Monday, December 17, 2012

Florida Medical Association: Predictable, but Still Disappointing

The Florida Medical Association (FMA) has decided, according to Florida State Senator Alan Hays, to oppose forthcoming legislation intended to remove the economic incentive for physicians to dispense medication.  The language of the bill is likely to mirror the language found in SB 668 from this past year's legislative session. 

The bill will not, in fact, restrict the rights of physicians to dispense medications but rather will focus on eliminating egregious billing practices by forcing physicians to essentially mirror the state fee schedule when they do choose to dispense medications to patients.  Given that we've seen virtually no evidence that such restrictions have resulted in either access or compliance issues for patients, this seems like something that should enjoy broad support.

While the FMA has refused public comment, Senator Hays indicated that FMA's opposition is based on the organization receiving "a significant number of emails objecting to the bill and saying it would diminish doctors' ability to dispense drugs." 

Maybe the FMA should read SB 668.  Or wait until Senator Hays submits his bill for the forthcoming legislative session.  And then maybe the FMA could help facilitate progress by educating its membership on the language of the legislation and helping doctors to understand that, by exploiting loopholes and artificially inflating drug prices, they are not doing themselves any favors.  Perhaps FMA could act strategically by helping doctors understand that the short-term economic windfall they are experiencing may not be in the best interests of the patient.

On the other hand, the FMA could stake out premature and thoughtless positions driven by what I hope is an uninformed minority of its membership. 

Senator Hays thinks he has the votes either way, so let's do what we can to help him.

On Twitter @PRIUM1

Thursday, December 13, 2012

Opioids and Cancer: Adding Risks to the List

As if we needed additional reasons to help injured workers avoid the detrimental effects of long term opioid use... we can now add cancer to the list.

A study published in the journal Anesthesiology and led by University of Chicago researcher Patrick Singleton has shown that opioids can enhance the malignant tendencies of cancer cells.  The study suggests that the same mu receptor cells that enable the powerful pain relieving effects of opioids are also present in cancer cells and, when opioids are present, can influence the progression and spread of cancer. 

Interestingly, this is good news in the oncology community.  The article states: "In a series of labortaory studies, Drs. Singleton and Moss found that drugs which blocked the mu opioid receptors reduced cancer growth in animals and helped prevent further invasion and spread of cancer cells.  Further, tumors did not grow in mice that lacked the mu opioid receptor."

Of course, I can't help but think about the inverse.  How many injured workers might (emphasis on might) experience more rapid cancer growth due to the abundance of opioids being taken? 

Granted, the studies thus far are all bench science - no human trials have been conducted.  But the body of evidence continues to grow regarding the dangers inherent in long term opioid use. 

On Twitter @PRIUM1

Tuesday, December 4, 2012

Managing the Managers Who Manage Managed Care

That's not a typo.  That's the challenge of contemporary workers' compensation claims management.  Part of the cynicism and frustration in workers' comp today is driven by the backward incentives and cumbersome statutory constraints of the system.  But another important driver of frustration is the rather complicated managed care infrastructure we've created for ourselves (albeit unintentionally).  As an artifact of the regulatory process in most states, work comp is now rife with the time lines and technicalities of MPNs, UR, BR, PPOs, IMEs, WCJs, ALJs, ADLs, AOE/COE, DOIs, MMIs, and lots of other acronyms that make injured workers and payers alike crazy. 

Commercial and government health plans grapple with some of these constraints, but work comp is a universe all its own when it comes to navigating a claim from start to finish (if, in fact, getting to a proverbial "finish line" is possible).  Others far more experienced than I could probably walk through the detailed history of the development of all of this, but I've simplified it (mostly so I can understand it) to the following: The grand bargain of work comp (a.k.a. the exclusive remedy) is not static.  In fact, it is dynamic and its evolution is marked by legislative and regulatory measures designed to rebalance the bargain when economic realities demand it.

When a state engages in "work comp reform", what that state is essentially doing is "rebalancing the bargain" because the economics of the current system are, in some material way, out of whack.  This is incredibly difficult to do given the micro and macro economic forces at work both within and outside of the work comp system and the special interests that attempt to influence the outcome of the effort.  Sometimes, the bargain tips too far toward the payer/employer... sometimes it tips too far toward the injured worker. 

Regardless of which direction the scale tips, there is no panacea for claims management.  On the other hand, the level of cynicism in work comp is creating blind spots in the claims management process that lead to missed opportunities for positive outcomes.  I find too many assumptions about bad doctors, unmotivated claimants, greedy lawyers, and ineffectual judicial processes.  All of these exist, no doubt.  But opportunities for progress are missed when we assume that engagement and discussion won't move the needle.

Let's engage the participants in the system not in new ways, but rather the old fashioned way.  Let's take the processes, time lines, and technicalities of managed care and call those "Plan B" (they have a place and we need to use those tools when necessary).  And let's develop a "Plan A" that's focused on simply communicating with each other about the best path forward to achieve the clinical and financial outcomes we all want. 

We've forgotten how to talk with each other. 

On Twitter @PRIUM1

Wednesday, November 28, 2012

Pain and Patient Satisfaction Surveys

Consumerism is all around us, particularly at this time of year.  The last decade has introduced a new level of consumerism in health care in various forms: high deductible plans that encourage choice of lower price providers, public and private agencies publishing hospital safety and efficacy data, and of course, the concept of patient satisfaction and its accompanying surveys, consequences, and controversies. 

I used to be a hospital strategy consultant and I've seen hospital leaders grapple with the concept of patient satisfaction.  On the one hand, there appears to be a correlation between patient satisfaction and overall health outcomes for an institution.  On the other hand, an individual patient's definition of "satisfaction" can be shockingly misaligned with the appropriate care pathway. 

Perhaps no better example of this can be found than in the area of chronic pain treatment.  The patient wants the pain to go away.  The doctor (unfortunately and all too often) wants the patient to go away.  The harsh reality of treating chronic pain: once all the surgeries and procedures have been tried, there isn't much money to be made in maintenance care.  (The exception, of course, is the physician who dispenses drugs from his office, creating one of healthcare's most obvious, most egregious, and most perverse incentives).

The best way to deal with this set of circumstances and keep the patient "satisfied" is to write another set of prescriptions.  Better yet, just call it into the pharmacy and have the patient go pick it up. 

I was encouraged to see Dr. Zachary Meisel and Dr. Jeanmarie Perrone take a stand on this topic in a piece that wrote for Time magazine:

"Medical guidelines already state that doctors shouldn’t be choosing opioids for most patients with chronic pain. But we doctors also need to start scaling back on prescribing opioids for acute pain, since some acute pain turns into chronic pain. Everyone with new pain should be started on a high dose of ibuprofen (like Motrin or Advil) or acetaminophen (like Tylenol). These medications have been proved to work as well as the opioids even for conditions like gall-stone attacks. For some patients, we can add a prescription for a limited number of opioid pills to be filled only if absolutely necessary. With that small prescription should come a big warning. Something like: 'These drugs are highly addictive, even in short-term use. These drugs have been associated with death, even in therapeutic dosing. These drugs, when accidentally ingested by children, are fatal.' As doctors, we must stop fearing patient-satisfaction surveys and talk honestly to our patients about pain. It may take an extra few minutes, but it will save lives."


