Friday, December 13, 2013

A Critique of the American College of Physicians Position Paper on Prescription Drug Abuse

The American College of Physicians (ACP) just published a “position paper” on prescription drug abuse.  While one might find fault in the details of such exercises (and I do… please read on), one should also commend such organizations for attempting to tackle this very difficult issue.  As the paper states, “the challenge for physicians and public policymakers is how to deter prescription drug abuse while maintaining patient access to appropriate treatment.”  A challenge, indeed.  In fact, it’s one of the most significant public health challenges in a generation. 

The paper includes several very helpful statements, including recommendations for:

-          A national prescription drug monitoring program (PDMP)

-          Consideration by physicians of “the full array of treatments available for the effective treatment and management of pain.”

-          A comprehensive national policy on prescription drug abuse

-          The adoption of evidence-based medical treatment guidelines

On the other hand, several of the other recommendations come with caveats that are hard to explain given the breadth and depth of the prescription drug abuse epidemic.  For instance:

The ACP “supports efforts to education physicians… on the appropriate medical uses of controlled drugs and the dangers of both medical and nonmedical use of prescription drugs.”  However, the ACP goes on to say that “it does not support additional legislative mandates or DEA registration prerequisites specifying education requirements regarding prescribing controlled substances.”  Why not?  “The prevention, identification, and treatment of prescription drug abuse take time, and the significant extra time required to adequately perform this task is not reimbursed.”  I find that a relatively weak rationale for the avoidance of mandatory education in light of the largest man-made epidemic in history. 

Education isn’t the only area where the economics of physician practice run afoul of potential best practices.  “ACP favors a fair and balanced approach to permit safe and effective medical treatment utilizing controlled substances and efforts to reduce prescription drug abuse.  However, educational, documentation, and treatment requirements toward this goal should not impose excessive burdens on prescribers or dispensers.”  I’m not suggesting that it’s ok for the provider community to bear excessive administrative burdens, but the position paper goes on to state that the real issues are potential loss of DEA licensure, state disciplinary actions, loss of medical license, and potential criminal sanctions based on failure to comply with documentation and treatment requirements.  We have reviewed thousands of pages of medical records here at PRIUM and I can vouch for the fact that most of them are awful.  The documentation related to chronic opioid therapy is critical to the physician education the ACP says it supports.  Lives are stake.  Our view: At a minimum, make sure documentation is thorough, accurate, and in compliance with legislative and regulatory standards.  Do it right or face penalties. 

The ACP appears to reluctantly support random drug testing when Medicare, Medicaid, private insurance, or law enforcement authorities identify patients as being at significant risk of drug abuse.  They emphasize that the 3rd party requiring such testing should pay for that testing (to which I have no objection), but go on to point out that when a third party mandates drug testing, the patient should be informed that the testing will occur on a random basis, patient consent should be obtained, and the procedure should be implemented in a manner that helps maintain the patient’s dignity.  Finally, the ACP points out that this recommendation only applies to third party mandated testing rather than a situation in which a physician includes monitoring as part of an overall treatment plan developed to meet the evaluated needs of a given patient.  Not one mention of the necessity of random drug monitoring to ensure both patient and community safety. 

The ACP position paper is a start, but rather than balancing deterrence of prescription drug abuse with access to appropriate treatment, the ACP appears more focused on balancing deterrence of prescription drug abuse with physician practice processes and economics. 

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Thursday, December 5, 2013

California: What's Working, What's Not

I spent some time recently visiting PRIUM's customers in California, a state that might as well be its own country when it comes to workers compensation (and lots of other things).  Some specific observations based on my interactions with carriers, self-insured employers, TPAs, and attorneys around the issues of chronic pain management and prescription drug utilization:

The IMR backlog is as frustrating as it is predictable.  While the DWC has recently called for a public meeting to gather input on process optimization, the case load continues to mount at Maximus.  My own reading of the publicly available IMR decisions has uncovered some disturbing results (like Maximus case number CM13-0000947, the summary of which states that Valium, Duragesic, and Norco are all "medically necessary and appropriate."  Read further into the detail of the report, however, and each of these three drugs is actually deemed NOT medically necessary and appropriate.  A typo, yes... but a pretty critical one).  The results of the medication-related cases that are being acted upon appear favorable amongst PRIUM's customers that have used our peer review, oversight, and utilization review services.  Until the process is somehow changed, its incumbent upon payers to have an airtight process to avoid procedural errors and ensure predictable, accurate results that are in the best interest of injured worker health. 

Payers are spending way too much on ineffective urine drug monitoring services.  I see broad-based intellectual acknowledgement by payers that drug testing should be a part of any chronic opioid therapy regimen.  But there remains confusion around implementation, pricing, and what to do with the results.  Best practice here is not just to secure a contracted rate with a national drug monitoring vendor, but to develop a process to ensure optimization of the testing process.  This means that injured workers are tested at the right time, in the right place, using the best technology and that the results are communicated to the provider and payer as actionable intelligence that informs treatment decisions (not just a diagnostic test that gets thrown in a file).  We have a long way to go before this kind of methodical approach is commonplace. 

The use of independent medical exams allowed under Labor Code Section 4050 varies widely, but should be used more often.  If PRIUM is unable to engage the prescriber in a peer to peer conversation, we ask ourselves, "is there another way to gather information about the injured worker's care?  Without having to go directly to UR/IMR and all of its timelines, technicalities, and backlogs?"  Several payers in California use these 4050 exams to do just that.  What's more, the results of a 4050 exam may be used in the UR/IMR process later and may (under certain circumstances) be admissible in the AME/QME process (if applicable).  We're always looking for ways to inject independent, objective, evidence-based views on complex cases and this is another tool available to payers in California - more of whom, in our opinion, should be using 4050 exams.

"Functional Restoration Programs" in California are fast becoming a routine, expensive, and ineffective answer to prescription drug overutilization.  Some payers talk about these programs with such disdain and disappointment that it's downright depressing.  I asked every customer we met with, "who do you like?  where should we send them?"  I got a few suggestions, but not many.  The few I got are probably familiar to most payers, but in a state with as big an issue as California, there's a dearth of effective alternative treatment centers for injured workers.

By the way, should anyone disagree with that last point and wish to share other treatment programs in California that have great outcomes... I'm more than willing to listen. 

On Twitter @PRIUM1