To Whom it May Concern:
On behalf of PRIUM, a URAC-accredited utilization review
company based in Duluth, GA, I’d like to commend the IAIABC on its efforts to
address the epidemic of prescription drug over-utilization in workers’ compensation
systems throughout the country. We have reviewed both the model statutory
language as well as the model regulatory language IAIABC developed and would
like to provide the following comments:
Regarding the model legislation, the critical components of
any state effort to stem the tide of prescription drug misuse appear to be
present. Treatment guidelines, PDMPs, dosage and duration limitations,
pre-authorization, appropriate billing for services, and dispute resolution
are, in fact, the essential elements of an effective statutory strategy to
address the issue. We see room for improvement, however, in the model
statutory language in two areas:
1) [Section
2: Treatment guidelines]: The current language leaves far too much latitude for
states to develop consensus-based guidelines (vs. evidence-based
guidelines). We recognize the use of the term “evidence based” in the
model language, but left open to the whims of state politics, medical boards,
and lobbying efforts from the pharmaceutical and medical device industries, a
state might be left with relatively weak, ineffectual medical treatment
guidelines that allow status quo prescribing patterns to continue
unabated. As an alternative, we suggest one of two approaches:
a.
Define the treatment guidelines to be adopted
within the statutory language itself (as opposed to leaving it to the state
agency to determine); or
b.
Provide a more thorough definition of
appropriate medical treatment guidelines, perhaps through a series of criteria
that must be met. Such criteria might include requirements that the
medical treatment guidelines:
i.
Rely on specified, comprehensive, systematic
review of medical literature;
ii.
Include transparent criteria for rating the
strength of evidence, including individual medical studies;
iii.
Remain current and incorporate contemporary
studies;
iv.
Address frequency, duration, intensity, and
appropriateness of treatment;
v.
Have been adopted by at least one other state.
2) [Section
6: Prohibition]: The use of the word “may” in connection with preauthorization
is troubling. In some states, the preauthorization process is viewed by
physicians as contentious and antagonistic. PRIUM advocates the use of
preauthorization procedures if, and only if, the treating physician refuses to
engage in collegial discussion or respond to the medical evidence when it is
presented to him/her by a peer. Nevertheless, should a treating physician
prove unresponsive to the evidence, we believe statutory language should
provide more stringent protocols for addressing such issues. We also find
the limit in Section 6 to “specific forms of opioids” far too narrow to address
the overarching issue the industry currently faces. We suggest the
following: “The Agency shall grant the insurance carrier the right to require
preauthorization for any medications being prescribed that do not appear to
meet the standard of care established by the medical treatment
guidelines.”
Regarding the model rules, the translation from statute to
regulatory approach is well defined. We found the “drafting notes” to be
particularly helpful in guiding lawmakers in the development of these critical
rules. There are a few areas, however, that we believe require more
nuanced thinking prior to launching the regulatory model:
1) [Section
1, (3): Effective Date]: Our industry learned a valuable lesson from the
creation, adoption, and implementation of the Texas Closed Formulary
Rules. Texas implemented these new rules in two stages: starting 9/1/11
for all new injuries as of that date, and starting 9/1/13 for all “legacy”
claims, effectively providing a two year remediation period for the insurance
carriers and treating physicians to address difficult cases in preparation for
the 9/1/13 requirement for preauthorization of all N drugs. This is smart
public policy. Contrast this with New York where adoption of medical
treatment guidelines as of a single, “line in the sand” effective date has
created a judicial and legislative battle that has yet to resolve itself.
On the one hand, a single effective date creates chaos as carriers and
physicians try to figure out how to address legacy claims, which tend to be
extremely complicated. On the other hand, only applying new rules to new
injuries creates two standards of care within a workers’ compensation system, where
an injured worker’s treatment plan is driven entirely by the date on which they
were injured (which makes no clinical sense). We recommend model
regulatory language that mirrors the Texas Closed Formulary approach – an
initial implementation date for new injuries, followed by a remediation period
for legacy claims, followed by a fully effective date for new rules and all
claims.
2) [Section
7: Continuing Education]: We understand that there was a lively discussion on
your most recent conference call regarding the mandated education component of
the model rules. Our view is that the absolute onslaught of marketing
dollars spent by the pharmaceutical industry to “educate” doctors should, in
fact must, be countered by mandated, unbiased continuing education focused on
the risks associated with chronic opioid therapy. In 2011, the
pharmaceutical industry generated $11 billion from the sale of opioids, a full
$3 billion just from Oxycontin. The #1 source of information for
physicians regarding these drugs remains the drug company sales
representative. This must change. PRIUM is disappointed that state
medical societies and the American Medical Association are opposed to such
measures. We strongly recommend that IAIABC remain committed to mandated
continuing education.
3) [Section
10, Preauthorization Required]: PRIUM believes that the best possible way to
eliminate the over-utilization of prescription drugs in workers’ compensation
is to engage the treating physician in the creation of a revised treatment plan.
Mandated preauthorization should not be the first step taken by an insurance
carrier when a particular claim is brought under scrutiny due to the
prescription medication regimen. That being said, if the treating
physician refuses to participate in the creation of a revised treatment plan
and continues to prescribe, in some cases, dangerous levels of medications,
mandated preauthorization can be a powerful tool to protect patient safety and
ensure positive clinical outcomes.
We appreciate the opportunity to provide this feedback and
commend IAIABC for the transparency and collaboration that have been emblematic
of this process thus far.
Respectfully submitted,
Michael Gavin
Chief Strategy Officer
PRIUM
Michael Gavin - Chief
Strategy Officer
2805 Peachtree Industrial Blvd.
Suite 112
Duluth, GA 30097
Direct Line: 678-735-7305
Toll Free: 888-588-4964 x104
Cell: 678-458-8216 Fax: 678-736-6585
Website: www.prium.net
Twitter: @PRIUM1