On Twitter @PRIUM1

Tuesday, November 27, 2012

Pennsylvania Supreme Court Saves Patient's Life

The Pennsylvania Supreme Court saved a patient's life last week.  Interestingly, the court accomplished this great feat by doing nothing. 

Linda Turner was injured on the job in December of 1987.  She underwent two surgical procedures and was diagnosed, over a number of years, with arachnoiditis, failed spinal fusion surgery, small fiber neuropathy, chronic pain syndrome, discitis, osteomyelitis, spinal stenosis, and mood disorder.  Her treatment, in May of 2009, consisted of Fentanyl 125 mcg patch every three days and Fetanyl 600 mcg lozenge four times a day for breakthrough pain.  I'll save you the math... that's about 400 mg morphine equivalents per day. 

Her employer conducted utilization review on the treatment and the lozenges were found to be unnecessary and unreasonable care.  This finding was not based on assessment of functionality or objective clinical evidence of sources of pain (as is often the case), but rather on the addictive nature of the medication, it's FDA approved indications (palliative care for late stage cancer patients), and the risk to the patient.  A Workers' Compensation Judge (WCJ) denied Turner's petition for review of the UR decision. 

The Workers' Compensation Appeals Board then reversed the WCJ, finding that the employer did not satisfy its burden of proving the Fentanyl lozenges were not reasonable and necessary. 

On appeal, the Commonwealth Court of Pennsylvania reversed the Board and reinstated the WCJ's denial of petition for review of the original UR decision. 

Last week, the Pennsylvania Supreme Court declined to hear Turner's appeal, thus giving credibility to the UR process, leverage for employers in Pennsylvania to avoid payment for unnecessary and unreasonable care, and saving Linda Turner's life (despite the fact the she probably doesn't realize it now).

The section of the Commonwealth Court's opinion I found most illuminating was on page 10:  "Further, in determining the reasonableness and necessity of a prescribed medication, it is entirely appropriate for a UR reviewer to consider the risk to the patient.  In other words, a UR reviewer may consider whether it is reasonable and necessary for a provider to expose a patient to the level of risk presented by a medication." 

Funny... all of us are in the "risk management" business.  Yet we often overlook the risks inherent in the treatment of these injured workers.  I hope more states take the view that PA has taken - risk to life and limb of the patient, even at the hands of a qualified physician, needs to be weighed when assessing the reasonableness of care. 

On Twitter @PRIUM1

Monday, November 19, 2012

Opioids for Chronic Pain: Modern-Day Bloodletting

I came across an amazing piece today written by Malcolm Butler, MD, Medical Director at Columbia Valley Community Health Services in Washington State.  This should be required reading for all of us doing battle in the trenches of the opioid epidemic. 

A link to the full piece is here.  In summary, Dr. Butler confronted the central challenge of his clinic by taking proactive steps to eliminate medically inappropriate opioid prescriptions from his practice.  He sums up the results of the initiative as follows:

"Here is what we have learned:
  1. After 15 years of trying to follow published standards of high quality pain management,
    1. There is NO evidence that opioids improve outcomes in chronic pain.
    2. There is good evidence that opioids impair social function, contribute to behavioral comorbidities, and decrease function.
    3. Opioids are excellent for acute pain but are just the wrong tool for chronic pain.
    4. It makes about as much sense to treat chronic pain with alcohol as with opioids. Both will help pain in the short run. Both will cause new and more difficult challenges in the long run.
  2. By asking every patient about pain at every visit, we had “medicalized” pain.
    1. Pain is a normal component of everyday life – it is not an anomaly requiring treatment.
    2. Pain is a protective reflex. It galvanizes us to improve and change. Removing it does the opposite, allowing us to become victims and to stagnate.
  3. As we have weaned our patients down on their opioids – nothing has changed. The patients who were working while taking 400mg a day are still working when taking 100mg a day. Those who were lying on the couch while taking 400mg a day are still lying on the couch while taking 100mg a day.
    1. There appears to be a dose above which more opioids don’t improve function in chronic pain – and it must be pretty low, as we still haven’t found it.
    2. As we have decreased the volumes of opioids we prescribe, bad behavior of all types has decreased within the clinic. Whereas the OOC used to review 6 cases per month, we now review 2 cases every 3 months.
  4. Chronic pain is a mélange of nociceptive pain, emotional pain, boredom, and anhedonia – all of which feel better on opioids, and all but one of which are made worse by chronic opioids.
      1. Acute pain is almost entirely nociceptive pain, and is well managed with opioids.
      2. Chronic pain is amplified and prolonged by the use of opioids."
This is what it takes.  Courage, transparency, honesty... and the ability to say NO.
On Twitter @PRIUM1

Thursday, November 15, 2012

Tennessee Follow Up: Fumble Recovered

I was able to speak with someone at TDOL regarding my post this week on SB 3315.  While TDOL acknowledges that the interpretation of the statute as I outlined was at one time accurate, the current TDOL interpretation is now much more in line with the legislative intent of the bill. 

Any Schedule II, III, or IV drug prescribed for pain management for more than 90 days will be subject to utilization review. 

Several pieces of good news here:

1)  TDOL is listening.  I was very pleased with the transparent and candid nature of my discussion with my contact there.  TDOL is really trying to get this right and wants to be a resource not just to injured workers, but to employers and carriers doing business in Tennessee. 

2) The state has, in fact, created a statutory framework for addressing opioid dependence.  That doesn't mean this is simple (a single adverse UR determination for someone on oxycodone for the past five years doesn't fix the issue), but it does mean progress is possible if employers and carriers are prepared to offer a clinically responsible path to weaning these medications. 

3) My contact at TDOL has no direct knowledge of any impending rule-making process; doesn't mean there won't be one at some point, but for now we all need to operate on the basis of the language in SB 3315.  So let's get to work.

One note: despite this strengthened UR statute in TN, I'm still a believer in UR as a "Plan B".  Plan A ought to be a voluntary, collegial, evidence-based engagement with the treating physician to explore alternative treatment.  The time frames and technicalities of UR should only be deployed when attempts at real clinical engagement have failed. 

And for those that have heard rumors (or had specific experience) with regard to adverse UR determinations being overturned by TDOL, my understanding is that this has been driven largely by the date range issue (the 90-day clock starting ticking on July 1 even if the patient had been on opioids for years previous to July 1).  Some payors apparently jumped in too early. 

Progress in Tennessee. 

