Louisiana: Will the Fix... Work?

I presented at the Louisiana Claims Association earlier this year to a room full of work comp adjusters, nurses, and executives.  We talked about the problem of opioid dependence and addiction and WCRI's analysis of Louisiana (not particularly good news for those assembled in that room). 
We talked about the new Medical Treatment Guidelines as well.  After sharing some uncomfortable laughs about the nature of Louisiana politics and how the development and adoption of the guidelines wasn't the most transparent of processes (I wrote about that here), we got into the specific area of the guidelines focused on prescription medications. 

In reality, the portion of the treatment guidelines dealing with drugs isn't bad.  Without going into the details, there's enough in the guidelines to, in theory, give Louisiana payers a way out of paying for medically unnecessary medication therapy. 

In theory.

I asked for a show of hands: How many payer organizations represented in the room were actively using utilization review, based on the treatment guidelines, to challenge inappropriate care?  A single hand went up.  And even that hand went up tentatively. 

What's the problem?  We all know.  Louisiana is like most state work comp systems.  Change isn't really change until the lawyers fight it out and the court says it's so.  And too often, the battle has been waged and lost by the payer community.  Thus, most payers take a "wait and see" approach to any level of reform that doesn't compel their action, but might cost them time and money. 

This week brings news that Louisiana is trying to clarify the appeals process for disputed medical treatment.  The goal is to edit form 1009 to make clear that the path to dispute resolution doesn't run immediately to the courts, but rather through the Office of Workers' Compensation Medical Director. 
A public hearing on the rule change is scheduled for tomorrow in Baton Rouge.

Louisiana readers: Will this make a difference?  Or is Louisiana creating a distinction in process without a difference in outcome?

Michael
On Twitter @PRIUM1

IAIABC Draft Rules on Opioids: Progress, But Work Still Needed

PRIUM submitted feedback on the original release of IAIABC draft rules on opioid prescribing back in May.  Last week, IAIABC revised those draft rules and we're pleased to see significant progress on the items we outlined as areas of concern based on the original version. 

Additional comment and feedback on the new has been submitted as follows:

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 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 more 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 1, (5): Evidence-based Treatment Guidelines]: We particularly appreciate the emphasis in the drafting note indicating that the model would be "most effective if there was a specific guideline on treatment of opioids that was presumptively correct".  However, in order to achieve the presumption of correctness, we believe the medical treatment guidelines adoption process is critical and should rely on one of the two following 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 7: Continuing Education]: 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 9, 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.  While the updated draft rules recognize the recent success of the Texas Closed Formulary, the example restrictions are of little value in light of what Texas has actually implemented.  Requiring pre-authorization of all drugs indicated as "N" in the Official Disability Guidelines Appendix A Formulary is a bold and necessary statement that only medically necessary drugs will be used to treat occupational injury.   

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

On Twitter @PRIUM1

Work Comp and Illicit Drug Use: A Physician's View

Last week, I wrote about an analysis from Ameritox that suggested the rate of illicit drug use in workers' compensation was comparably lower than in other payer classes.  I asked readers to weigh in on one of two possible explanations:

A) Injured workers, generally speaking, have a goal to return to work and dealing with chronic pain through medication therapy is something injured workers, because they are "workers", do responsibly. We know this isn't true for 8.6% of them, but those are bad apples and shouldn't spoil our view of the bunch.

B) Injured workers in chronic pain enjoy a higher rate of iatrogenic (physician-caused) tolerance, dependence, and addiction. Work comp claimants don't need illicit drugs because they're getting all the narcotics they need from their physicians. The existence of an indemnity benefit (which doesn't exist in the other payer classes) drives patient-directed care and higher levels of narcotics use without the need to seek out illicit drugs. 
The overwhelming response (via direct blog comments, emails to me, and LinkedIn group comments) was B.  A few of you weighed in with an "A... then B" perspective that suggested a lot of claims start out on the right track and then get derailed due to a number of factors ranging from legal representation to iatrogenic causes. 

One of PRIUM's physician reviewers, Dr. Bob Taber, offered an option "C":

Many WC chronic pain patients have learned by research (info readily available on internet sites), word of mouth or personal experience that many drugs (licit and illicit) are quickly cleared by the body. A Urine Drug Test (UDT) will not be able to detect the presence of such drugs if it has been more than 5-7 days since the drug was last used/abused. UDTs are recommended to be performed randomly on chronic pain patients receiving opioid therapy but this almost never happens. The patient knows that the only time s/he will possibly be subjected to a UDT is on the day of a scheduled follow up appt with their Doc. They know this date a month or two ahead of time. They are free to use their illicit drug of choice until about a week before their appt date without risk of detection. THC can linger much longer in the body than other drugs so frequent users risk a positive UDT for THC if they continue using until a week before their appt. (assuming that THC is in the test panel).

Dr. Taber suggests that the solution is to make UDT testing truly random and to ensure real, enforceable consequences for positive tests and/or non-participation.  In fact, he suggests that such an approach would mitigate the use of illicit drugs across payer classes, not just workers' compensation.

