Thursday, May 17, 2012

Connecticut Opioid Protocols: Great Step, Now Let Us Talk to the Docs

The State of Connecticut's Workers' Compensation Commission (WCC) released revised protocols for opioid prescribing.  Like several other states, CT goes out of its way to emphasize that "the protocols are not meant to be absolute; there must be room for medical judgment."  Granted. 

I was pleased to read, though, that the WCC has placed a 90 mg morphine equivalent dosage (MED) per day as the threshold above which opioid treatment should not rise unless there is "measured improvement in function, pain, or work capacity" (which we almost never see - once you get in the 100 mg MED range, we consistently see evidence in medical records of declining function).  Most of the literature suggests 120 mg MED as an appropriate threshold, so the more aggressive approach in CT is enlightened. 

I also thought it was interesting that the WCC encourages treating physicians to contact the insurer if treatment beyond the protocol is needed.  I'm left wondering how nice it would be if the reverse was possible - if the insurer could easily and reliably engage the treating physician to discuss the care of the patient.

In CT, 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" 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 launch a call to the treating physician 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 CT, that call can't happen.  And that's a shame. 
Workers compensation attorneys in Connecticut agree that these guidelines are strictly followed and that there is no ex parte communication with treating physicians. The only time that ex parte communication is permitted is when the claimant has approved a Nurse Case Manager. In that case the NCM may discuss treatment and medical data with the treating physician.  But how many plaintiff's attorneys are going to say to their clients, "Yeah, sure, let's get an NCM involved"?  Not many. 

These WCC rules make it nearly impossible for insurers to collegially engage treating physicians in CT to discuss how best to rationalize pharmacological treatment.  CT is one of the few states where this is the case. 

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