Texas Closed Formulary – 9/1/13, Legacy Claim Cleanup

Given the apparent success to-date of the TCF Phase 1, now the focus shifts to Phase 2 for cleaning up the “legacy claims” (those with a Date of Injury prior to 9/1/11).

Every jurisdiction has the issue of longstanding claims that have accrued large medical costs (and continue to do so), involved failed treatment regimens over time, and included various attempts at mitigating the cost / treatment scope that for the most part have not succeeded.  These claims are called various things - legacy, high exposure, old dog, trainwreck - but the bottom line is they have cost a lot of money yet provided unsatisfactory improvement in health.

The TCF Phase 2 is an interesting take.  The DWC has essentially granted 2 years for payers and physicians to work collegially and bring the drug regimens into compliance with ODG or face preauthorization (and likely denial) of drugs at the pharmacies starting on 9/1/13.  Everyone knows that this process is going to be complicated (several stakeholders with different motivations), there likely will not be 100% compliance (some physicians, even with the mandate, still might not cooperate), and it will take a long time to accomplish (ODG classified these as “N” drugs because they are addictive and have long-term negative consequences).  Hence, the strategy should be to get started ASAP while time is our friend.

Our suggestion, after reading the rules and talking with experts, is to use 2012 as the “handshake” and reserving 2013 for the “hammer”:

• The 2012 handshake is a collegial outreach to cooperative physicians, reaching consensus on any necessary changes, and implementing those changes so the patient is clinically stable with an appropriate treatment plan
• The 2013 hammer is the second pass through where those that chose not to cooperate have more assertive pressure applied with the impending 9/1/13 deadline

I remember Y2K as an IT professional, and the months of effort to prepare, and the anxiety I felt as the clock struck midnight and then 4 hours later when we turned all of the mainframe computers back on to see if they actually would.  You might be of the opinion that Y2K was a made-up crisis by the technology industry - I know the amount of effort and planning that was required.  The DWC has ensured, with punitive measures for non-compliance, that 9/1/13 is a deadline that cannot be ignored.  For those proactive in the process, 9/1/13 will be just another day.

In this together – Mark

On Twitter @PRIUM1