On Twitter @PRIUM1

Death Benefits: More (Disturbing) Case Law

This morning's workcompcentral brings news of a Washington state decision that, in short, upheld surviving spousal benefits in light of an accidental death caused by a combination of six different medications and alcohol.  I'm not an attorney and won't dive into specifics (the article is here, the court decision here, and the dissent is here), but I was struck by two overarching facts:

First, this is just the beginning.  The work comp industry is going to see more and more accidental overdose deaths and courts are more likely than not to award death benefits as a result.  This is going to be expensive and has already caused some insurers and excess carriers to exit the work comp market.  Aggressively intervening in chronic pain cases with complex drug regimens is imperative or your claims organization is going to face liabilities not contemplated when the policy was underwritten. 

Second, note that the original 2004 claim for back injury was, in fact, closed.  And at the time the claim was closed in March 2005 (with no award for permanent partial disability), the injured worker was only taking ibuprofen.  Two years later, at 37 years old, the injured worker's wife found him dead.  Cause of death was determined to be accidental; the injured worker's blood alcohol level was actually lower than the state-presumed intoxication level, but traces of oxycodone, citalopram, desmethylcitalopram, alprazolam, Nortryptyline, amitriptyline, carbamazepine, Promethazine, and acetometophen were found in his system.  Quite a cocktail. 

The court determined that the causal link between the original injury and the accidental overdose had not been broken - not by the claim's closure, not by the time elapsed, not by the alcohol use, not by the mix of drugs consumed.  One could rationally argue, as the dissent in this case does, that the causal chain was, in fact, broken.

I happen to agree with the dissent.  But you know what?  Doesn't matter. 
Get ready to start paying more benefits related to accidental overdoses, perhaps even on claims you think are closed and never to be heard from again.

On Twitter @PRIUM1

Tuesday, November 13, 2012

Tennessee and Opioids: Fumble at the Goal Line

(An update to this post is available here).

I was as excited as anyone this past summer when Tennessee’s legislature passed Senate Bill 3315.  SB 3315 amends the definition of Utilization Review to explicitly include Schedule II, III, and IV drugs being used for pain management.  Specifically, the bill states “it is the intent of the general assembly to ensure the availability of quality medical care services for injured and disabled employees and to manage medical costs in workers’ compensation matters by eradicating prescription drug abuse through the employment of the system established by subsection (a) to review any health care provider prescribing one (1) or more Schedule II, III, or IV controlled substances for pain management to an injured or disabled employee for a period of time exceeding ninety (90) days from the initial prescription of such controlled substances.”  Pretty clear legislative intent. 
Elsewhere in TN regs (specifically Chapter 0800-02-06.05 of the General Rules of the Workers’ Compensation Program), the circumstances under which mandatory UR can be invoked are clearly outlined: “The parties are required to participate in utilization review under this Chapter whenever a dispute arises as to the medical necessity of a recommended treatment.”

So, this should be simple.  Any opioid prescribed for pain management for more than 90 days should be subject to utilization review, allowing for a 3rd party assessment of medical necessity and offering the payor community a statutorily recognized path to rein in opioid abuse.  Great news. 

If only that were the interpretation being offered by the Tennessee Department of Labor (TDOL)…   We’re hearing from several of our TN customers that SB 3315 is being misinterpreted by TDOL. 
There are several other components of SB 3315 among which is a section that states “If a treating physician determines that pain is persisting for an injured or disabled employee beyond an expected period for healing, the treating physician may either prescribe, if the physician is a qualified physician as defined… or refer, such injured or disabled employee for pain management encompassing pharmacological, non-pharmacological and other approaches to manage chronic pain.” 

Apparently, TDOL is unwilling to consider an otherwise valid UR determination unless:
1)      The treating physician has first documented that the pain has persisted “beyond an expected period for healing”; and

2)      The referral to a “qualified physician” has occurred and that physician has reached the same conclusion (that the pain has persisted “beyond an expected period for healing”); and

3)      An additional 90 days have elapsed.
I see several issues.
First, I’ve read SB 3315 over and over… and I have no idea how TDOL could stitch together these requirements, particularly based on the clearly stated legislative intent.
Second, the path outlined here relies entirely on a treating physician, who in many cases caused or at least contributed to the opioid dependence, to suddenly concede that his treatment might not be working after all… despite the increasing dosage of opioids and the addition of half a dozen companion drugs over the last 5 years.  Never.  Going.  To.  Happen.

Third, there are no statutorily recognized treatment guidelines in TN.  How is the “expected period of healing” to be determined by the physician?  On what should that determination be based? 
Fourth, this process has no chance of achieving the stated goal of SB 3315: to manage costs by eradicating (the bill actually uses the word “eradicate”!) prescription drug abuse.

SB 3315 had a chance of making a real impact.  Given the misinterpretation of the bill by TDOL, I fear Tennessee is coughing up the ball right at the goal line. 
If TDOL doesn’t straighten this out, we’ll be left with a court battle as TN payors fight for a proper regulatory interpretation of the legislative intent of SB 3315.  I hope it doesn’t come to that, but if it does, the real loser will be patients who continue to grow ever more dependent on opioid medications that have no hope of alleviating their chronic pain over the long term. 
On Twitter @PRIUM1

Tuesday, November 6, 2012


PRIUM has several events planned this week and wanted to let you know where to find us!

First and foremost, we're at booth 117.  Come by and see us. 

Second, we're sponsoring the Wednesday afternoon cocktail reception in the exhibit hall along with our friends at Health Care Solutions.  Grab a drink, a PRIUM koozie, and enjoy the networking opportunity in the exhibit hall before running out to the ten events you have to attend that night!

Third, PRIUM is excited to be participating in this year's "Opioid Solutions" track.  Mark Pew, PRIUM's SVP, is presenting on two panels this week:

On Thursday morning, Mark is co-presenting with Jim Andrews from Health Care Solutions.  You can catch their session, "Claim Cleanup: Review of Texas' Closed Formulary and National Implications" in LVCC N252 at 8:45 am Thursday.

On Friday morning, Mark is co-presenting with Jeff White and Paul Kauffman from Accident Fund.  Their presentation, "The Insurer's View: Developing a Narcotics Management Program" is at 9:00 am in LVCC N252. 

Busy week ahead.  Travel safely and enjoy the conference.

On Twitter @PRIUM1

Thursday, November 1, 2012

Texas Closed Formulary: Still an Education Gap

The Texas Department of Workers' Compensation is hearing about some troubling, albeit isolated, incidents of adjusters denying medication therapy for legacy claims (i.e., claims with dates of injury prior to 9/1/11).  These claims are still subject to the "open formulary" - and even when the "closed formulary" kicks in on 9/1/13, these medications still must run through the established preauthorization process (unless, alternatively, the applicability of the closed formulary has been documented between the carrier/employer and the prescriber prior to 9/1/13). 

