WC experts eye Texas closed formulary for legacy claims

Long-term opioid users in the Texas workers' comp system are getting a wake-up call. The state next year is shutting off their supply unless they have pre-authorization.

While the intended result is fewer injured workers unnecessarily suffering the detrimental effects of these medications, the transition could be tricky. But experts say Texas has an opportunity to be a model for the nation as it addresses one of the most significant issues affecting the workers' comp system.

Closed formulary. Legislation passed in 2005 mandated that Texas adopt a pharmacy closed formulary to curb the use of certain medications. The closed formulary went into effect for new injuries in September 2011, requiring preapproval for certain drugs -- including many opioids. For legacy claims with injury dates prior to Sept. 1, 2011, the closed formulary takes effect Sept. 1, 2013.

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"By no later than March 1, 2013, payers must start the process of notifying physicians, pharmacies, and injured workers that there will be a process for evaluating drugs they are on," said Jim Andrews, senior vice president of pharmacy services for Cypress Care, a Healthcare Solutions company. "The industry can't wait until Sept. 1 and hope the program will immediately be turnkey. There are a lot of stakeholders and processes involved."

The initial phase of the program has generated impressive results, according to the preliminary results of a study looking at claimants affected by the closed formulary. Officials are hoping for a similar, smooth implementation of phase two in September 2013.

"That's the deadline when these patients must have a pre-authorized plan in place in order to make sure there are no hiccups in terms of payments or processes," Andrews said.

The transition. The time for workers' comp stakeholders to begin looking at alternative treatment plans for long-term opioid claimants is now, according to Texas workers' compensation officials. Experts admit there are many moving parts involved in these legacy claims.

"There is no magic bullet," said Phil Walls, clinical director at myMatrixx. "They must be handled one at a time. But when patient and physician agree it's time to be weaned off these medications, patients end up feeling better. That's a huge message."

Getting long-term opioid users to agree to be weaned off the drugs requires a plan to continue treating the injured worker's pain, as well as decreasing their dependence on the medication. One medical expert said long-term opioid users really believe they need their medications. An abrupt announcement removing it without offering a replacement treatment would leave them frightened and fearful.

"They think, 'I'm depending on this; this is the main thing that's keeping me OK. If you take that away, what am I going to do instead?'" said Dr. Jennifer Christian, founder of the Maze-Masters Program and president of Webility Corporation, "They need a reassuring answer. Otherwise, they will fight you like cats and dogs."

Working with physicians. Christian, who works with legacy claimants to help them get their lives back on track, said part of the problem is the lack of awareness among physicians of other treatments.

"What we've found in Maze-Masters is some people are on high doses for a long time because their doctors really don't know what else to do with them," she said. "We've been struck by the intellectual poverty of the physicians' treatment plans."

One problem, for example, is convincing physicians that an alternative treatment may be in the best interest of the patient.

Christian cautions that there are better treatments to substitute for opioids other than injections and stimulators and other technology. "Encourage referrals for other things that have been shown to work," she said. "Education is one. Because no one takes the time today to do it well, patients are woefully ignorant about the nature of chronic pain and the vicious cycles it creates in both nervous systems and body, and how they can use their mind to break those cycles."

Christian said programs that provide active support for physical and mental reconditioning, resumption of activity, and restoring the normal rhythm of daily life can be very effective.

"Consider that [physicians] may have a limited view of what is possible and try to give them face saving ways to say yes to you," she said. "Make it easy for doctors to prescribe better alternatives. Evaluating biopsychosocial factors and intervening to resolve them is critical. If you want the doctor to prescribe these things that are better than opioids, tell them you have pre-authorized it and who offers it."

Communicating to physicians, as well as payers and injured workers, is vital for the Texas program to be successful. The practice of using physician peer reviewers can go a long way.

"They are more comfortable talking to peer physicians," said Nancy Hamlet, senior vice president of marketing at Cypress Care/Healthcare Solutions. "That's been part of our strategy."

Most importantly is addressing the impending closed formulary for legacy claims now, rather than later. "Ideally, the process should start immediately," Andrews said. "I think a lot of people are looking at Texas as a model program."

Read more at the WorkersComp Forum homepage.

August 20, 2012

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