Friday, March 23, 2012

Arizona is making progress

I was in Phoenix yesterday presenting our Continuing Education program “Best Practices in Opioid Management” to a large Payer and received some feedback I was not expecting.

If you read this blog regularly, you know that Michael and I are both big believers in Evidence Based Medicine (EBM).  Using the patient’s subjective perception of pain and a physician’s personal clinical expertise and experience as the sole determinant of ongoing treatment plans is one of the reasons the U.S. has what the CDC calls an “epidemic” of prescription drug over-utilization.  In my opinion, and that of others much smarter than me, this should be augmented regularly with the science of EBM as a baseline standard of care and reference point for how to manage pain.  While I do not have any specific rooting interest on the tool, I do believe strongly it is more effective to use EBM than consensus-based guidelines (i.e. Colorado, New York) as those potentially allow for lobbyists (clinical and business) to flip the science to fit their purposes.  But I digress …

When I began talking about the concepts and application of EBM, one of the attendees said that Arizona had just passed a bill regarding EBM but wasn’t sure of the details.  And according to workcompcentral this morning, there was indeed an omnibus bill signed by Governor Brewer to allow electronic payment of Work Comp benefits, but nothing that I could find about EBM.  Michael and I have been following the subject of EBM in Arizona for awhile (see his post on February 1 on House Bill 2365).  But it prompted more digging and I found there is being progress made on prescription drug management:
  • House Bill 2365, “Workers’ compensation; evidence based treatment”: No progress listed since February 6, but it does select ACOEM as “presumptively correct on the issue of extent and scope of medical treatment.”  You can see the full bill here.
  • House Bill 2155, “Controlled substances, workers’ compensation”:  This was passed by the House on February 7, and yesterday was passed by the Senate with amendments and referred back to the House.  You can see the full bill here.  There are two primary major initiatives in this legislation:
    1. Section 23-1026: If the employee refuses to submit to a periodic medical examination then the right to compensation can be suspended until that examination occurs, and if the result of the examination shows the employee persists in unsanitary or injurious practices or refuses to submit to reasonable medical/surgical treatment to promote their recovery then compensation can be reduced or suspended.
    2. Section 23-1062.02: A treating physician, upon written request by an “interested party”, shall include justification for use of the controlled substance and a treatment plan that includes a description of measures to monitor and prevent the development of abuse, addiction or diversion by the employee.  The physician shall include in their reports the off-label use of a narcotic or Schedule II substance, the use of a narcotic exceeding 120mg MED per day and the prescription of long-acting opioid.  If the physician does not comply, the “interested party” is not responsible for payment of the physician’s services and the employer or carrier or commission may request a change of physician.
This is all very good news, but it hasn’t reached the Governor’s desk yet.  It seems as though the battle of consensus-based vs. evidence-based has been won (which is the right decision), and HB 2155 is forcing (with the use of “shall”) the treating physicians to comply with best practices.  The attendees in Phoenix were frustrated with the number of claimants on obviously inappropriate drug regimens without much course of action.  My speculation is that the Arizona legislature has decided to set the rules of engagement in place first with HB 2155 as that seems to be on the fast-track, then follow-up with the establishment of the standard of care with HB 2365.

If you’re interested in making a change for the betterment of patient health and safety in Arizona, let’s hope these bills pass and soon.

In this together – Mark

On Twitter @PRIUM1

1 comment:

  1. Mark,

    I am confident that you are aware that EBM guidelines are not the sole result of "class A" (my term)evidence. There are simply not enough double-blinded, placebo controlled(etc.) studies to cover the landscape. Thus ACOEM and other guideline sets include a large proportion of consensus-based recommendations both for and against well established therapies. It seems to me disingenuous to promote EBM as anything but the sum total of the entire process of evaluating all the available "evidence." Therefore, a thorough discussion of EBM must include the fact that ACOEM, ODG, and I am willing to state virtually all comprehensive guideline sets rely on consensus to a great degree. Your thoughts?