We spend a lot of time here at PRIUM thinking about, traveling to, and conducting business in Texas.  I am still uncomfortably surprised at how little is understood about the new closed formulary rules.  Granted, carriers, employers, and providers routinely express that they've heard about the rules and loosely understand them... but too often, they go on to completely and totally misinterpret the timeline, process, and rules associated with the closed formulary. 

I try very hard to ensure this blog isn't used as a direct marketing tool and I'm not going to start now. 
Whether you use PRIUM as your preferred URA or not, give us a call.  We'll deliver our certified continuing education unit to you, your team, your office, your company, etc. and we won't try to sell you anything (unless, of course, you ask).  We've worked hard to develop a deep understanding of the necessary approach to addressing the legacy claims and we're happy to help in any way we can - even if it's a simple webinar to walk through the rules and the associated process steps. 

If you don't take appropriate action now, legacy claim management is going to get tough come next September.  Let us know if we can help.

On Twitter @PRIUM1

Tuesday, October 30, 2012

Treatment Guidelines, Prospective Review, and Patient Safety

New Mexico is currently working through the process of adopting medical treatment guidelines.  Thankfully, they appear to be leaning toward nationally recognized, evidence-based guidelines like ODG and ACOEM (vs. the Medtronic-influenced, politically-driven brew of guidelines that states inevitably end up with when they try to develop their own guidelines).  Also encouraging is the presumption of correctness that the New Mexico rule contemplates.  Holding treating physicians accountable to the guidelines (even if that means ensuring clear, documented rationale for treating outside of said guidelines) is the only way to improve patient care and reduce state-to-state, practice-to-practice, and physician-to-physician variability in care.

Less encouraging is the proposed elimination of the requirement for providers to obtain prior authorization for medical services that are recommended by the guidelines.  While that sounds logical and efficient, there may be unintended consequences.

Prior authoriziation (or pre-authorization or pre-certification) comes in several shapes and sizes.  In many states, it's optional - something the provider will utilize only in circumstances where high cost care is being rendered and the provider wishes to ensure future payment (i.e., for a surgery).  In some states, pre-authorization is mandated - something the provider must do prior to delivering care.  There are pros and cons to both approaches.  Optional pre-authorization is administratively simpler and less onerous on providers.  Mandated pre-authorization is the opposite - more demanding administratively and on doctors.

But the clearest and most compelling argument for mandated pre-authorization is patient safety. New Mexico may allow for retrospective review if a physician performs a surgery or procedure outside of ODG or ACOEM.  But by then, the care has been rendered, potentially to the detriment of the patient. 

Texas serves as a bright spot in this regard.  Texas has adopted nationally recognized medical treatment guidelines and still maintains mandated pre-authorization, which now includes pre-authorization for certain pharmaceutical treatment as well.  Does anyone doubt that measures such as these have made Texas one of the most cost-effective work comp systems in the nation? 

High marks for New Mexico regarding treatment guidelines.  Low marks for trying to remove mandated prior authorization.  This strikes me as a quid pro quo with the physician community ("we're going to adopt these guidelines... but you don't have to ask permission anymore..."), but I don't think this bargain is in the best interest of patient safety.

On Twitter @PRIUM1

Tuesday, October 23, 2012

Thanks to LexisNexis

PRIUM's Evidence Based blog has been named a LexisNexis Top 25 Blog for Workers' Compensation and Workplace Issues for 2012.  We're grateful to LexisNexis for the honor and humbled to be in such good company.  I've had the opportunity to not only read the content generated by the other honorees on a daily or weekly basis, but also to interact and collaborate with many of them.  I like the feeling I'm often left with... that we're pulling in the same direction.   

Writing about important health care and public policy issues is energizing.  Writing about issues I care about is a blessing.  Getting to do both simultaneously is pure joy. 

We're just getting started.  Plenty of battles left to fight.  If a simple but thoughtful blog post can inform an important debate, change a single mind, or influence even one decision maker... then that post was worth writing. 

Thanks for reading.

On Twitter @PRIUM1

Thursday, October 18, 2012

Prescription Drugs and Kids: This Will Make You Cringe

The New York Times published a piece last week that I find incredibly troubling.  While not directly impacting the workers' compensation system, the article sheds light on our cultural proclivity to rely on prescription medication for uses that were not intended and are not appropriate.  Further, it highlights the role of well-meaning medical practitioners who, in reality, are creating more harm than good. 

Dr. Michael Anderson, a pediatrician in Cherokee County, Georgia, noticed that some of his patients were performing poorly in school.  Unable to determine that anything was medically wrong with these children, Dr. Andersen assumed that the school itself was inadequate.  He may be right about that.  But his solution to the problem is shocking.

He prescribes Adderall. 

He admits, according to the NY Times, that the ADHD diagnosis that he makes is "made up" and "an excuse" to prescribe the drug for the express purpose of boosting academic performance (Adderall improves focus and impulse control).  Dr. Anderson goes on to say, "We've decided as a society that it's too expensive to modify the kid's environment.  So we have to modify the kid."


Later in the article, we come to discover that one of the kids prescribed Adderall began hearing voices that were not there and admitting to suicidal thoughts.  Dr. Anderson's solution?  A week in a psych hospital and a switch from Adderall to Risperdal.  Problem solved.  For now. 

Gradually over the last half century, we have become far too comfortable with the idea that there is a pill to solve every problem, even when legitimate medical diagnoses don't exist.  Struggling in school?  Take a pill.  We see this every day in workers' comp.  Pain? Take a pill.  Still hurts?  Take a stronger pill.  And take more of them.  We have to focus on non-pharmacological solutions to social, environmental, and even biological problems. 

Dr. Anderson acknowledges that no one knows the long term effects of pharmacological solutions like Adderral for academically under performing kids.  But, he says, "I am the doctor for the patient, not for society."  In reality, he is doing a disservice to both.

On Twitter @PRIUM1

Wednesday, October 17, 2012

Connecticut: A Simple Suggestion to Help Control Costs

There's a great post today by Jon Coppelman over at Workers' Comp Insider that compares and contrasts the work comp systems of Massachusetts and Connecticut in light of the recently released Oregon Rate Study.  (Side note: see David DePaolo's post on the Oregon study here - good data, but certainly needs to be read in proper context).

After a thorough overview of each state's woes (which happen to be equally painful, but polar opposite sets of issues), Jon suggests the following for Connecticut: "... regulators must confront entrenched stake holders and begin to exert control over runaway costs." 

Well said.  And I have a suggestion for where the good people of Connecticut might start: Let us talk to the treating physicians.

The employer/insurer community in Connecticut is severely restricted with respect to being able to initiate a peer-to-peer conversation with a claimant's treating physician.  Communication between payor and the attending physician where such communication would involve unilateral disclosure or discussion of material information is not allowed.

