Roughly 70 percent of problematic, "grey zone," drug prescriptions for injured workers are prescribed to reduce pain, estimates Beth Kuschner, a pharmacist at Progressive Medical, Inc. the pharmacy benefit manager. And opioids are often a key problem drug, as has been well documented.
Many injured workers have died from misuse of prescribed opioids. For every death, hundreds of injured workers remain dependent on opioids and other pain killers with little or no access to conservative (or as some put it) holistic care.
So it is a pleasure to report marked progress in risk reduction in some quarters, although most claims payers remain somewhat uncertain about concerted, broad-scale strategies to address chronic pain.
Texas introduced in 2011 an approved list of drugs. It withholds approval of leading opioids and other pain-treating drugs such as anti-depressants for "first line" treatment of pain.
Mark Pew, an executive with Prium, a managed care company, briefed me on the impact in Texas to date.Prium and others geared up for a "huge influx" of pre-authorization requests of unauthorized drugs, but that did not happen. He says use of these drugs has dropped precipitously due to people switching prescriptions to alternatives with less addictive secondary effects.
Pew and Kuschner also commented on the merits of other, less aggressively written, state guidelines on drugs. Pew believes that West Virginia's regulation has contributed to a reduction in opioid prescribing. Minnesota's and New York's laws are too new and perhaps too weak to be effective.
In 2007, Washington state introduced procedures to control the prescription of opioids over a specified daily dose that the state's medical directors saw as a threshold to patient safety problems. The state just reported that dosages over the threshold have dropped by 35 percent and that drug-related deaths have declined by 50 percent.
Insurers and third-party administrators are now just beginning to make more judicious prescribing a condition for participating in medical provider networks. The State Compensation Insurance Fund of California sent a letter to its network doctors last June that set limits to opioid prescribing (as well as to physician office dispensation of drugs).
Bernyce Peplowski, SCIF's medical director, has held firm in the face of criticism by the California Medical Association. The California Society for Industrial Medicine and Surgery alleged that SCIF's opioid guidelines might cost doctors their medical licenses. Bravo to Peplowski and the SCIF's head of claims, Julie Jenkinson. They are advocating a balanced chronic-pain strategy that includes conservative care which is endorsed by all the major treatment guidelines. SCIF is using doctors to coach treating doctors on the full range of care options.
At some point, claims payers need to become honest about how they are using the best practice guidelines. They cite the guidelines on opioid prescribing, but don't talk about conservative care, which the guidelines also uniformly endorse. Managed-care consultancies that focus on chronic pain strongly support them.
PETER ROUSMANIERE is an expert on the workers' compensation industry. He can be reached at email@example.com.
February 21, 2012
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