Thursday, April 26, 2012

Texas: Plan-Based Audit for Opioids

The state of Texas (Texas Department of Insurance, Division of Workers' Compensation) is currently accepting public comment on its proposed plan-based audit for pain management services in workers' compensation.  Since our comments will be made public anyway, I thought I'd throw them out here on the blog:

To: Donald Patrick, M.D., J.D., Medical Advisor
Date: Thursday, April 26, 2012

As a utilization management company focused on the application of the Official Disability Guidelines to prescription drug utilization in the State of Texas, we appreciate the opportunity to provide input and suggestions on the development of the new Plan-Based Audit for health care providers prescribing opioids.  We applaud the state of Texas for its efforts thus far in the area of narcotics control in workers' compensation and hope that this new Plan-Based Audit will further limit the inappropriate use of prescription narcotics.

Regarding Section III: Scope and Methodology - We understand the budgetary limitations associated with any undertaking such as this.  That said, we're concerned that a focus on early prescribing of an opioid (within 10 days of the date of injury and >30 days supply) is too narrow to capture the broad nature of the problem.  Often, injured workers only end up on grossly inappropriate drug regimens well after the initial injury, perhaps even years later.  Dose escalations, tolerance, dependence, and addiction develop months and years down the road.  While a focus on early prescribing behavior will alleviate a portion of the problem, our view is that the most intractable cases would not be identified with the criteria as currently proposed.

We suggest the Plan-Based Audit consider focusing on a measures much more likely to capture the most prevalent (and expensive) issue in the system - long term use of high dose narcotics.  We suggest the following:
- Health care providers who have prescribed opioids to injured employees where the morphine equivalent dosage (MED) exceeds 120 mg per day. 

Regarding Section IV: Selection Criteria - Again, we acknowledge budgetary constraints as a real issue in deploying a program such as the Plan-Based Audit.  However, selecting a mere 15 physicians may not be sufficient to change or influence overall system behavior.  The stated purposed of the Plan-Based Audit is to "focus attention on the issue of opioid utilization in the Texas workers' compensation system."  We fear that the relatively small scope of the current proposed plan will fail to garner sufficient attention to guide future clinical decision-making. 

Regarding Section V - Roles and Responsibilities - We suggest the following questions for the Medical Advisor's consideration as he develops guidance for the MQRP experts (these questions would be in addition to the already stated objecting of ensuring "that health care providers adhere to the Official Disability Guidelines and medically accepted standards of care for prescribing pain management services including opioids"):
1) Has the patient signed an opioid treatment agreement or narcotics contract?
2) Does the provider have the patient undergo regular urine drug monitoring?
3) Did the provider consult a prescription drug monitoring database prior to writing the prescription?
4) Has an opioid risk assessment been completed to evaluate likelihood of abuse issues?
5) What are the specific treatment goals for this patient in terms of functional improvement?

These questions represent several "best practices" in prescription drug utilization management and we believe these questions provide a potential road map for evaluating the treatment patterns of selected physicians. 

We appreciate of the opportunity to provide input and suggestions. 

Michael Gavin
Chief Marketing Officer

On Twitter @PRIUM1

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