Payors, however, may request the physician to complete the "Employee Medical & Work Status Form" or provide progress notes. Copies of this communication, as well as any responses from the physician, must be provided to the injured worker or his/her representative (Payor and Medical Provider Guidelines to Improve the Coordination of Medical Services, 2010).

But there is no allowance for the insurer to engage a peer physician to launch a call to the treating doctor and say, "Hey Dr. Smith... can we chat about why Joe has been on Oxycontin for three years? The evidence suggests that might not be good for him. Are there mitigating circumstances? Do you need help with weaning? How can we be of assistance?" In Connecticut, that conversation can't happen. And that's a shame. 

The goal of a peer-to-peer conversation is not to coerce or connive our way to a cheaper treatment plan.  That is a disservice to all stake holders and peer review companies that conduct clinical conversations that way have no place in our industry.  Yes, we will challenge the current treatment plan if it falls outside of the medical treatment guidelines.  But we do that with a specific end in mind.  The goal of a well conducted peer-to-peer conversation (which is admittedly harder than it might initially seem) is to engage, to understand, to educate, to guide... in a word, to help

These conversations play an important role in the dissemination and adoption of contemporary research and best practices.  Without them, treating physicians are often left with an unattractive and biased alternative information source: the local drug rep. 

Allowing for peer-to-peer conversation in Connecticut is not a magic bullet that will, by itself, lead to significant cost reduction.  But it's a start.

On Twitter @PRIUM1

Tuesday, October 16, 2012

The Repackagers Pivot to Drug Screening

Legislative and regulatory action across the country is likely to put a dent in the P&Ls of drug repackaging companies.  They'll fight every step of the way and spend lots of money on lobbyists, but the fundamental business model simply isn't sustainable.  They're not going away tomorrow, but the writing is on the wall.  Some of the more strategically adroit drug repackagers are beginning to explore new revenue sources to replace the waning dollars earned from helping physicians dispense medications.  Where are they looking?

One clear area is drug screening.  Random urine drug monitoring for chronic opioid users is indicated in several sets of medical treatment guidelines and PRIUM believes strongly in the practice.  In fact, this is one of the standard areas we explore on every review we conduct.  The importance of random drug screening cannot be overemphasized given its impact on patient safety.   But any virtue taken to an extreme can become a vice. 

The logic trail here is similar to drug repackaging.  Take a therapy or procedure that the doctor feels the patient needs... allow the doctor to administer the therapy or procedure directly in the office... bill the insurance company for services provided... increasing patient convenience and compliance.  Sounds rational, right?

The devil, as they say, is in the details. 

Drug repackagers routinely develop novel NDC codes, allowing them to create arbitrary average wholesale prices.  This practice allows doctors to bill insurance companies significantly more than the insurer would have paid had the drug been filled at a typical retail pharmacy.  And there is no evidence to suggest that the practice increases safety or compliance.  Additionally, restricting this activity entirely (as several states do) does not appear to impact access to needed medications on the part of injured workers.  Not so rational after all.

We see the same trend coming in drug screening.  Keep a look out for excessive utilization and/or obnoxiously high bills for urine drug screening performed in the treating physician's office.  The drug repackagers are going to start teaching docs how to game this system as well.  A couple of examples: and

Be vigilant.  Understand the services you're buying.  Ensure that the screening is truly random and within the treatment guidelines.  Get another clinician to look at the test results - is the money you're paying actually telling you anything about the patient's adherence to the drug regimen? 

On Twitter @PRIUM1

Thursday, October 11, 2012

Kentucky Revisited: Opioids and HB 1

Back in August, I wrote a post on the immediate impact of HB 1 in Kentucky.  I was a little surprised that most of the comments on that post (several of which I posted, some of which I didn't for reasons of either discretion or propriety) were negative in nature.  HB 1 was characterized as an overreach, dangerous to patients, and costly to the health care system in the state.  Further, the bill's basic constitutionality was brought into question (something along the lines of the KASPER database representing an invasion of privacy... shouldn't a citizen have a right to abuse drugs prescribed by multiple doctors without any consequences?)

This week, however, yields more data on the extent and severity of the opioid epidemic in Kentucky.  Turns out, Kentucky Medicaid patients are prescribed more narcotics than any other class of drug from 2000 to 2010.  According to this report from the University of Kentucky's Center for Business and Economic Research, the state spent $212 million on pain meds over this 10 year period for over 3.8 million prescriptions (just for Medicaid patients!). 

I understand HB 1 isn't perfect.  But I think the detractors owe us more than just a critique.  What's the specific set of alternative policies that could be implemented to help alleviate the epidemic of prescription drug use in Kentucky? 

HB 1 does inflict a greater burden on Kentucky medical providers and it does create a higher standard of care for chronic pain patients.  But I don't believe for one second that the increased cost to the state's health care system of these measures will not be easily overcome by the cost savings related to the mitigation of prescription drug misuse and abuse. 

On Twitter @PRIUM1

Thursday, October 4, 2012

WCRI Report on Opioids: Only Part of the Story

WCRI published a very revealing report this week on long term opioid use and adherence to medical treatment guidelines.  The findings were disheartening, though not terribly surprising. 

The 21-state median percentage of long term opioid users receiving psychological evaluations was 7%.  For psychological treatment the number was 4% (vs. 6% is the prior period studied two years before).  Claims with indications of urine drug testing stood at 24%.  This means that more than 9 out of 10 long term opioid users aren't receiving any kind of psychological screening or treatment.  Only 1 in 4 is being tested to ensure the drugs are being taken properly. 

What's potentially more interesting is what WCRI didn't measure (or perhaps more appropriately, couldn't measure).  The component of the "medical treatment guidelines" for which WCRI was able to collect and analyze data was limited to urine drug monitoring, psychological evaluation, psychological treatment, and physical medicine.  These components of the the medical treatment guidelines all have one thing in common: each can be associated with one or more CPT codes, making data collection and analysis feasible. 

But what about other components of the medical treatment guidelines that doctors should consider in light of chronic opioid therapy?  I'm thinking mainly about functionality.  You can't measure that via a CPT code, but all too often long term opioid use leads to decreased functionality, not improved functionality. 

The WCRI study, along with this basic issue of functionality, begs a broad and important question:

If, theoretically, medical treatment guidelines were properly considered and adhered to for 100% of claims where opioids might have been prescribed... what percentage of opioid spend would disappear from work comp?  What's your best guess?

On Twitter @PRIUM1

Tuesday, October 2, 2012

Fighting Fire with Fire: Kudos to Florida Payers

Back in March, I wrote a post about a little known corner of the Florida work comp regs that allows carriers and employers to reduce the price they pay for repackaged drugs. 

Here's how this works: An injured worker gets hurt and sees a doctor. The doctor prescribes and dispenses a drug, then makes up an NDC code, marks it up 300%, and bills the insurer. However, if a retail pharmacy, under contract with the insurer, is "reasonably accessible" for the injured worker, the insurer can re-price the drug to the contracted rate it has with the retail pharmacy. I've talked to the Florida DWC about the definition of "reasonably accessible" - candidly, they're not really sure.  Perhaps they've clarified this for payers in the state, but I couldn't get a straight answer. 

