Tuesday, January 31, 2012

Ohio's New Rules: A Good Start (with a Potential Gap)

The Ohio Bureau of Workers’ Compensation formally adopted new rules intended to control the inappropriate use of prescription narcotics within the state-controlled work comp system.  The rules are known collectively as the “coordinated services program” and they’re being referred to colloquially as the “lock in” program. 
At first pass, I thought the program appeared cumbersome and difficult to understand.  Now that I’ve studied the rules and had a chance to discuss them with clinicians and claims people, I’m quite impressed with the new rules and I’m hopeful they’ll have a significant impact (for now, BWC estimates savings to the system of $15 million just by the end of this year). 
In summary, claimants that receive certain combinations of drugs from certain combinations of either prescribers or pharmacies are potentially subject to being placed in the “coordinated services program” by the BWC.  This means the claimant must:
1)      Choose a single prescriber from a list of BWC pre-qualified physicians
2)      Choose a single pharmacy from a list of BWC pre-qualified pharmacies
3)      Be subject to a physician review of the most recent 12 months of prescription history to assess the medical necessity of the drug regimen. 
From here, the path to successfully weaning and/or discontinuing unnecessary medications isn’t exactly clear.  There are no clear cut statements in the new rules that disallow payment for medically unnecessary drugs – the rules simply stipulate that drugs must be prescribed by a single physician and dispensed by a single pharmacy.  Perhaps the assumption is that because these physicians and pharmacies are pre-qualified by BWC for participation in the “coordinated services program,” they will do the right thing and get the drug regimen under control.  Appears logical, but if the new rules have a gap, this is it.   
So, a decent start for Ohio.  But as I said about Washington State’s new rules, for employers and insurers in other, non-monopolistic states waiting for legislation to fix the problem of opioid abuse in work comp, don’t hold your breath.  Get to work on a market-driven solution. 
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