana

The headline from workcompcentral today is Comp Industry Urged to Prepare for Medical Marijuana.  As usual, it's a solid and informative article from a great source (and I'm not just saying that because PRIUM's own Mark Pew is quoted throughout).  Nonetheless, I'm always concerned when I hear talk of medical marijuana that takes on a foreboding and troubling tone.  I'm sure Sedgwick's Mr. Canavan meant no harm.  And I have to admit that I wasn't present.  But comments like, "You can blame New Mexico the next time you pay for medical marijuana" strike me as fodder for filling hotel ballrooms at conferences and not reflective of the actual medical and legal realities with which we're dealing.

Back in April, I wrote the following:

"Did you know that of the 24 states with medical marijuana laws, most have either explicit or implicit provisions allowing for commercial payers to avoid reimbursement for medical marijuana?

Did you know that most of these states have a list of allowable conditions that provide a second layer of potential protection for commercial payers? 

Did you know that most of these states have medical treatment guidelines that address the use of medical marijuana?

Did you know that the New Mexico cases that have most of our industry concerned about this issue exhibit systemic failure on the part of the payers in those cases to take advantage of these various provisions and protections?" 

So let's all take a deep, cleansing breath.  If we're smart about this - if states are thinking about evidence based guidelines and payer carve outs, if payers are thinking about UR and peer review, if doctors are thinking about what's best for patients - we can keep medical marijuana in the box in which it belongs.  Mark Pew is right that the legalization of medical marijuana is inevitable and the advent of recreational marijuana is upon us.  But the risk management issue should be in the areas of drug-free work place issues and on-the-job safety.  

When it comes to injured worker treatment, we're not suggesting that medical marijuana is a non-event that deserves no attention.  We're suggesting that smart payers with smart medical management strategies need not fear being overwhelmed with medical marijuana spend.  

Michael 

On Twitter @PRIUM1

Guidelines That Matter, Part 2

Michigan is in the midst of developing opioid guidelines that matter (and yes, some guidelines matter more than others).  Guidelines that matter are specific, based on clinical evidence, and are tied to reimbursement.  Any guidelines that don't meet those criteria are mere suggestions that only help ensure the safety of injured workers in the most extreme circumstances (e.g., when a judge finally says to a doctor and patient, "that's enough with the opioids..." - and we all know how hard and expensive it is to get to that point).  Guidelines that matter exist within a regulatory structure and dispute resolution process that allows for mitigation of patient safety concerns without consistent involvement of judges.  Medical professionals should be able to work out these differences based on rational discussion and evidence based guidelines.

Michigan has taken a huge leap toward such an approach with the proposed draft of rules developed by the Health Services Committee of the state's Workers' Compensation Agency.  Paul Kauffman from Accident Fund chaired the committee and several other devoted members worked along with him for over a year on these draft guidelines.

Voices of dissent have cropped up, predictably from plaintiff's attorneys that fear this is simply a mechanism to take away needed medications from injured workers.  I don't think that's the case here.  Candidly, Michigan is a state where it's far too hard to ensure injured worker safety and far too easy for injured workers to remain on dangerous levels of opioids for too long.  These guidelines clearly aren't aimed at people who genuinely need pain management therapy.  Rather, these guidelines are aimed at ensuring the safe and effective use of these medications.

In an effort to provide some transparency to the discussion, here's the exact proposed language.  In it, you'll find a list of best practices all doctors should follow.  You'll also find that doctors can be reimbursed for checking the state's prescription drug monitoring database.


Rule 1008a. (1) In order to receive reimbursement for opioid treatment beyond 90
days, the physician seeking reimbursement shall submit a written report to the payer
not later than 90 days after the initial opioid prescription fill for chronic pain and every
90 days thereafter. The written report shall include all of the following:
 (a) A review and analysis of the relevant prior medical history, including any
consultations that have been obtained, and a review of data received from an automated
prescription drug monitoring program in the treating jurisdiction, such as the
Michigan Automated Prescription System (MAPS), for identification of past history of
narcotic use and any concurrent prescriptions.
 (b) A summary of conservative care rendered to the worker that focused on increased
function and return to work.
 (c) A statement on why prior or alternative conservative measures were ineffective or
contraindicated.
 (d) A statement that the attending physician has considered the results obtained from
appropriate industry accepted screening tools to detect factors that may significantly
increase the risk of abuse or adverse outcomes including a history of alcohol or other
substance abuse.
 (e) A treatment plan which includes all of the following:
 (i) Overall treatment goals and functional progress.
 (ii) Periodic urine drug screens.
 (iii) A conscientious effort to reduce pain through the use of non-opioid medications,
alternative non-pharmaceutical strategies, or both.
 (iv) Consideration of weaning the injured worker from opioid use.
 (f) An opioid treatment agreement that has been signed by the worker and the
attending physician. This agreement shall be reviewed, updated, and renewed every 6
months. The opioid treatment agreement shall outline the risks and benefits of opioid
use, the conditions under which opioids will be prescribed, and the responsibilities of
the prescribing physician and the worker.
 (2) The provider may bill the additional services required for compliance with these
rules utilizing CPT procedure code 99215 for the initial 90 day report and all
subsequent follow-up reports at 90-day intervals.
 (3) Providers may bill $25.00 utilizing code MPS01 for accessing MAPS or other
automated prescription drug monitoring program in the treating jurisdiction.
R 418.101008b Denial of reimbursement for prescribing and dispensing opioid
medications used to treat chronic, non-cancer pain.
 Rule 1008b. Reimbursement for prescribing and dispensing opioid medications may
be denied, pursuant to the act. Denial of reimbursement shall occur only after a
reasonable period of time is provided for the weaning of the injured worker from the
opioid medications, and alternative means of pain management have been offered.

Judge for yourself.

Michael
On Twitter @PRIUM1