I'm not the only one that pointed this out.  The folks at workcompcentral and several other bloggers pointed to Florida statute 440.13 (12) as a potential tool for payers in the fight against repackaged drug pricing. 

Today brings news from NCCI that this tactic appears to be working.  NCCI has cut its estimate of savings from a proposed repackaged drug bill by half (from about $62 million to about $27 million) due to employers and carriers re-pricing obnoxious bills on their own. 

Predictably, AHCS (a software firm specializing in drug repackaging) says this is further evidence that NCCI's numbers are a moving target.  On the contrary, NCCI's numbers reflect the market reality of payers taking control of the situation in Florida and using any and all available statutes and regulations to stem the tide of inappropriately priced drugs. 

Way to go Florida payers. 

On Twitter @PRIUM1

Monday, October 1, 2012

An Important Message from Physicians for Responsible Opioid Prescribing

I received the following note from Dr. Andrew Kolodny and with his permission, I'm passing it along to all of you.  Please take 5 minutes and do your part. 

Dear Friends and Colleagues,
As you may know, PROP filed a request to FDA for changes to opioid labels. Specifically, we asked them to add a suggested duration of use, a suggested upper dose and to limit (on-label) use to severe pain. You can read about this here:

If FDA implements our request, opioid manufacturers will be prohibited from advertising long-term use of opioids for chronic non-cancer pain and the medical community will be informed that this practice has not been proven safe and effective. (However, clinicians will still be permitted to prescribe long-term opioids). We believe that this will help reduce overprescribing of opioids. And since it’s overprescribing that’s harming pain patients and fueling the opioid addiction epidemic, the label change could help bring this unprecedented public health crisis under control.

FDA is seeking public comment about the Petition. Thus far, they have received about 200 comments supporting the petition and 130 opposed to the petition. Not surprisingly, industry-funded pain groups (and pain patients misled to believe that this is an effort to ban opioids) have weighed in against the Petition.

Submitting comments to FDA is easy... just click here:

A couple of sentences is all you need. Please make sure to state clearly in the first or second sentence that you support the petition.

For example, you can write: 

I support this petition. Drug companies should not be permitted to advertise long-term and high dose opioids for moderate chronic pain because this treatment has not been proven safe and effective. The medical community should be informed  by a revised label that risks may outweigh benefits when opioids are prescribed long-term. 

Please try to do this ASAP. As soon as FDA takes an action on the Petition (which could be very soon), they will close the comment period.

If you are interested in reading comments that have already been posted, you can do this here:

Thank you for your support!


Andrew Kolodny, MD
President, Physicians for Responsible Opioid Prescribing
Chair, Department of Psychiatry
Maimonides Medical Center
920 48th St., Brooklyn, NY 11219
Tel: 718 283-7557; Fax: 718 283-6540

On Twitter @PRIUM1

Wednesday, September 26, 2012

Louisiana: Will the Fix... Work?

I presented at the Louisiana Claims Association earlier this year to a room full of work comp adjusters, nurses, and executives.  We talked about the problem of opioid dependence and addiction and WCRI's analysis of Louisiana (not particularly good news for those assembled in that room). 
We talked about the new Medical Treatment Guidelines as well.  After sharing some uncomfortable laughs about the nature of Louisiana politics and how the development and adoption of the guidelines wasn't the most transparent of processes (I wrote about that here), we got into the specific area of the guidelines focused on prescription medications. 

In reality, the portion of the treatment guidelines dealing with drugs isn't bad.  Without going into the details, there's enough in the guidelines to, in theory, give Louisiana payers a way out of paying for medically unnecessary medication therapy. 

In theory.

I asked for a show of hands: How many payer organizations represented in the room were actively using utilization review, based on the treatment guidelines, to challenge inappropriate care?  A single hand went up.  And even that hand went up tentatively. 

What's the problem?  We all know.  Louisiana is like most state work comp systems.  Change isn't really change until the lawyers fight it out and the court says it's so.  And too often, the battle has been waged and lost by the payer community.  Thus, most payers take a "wait and see" approach to any level of reform that doesn't compel their action, but might cost them time and money. 

This week brings news that Louisiana is trying to clarify the appeals process for disputed medical treatment.  The goal is to edit form 1009 to make clear that the path to dispute resolution doesn't run immediately to the courts, but rather through the Office of Workers' Compensation Medical Director. 
A public hearing on the rule change is scheduled for tomorrow in Baton Rouge.

Louisiana readers: Will this make a difference?  Or is Louisiana creating a distinction in process without a difference in outcome?

On Twitter @PRIUM1

Monday, September 24, 2012

IAIABC Draft Rules on Opioids: Progress, But Work Still Needed

PRIUM submitted feedback on the original release of IAIABC draft rules on opioid prescribing back in May.  Last week, IAIABC revised those draft rules and we're pleased to see significant progress on the items we outlined as areas of concern based on the original version. 
Additional comment and feedback on the new has been submitted as follows:

On behalf of PRIUM, a URAC-accredited utilization review company based in Duluth, GA, I’d like to commend the IAIABC on its efforts to address the epidemic of prescription drug over-utilization in workers’ compensation systems throughout the country. We have reviewed both the model statutory language as well as the model regulatory language IAIABC developed and would like to provide the following comments:

Regarding the model rules, the translation from statute to regulatory approach is well defined. We found the “drafting notes” to be particularly helpful in guiding lawmakers in the development of these critical rules. There are a few areas, however, that we believe require more nuanced thinking prior to launching the regulatory model.

1) [Section 1, (3): Effective Date]: Our industry learned a valuable lesson from the creation, adoption, and implementation of the Texas Closed Formulary Rules. Texas implemented these new rules in two stages: starting 9/1/11 for all new injuries as of that date, and starting 9/1/13 for all “legacy” claims, effectively providing a two year remediation period for the insurance carriers and treating physicians to address difficult cases in preparation for the 9/1/13 requirement for preauthorization of all N drugs. This is smart public policy. Contrast this with New York where adoption of medical treatment guidelines as of a single, “line in the sand” effective date has created a judicial and legislative battle that has yet to resolve itself. On the one hand, a single effective date creates chaos as carriers and physicians try to figure out how to address legacy claims, which tend to be more complicated. On the other hand, only applying new rules to new injuries creates two standards of care within a workers’ compensation system, where an injured worker’s treatment plan is driven entirely by the date on which they were injured (which makes no clinical sense). We recommend model regulatory language that mirrors the Texas Closed Formulary approach – an initial implementation date for new injuries, followed by a remediation period for legacy claims, followed by a fully effective date for new rules and all claims. 
2) [Section 1, (5): Evidence-based Treatment Guidelines]: We particularly appreciate the emphasis in the drafting note indicating that the model would be "most effective if there was a specific guideline on treatment of opioids that was presumptively correct".  However, in order to achieve the presumption of correctness, we believe the medical treatment guidelines adoption process is critical and should rely on one of the two following approaches:
a. Define the treatment guidelines to be adopted within the statutory language itself (as opposed to leaving it to the state agency to determine); or
b. Provide a more thorough definition of appropriate medical treatment guidelines, perhaps through a series of criteria that must be met. Such criteria might include requirements that the medical treatment guidelines:

                                                               i. Rely on specified, comprehensive, systematic review of medical literature;

                                                             ii. Include transparent criteria for rating the strength of evidence, including individual medical studies;

                                                            iii. Remain current and incorporate contemporary studies;

                                                           iv. Address frequency, duration, intensity, and appropriateness of treatment;

                                                             v. Have been adopted by at least one other state.