Many thanks to Dr. Taber for his insights.

Michael
On Twitter @PRIUM1

Where Are They Now? The "Oxycontin Seven" from 1998

For those of you who have seen my educational presentation on chronic opioid therapy, you know I'm fond of playing a video clip in which Dr. Alan Spanos says, among other things, that opioids are "our best, strongest pain medicines" and that "in fact, the rate of addiction amongst pain patients who are treated by doctors is much less than 1%".  He concludes by suggesting that opioids "should be used much more than they are for patients in pain".  This usually leads to audible gasps in the audience, many of whom see claims every day that fly in the face of this supposed medical wisdom. 

This clip is from a 1998 promotional video produced by Purdue Pharma that highlights the experiences of seven individual patients taking Oxycontin at the time.  The Milwaukee Journal Sentinel has just published a very well done "where are they now?" on these seven patients. 

Here's a summary of what happened to the seven: "Two of the seven patients were active opioid abusers when they died.  A third became addicted, suffered greatly, and quit after realizing she was headed for a overdose.  Three patients still say the drug helped them cope with their pain and improved quality of life.  A seventh patient declined to answer questions." 

As for Dr. Spanos, he's backed down considerably from his original stance on opioids.  He now says, "We don't know whether success stories like this are one in five, one in 15, one in 100, one in a thousand.  They may be quite rare." 

Quite rare, indeed.

Interestingly, Bob Twillman, Director of Policy and Advocacy for the American Academy of Pain Management, posted a link to this article on Twitter.  His take on the outcomes for the seven patients?  "... film shows that 3 of 6 chronic pain patients had really good results!"

While we can't fault Bob for trying his best to do his job, I can't imagine any rational member of the clinical community taking such a "glass half full" view of these outcomes, particularly when there is no reliable, replicable way to determine which patients will end up with positive clinical outcomes... and which patients will end up dead. 

Michael
On Twitter @PRIUM1

Work Comp and Illicit Drug Use: What Do You Think?

A new study from Ameritox indicates that work comp claimants are less likely than other payer groups to engage in illicit drug use. 

Ameritox looked at 2 million samples for 1.5 million chronic pain patients over a 2 year span from July of 2010 to June of 2012.  They found that rates of illicit drug use by payer class varied as follows:
- Medicaid (17.1%)
- Self-pay (14.8%)
- Commercial insurance (9.7%)
- Medicare (8.9%)
- Work comp (8.6%)

This finding likely runs contrary to assumptions I've heard many claims executives make about the chronic pain cases on adjusters' desks. 

So, while there are a range of potential explanations, I'll offer two possible perspectives and ask readers to weigh in.

A) Injured workers, generally speaking, have a goal to return to work and dealing with chronic pain through medication therapy is something injured workers, because they are "workers", do responsibly.  We know this isn't true for 8.6% of them, but those are bad apples and shouldn't spoil our view of the bunch.

B) Injured workers in chronic pain enjoy a higher rate of iatrogenic (physician-caused) tolerance, dependence, and addiction.  Work comp claimants don't need illicit drugs because they're getting all the narcotics they need from their physicians.  The existence of an indemnity benefit (which doesn't exist in the other payer classes) drives patient-directed care and higher levels of narcotics use without the need to seek out illicit drugs. 

What say you?  A or B?
I'll post the (informal) results in a few days. 

Michael
On Twitter @PRIUM1

Real Data: Prescription Drug Monitoring Works

A new retrospective study out of Canada helps paint a picture of the impact a real-time prescription drug monitoring program can have. 

Back in 1995, British Columbia was the first Canadian province to introduce a real-time prescription drug monitoring system (called PharmaNet).  This week, analysis of data gathered since the program's introduction was published in the journal of the Canadian Medical Association. 

The study finds that duplicate or inappropriate opioid prescriptions fell from 3.2 percent to 2.1 percent of total prescriptions after the system was put in place.  And inappropriate prescriptions for benzodiazdepines fell from 1.2 percent to 0.71 percent.

Contrast this with the following:

- While 49 states in the US have adopted legislation to authorize the creation of a Prescription Drug Monitoring Program, only 37 are up and running.  Of note: Missouri is the lone hold out.  See my post from June on the sorry state of affairs in that state.

- Funding in many of the 37 states is lacking.  California apparently has a single person responsible for administering the entire state program.

- We have yet to find a way to coordinate data sharing (or even data access) across state lines, severely inhibiting our ability, as a nation and as a collection of state work comp systems, to properly manage and leverage prescribing information. 

We have a long way to go on prescription monitoring.  But we have data that suggests it works.  Colin Dorumut, the epidemiologist at the University of British Columbia that led the research, put it best: "The cost of implementing these networks in terms of hardware and resources to build them is probably trivial compared to the millions of inappropriate prescriptions that can be prevented."

Michael
On Twitter @PRIUM1