2) [Section 7: Continuing Education]: Our view is that the absolute onslaught of marketing dollars spent by the pharmaceutical industry to “educate” doctors should, in fact must, be countered by mandated, unbiased continuing education focused on the risks associated with chronic opioid therapy. In 2011, the pharmaceutical industry generated $11 billion from the sale of opioids, a full $3 billion just from Oxycontin. The #1 source of information for physicians regarding these drugs remains the drug company sales representative. This must change. PRIUM is disappointed that state medical societies and the American Medical Association are opposed to such measures. We strongly recommend that IAIABC remain committed to mandated continuing education.

3) [Section 9, Preauthorization Required]: PRIUM believes that the best possible way to eliminate the over-utilization of prescription drugs in workers’ compensation is to engage the treating physician in the creation of a revised treatment plan. Mandated preauthorization should not be the first step taken by an insurance carrier when a particular claim is brought under scrutiny due to the prescription medication regimen. That being said, if the treating physician refuses to participate in the creation of a revised treatment plan and continues to prescribe, in some cases, dangerous levels of medications, mandated preauthorization can be a powerful tool to protect patient safety and ensure positive clinical outcomes.  While the updated draft rules recognize the recent success of the Texas Closed Formulary, the example restrictions are of little value in light of what Texas has actually implemented.  Requiring pre-authorization of all drugs indicated as "N" in the Official Disability Guidelines Appendix A Formulary is a bold and necessary statement that only medically necessary drugs will be used to treat occupational injury.   

We appreciate the opportunity to provide this feedback and commend IAIABC for the transparency and collaboration that have been emblematic of this process thus far.

Respectfully submitted,

Michael Gavin
Chief Strategy Officer

On Twitter @PRIUM1

Monday, September 17, 2012

Work Comp and Illicit Drug Use: A Physician's View

Last week, I wrote about an analysis from Ameritox that suggested the rate of illicit drug use in workers' compensation was comparably lower than in other payer classes.  I asked readers to weigh in on one of two possible explanations:

A) Injured workers, generally speaking, have a goal to return to work and dealing with chronic pain through medication therapy is something injured workers, because they are "workers", do responsibly. We know this isn't true for 8.6% of them, but those are bad apples and shouldn't spoil our view of the bunch.

B) Injured workers in chronic pain enjoy a higher rate of iatrogenic (physician-caused) tolerance, dependence, and addiction. Work comp claimants don't need illicit drugs because they're getting all the narcotics they need from their physicians. The existence of an indemnity benefit (which doesn't exist in the other payer classes) drives patient-directed care and higher levels of narcotics use without the need to seek out illicit drugs. 
The overwhelming response (via direct blog comments, emails to me, and LinkedIn group comments) was B.  A few of you weighed in with an "A... then B" perspective that suggested a lot of claims start out on the right track and then get derailed due to a number of factors ranging from legal representation to iatrogenic causes. 

One of PRIUM's physician reviewers, Dr. Bob Taber, offered an option "C":

Many WC chronic pain patients have learned by research (info readily available on internet sites), word of mouth or personal experience that many drugs (licit and illicit) are quickly cleared by the body. A Urine Drug Test (UDT) will not be able to detect the presence of such drugs if it has been more than 5-7 days since the drug was last used/abused. UDTs are recommended to be performed randomly on chronic pain patients receiving opioid therapy but this almost never happens. The patient knows that the only time s/he will possibly be subjected to a UDT is on the day of a scheduled follow up appt with their Doc. They know this date a month or two ahead of time. They are free to use their illicit drug of choice until about a week before their appt date without risk of detection. THC can linger much longer in the body than other drugs so frequent users risk a positive UDT for THC if they continue using until a week before their appt. (assuming that THC is in the test panel).

Dr. Taber suggests that the solution is to make UDT testing truly random and to ensure real, enforceable consequences for positive tests and/or non-participation.  In fact, he suggests that such an approach would mitigate the use of illicit drugs across payer classes, not just workers' compensation.

Many thanks to Dr. Taber for his insights.

On Twitter @PRIUM1

Wednesday, September 12, 2012

Where Are They Now? The "Oxycontin Seven" from 1998

For those of you who have seen my educational presentation on chronic opioid therapy, you know I'm fond of playing a video clip in which Dr. Alan Spanos says, among other things, that opioids are "our best, strongest pain medicines" and that "in fact, the rate of addiction amongst pain patients who are treated by doctors is much less than 1%".  He concludes by suggesting that opioids "should be used much more than they are for patients in pain".  This usually leads to audible gasps in the audience, many of whom see claims every day that fly in the face of this supposed medical wisdom. 

This clip is from a 1998 promotional video produced by Purdue Pharma that highlights the experiences of seven individual patients taking Oxycontin at the time.  The Milwaukee Journal Sentinel has just published a very well done "where are they now?" on these seven patients. 

Here's a summary of what happened to the seven: "Two of the seven patients were active opioid abusers when they died.  A third became addicted, suffered greatly, and quit after realizing she was headed for a overdose.  Three patients still say the drug helped them cope with their pain and improved quality of life.  A seventh patient declined to answer questions." 

As for Dr. Spanos, he's backed down considerably from his original stance on opioids.  He now says, "We don't know whether success stories like this are one in five, one in 15, one in 100, one in a thousand.  They may be quite rare." 

Quite rare, indeed.

Interestingly, Bob Twillman, Director of Policy and Advocacy for the American Academy of Pain Management, posted a link to this article on Twitter.  His take on the outcomes for the seven patients?  "... film shows that 3 of 6 chronic pain patients had really good results!"

While we can't fault Bob for trying his best to do his job, I can't imagine any rational member of the clinical community taking such a "glass half full" view of these outcomes, particularly when there is no reliable, replicable way to determine which patients will end up with positive clinical outcomes... and which patients will end up dead. 

On Twitter @PRIUM1

Monday, September 10, 2012

Work Comp and Illicit Drug Use: What Do You Think?

A new study from Ameritox indicates that work comp claimants are less likely than other payer groups to engage in illicit drug use. 

Ameritox looked at 2 million samples for 1.5 million chronic pain patients over a 2 year span from July of 2010 to June of 2012.  They found that rates of illicit drug use by payer class varied as follows:
- Medicaid (17.1%)
- Self-pay (14.8%)
- Commercial insurance (9.7%)
- Medicare (8.9%)
- Work comp (8.6%)

This finding likely runs contrary to assumptions I've heard many claims executives make about the chronic pain cases on adjusters' desks. 

So, while there are a range of potential explanations, I'll offer two possible perspectives and ask readers to weigh in.

A) Injured workers, generally speaking, have a goal to return to work and dealing with chronic pain through medication therapy is something injured workers, because they are "workers", do responsibly.  We know this isn't true for 8.6% of them, but those are bad apples and shouldn't spoil our view of the bunch.

B) Injured workers in chronic pain enjoy a higher rate of iatrogenic (physician-caused) tolerance, dependence, and addiction.  Work comp claimants don't need illicit drugs because they're getting all the narcotics they need from their physicians.  The existence of an indemnity benefit (which doesn't exist in the other payer classes) drives patient-directed care and higher levels of narcotics use without the need to seek out illicit drugs. 

What say you?  A or B?
I'll post the (informal) results in a few days. 

On Twitter @PRIUM1

Thursday, September 6, 2012

Real Data: Prescription Drug Monitoring Works

A new retrospective study out of Canada helps paint a picture of the impact a real-time prescription drug monitoring program can have. 

Back in 1995, British Columbia was the first Canadian province to introduce a real-time prescription drug monitoring system (called PharmaNet).  This week, analysis of data gathered since the program's introduction was published in the journal of the Canadian Medical Association. 

The study finds that duplicate or inappropriate opioid prescriptions fell from 3.2 percent to 2.1 percent of total prescriptions after the system was put in place.  And inappropriate prescriptions for benzodiazdepines fell from 1.2 percent to 0.71 percent.

Contrast this with the following:

- While 49 states in the US have adopted legislation to authorize the creation of a Prescription Drug Monitoring Program, only 37 are up and running.  Of note: Missouri is the lone hold out.  See my post from June on the sorry state of affairs in that state.

- Funding in many of the 37 states is lacking.  California apparently has a single person responsible for administering the entire state program.

- We have yet to find a way to coordinate data sharing (or even data access) across state lines, severely inhibiting our ability, as a nation and as a collection of state work comp systems, to properly manage and leverage prescribing information. 

We have a long way to go on prescription monitoring.  But we have data that suggests it works.  Colin Dorumut, the epidemiologist at the University of British Columbia that led the research, put it best: "The cost of implementing these networks in terms of hardware and resources to build them is probably trivial compared to the millions of inappropriate prescriptions that can be prevented."

On Twitter @PRIUM1

Wednesday, August 29, 2012

Michigan Moves on Repackaged Drugs

State regulators in Michigan are working on draft rules to address drug repackaging in work comp.  Several weeks ago, I wrote a post on the 6 core tenets of any strong statutory/regulatory action in this area.  Let's see how Michigan's newly proposed rules stack up.

1) The rule doesn't ban physician dispensing. There are legitimate reasons a doctor may need to dispense medications to a patient and the rule allows for those limited circumstances.

Michigan = check. 

2) The rule focuses on the financial remuneration tied to physician dispensing and fixes such fees at the Average Wholesale Price (AWP) of the medication plus a reasonable dispensing fee.

Michigan = check. (AWP - 10% + $3.50 for brands and AWP - 10% + $5.50 for generics)

3) The rule clearly specifies the source for the AWP (Medi-Span, Redbook, etc.). Many states are silent to the AWP source and this creates a lot of noise in the system.

Michigan = check.  (Redbook)

4) The rule specifies that fees are determined by "a) the NDC for the underlying drug product from the original manufacturer, or b) the therapeutic equivalent drug product from the original manufacturer/labeler NDC." This leaves no room for physicians or other agents to create new NDC codes as a result of repackaging.

Michigan = check. 

5) If the underlying NDC isn't known or isn't shared, discretion rests with the payer to determine the most appropriate NDC code. There is a dispute resolution process outlined if the provider disagrees.

Michigan = unclear.  The Michigan rules stipulate that if a pharmaceutical bill is submitted for more than $35 using an unlisted or "not otherwise specified" code, then the bill must be accompanied by an invoice.  Not sure I follow, but at least they're thinking about it. 

6) Perhaps most importantly, this is a regulatory change, not a statutory change.  This won't be possible in all states, but where it is, it's the way to go. 

Michigan = check.

A great start for Michigan.  Well done.

On Twitter @PRIUM1

Tuesday, August 28, 2012

Massachusetts Prescription Drug Monitoring Program: A Critique

Massachusetts has a problem with prescription drugs in work comp.  Despite its relatively small geographic footprint, the state's doctors prescribe a lot of narcotics.  According to WCRI's report from last summer, Interstate Variations In Use of Narcotics, which studied narcotics use in 17 states, MA had the highest rate of schedule II narcotic usage among cases for which narcotics had been prescribed (for non-surgical cases experiencing >7 days of lost time). 

So I was pleased to read that Governor Patrick signed legislation recently that will strengthen the state's prescription drug monitoring program (PDMP).  A strong PDMP program is a necessary tool(albeit insufficient by itself) to help stem the over-utilization of prescription narcotics.

The law (SB 01125) requires doctors to register and pharmacists to report prescriptions to the PDMP.  And at first glace, the law requires doctors to consult the PDMP database before the issuance of a prescription for a Schedule II or III narcotic.  This would make Massachusetts only the second state to require such a step (Kentucky being the other).  A closer reading, however, shows there are nuances to the bill...

The bill reads: "The department shall promulgate rules and regulations relative to the use of the prescription monitoring program by registered participants that shall include requiring participants to utilize the prescription monitoring program prior to the issuance of a prescription for a narcotic drug contained in Schedule II or III to a patient for the first time."

So close. 

I understand the theory here.  If each prescriber must check the database at the outset of narcotic therapy, any previous prescriptions should show up.  But I fear that requiring a single consultation with the database that occurs only at the beginning of narcotic therapy will allow some patients to slip through the cracks.  The law also doesn't indicate what enforcement mechanisms will be available to the department of workers compensation to ensure compliance with the new rules (once those rules are developed). 

One additional note on the bright side: the statute does stipulate that the regulatory approach needs to allow for "licensed support staff" to conduct the database checks.  While I acknowledge that requiring PDMP checks for all narcotics scripts creates costs for the physician practice, I also believe it's in the best interest of patient safety to do so.  Allowing support staff to do that work will at least create some cost savings and efficiencies in doctors' offices throughout the state. 

On Twitter @PRIUM1