The Texas Way Holds Promise

A closed formulary in place since September 2011 is showing promise, thanks to strict preauthorization checks embedded at the point of sale.

By DAN REYNOLDS, managing editor of Risk & Insurance®

A system in Texas which cuts down on the use of dangerous, inappropriate pain medications in workers' compensation could be an example for other states, experts said Thursday at the 21st Annual National Workers' Compensation and Disability Conference® & Expo.

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"At least short term, this has been a great success," said Mark Pew, a senior vice president of business development for PRIUM, the national utilization review company based in Duluth, Ga.

Pew and Jim Andrews, an executive vice president of pharmacy services for Healthcare Solutions, also based in Duluth, pointed to a year's worth of data on claims that have been governed by a closed formulary in Texas since September 2011.

By subjecting pharmacy workers' compensation claims to preauthorization for a schedule of dangerous and addictive narcotic prescriptions, Texas has succeeded in reducing the pharmacy fills on unapproved drugs by 53 percent.

One key element of the system is that the preauthorization check, in those cases where a physician failed to seek preauthorization for a medication, is embedded at the pharmacy point of sale.

The formulary was put in place for new claims, but payers and administrators who own "legacy" claims, or claims involving prescriptions that were active before September 2011, need to prepare themselves for when the closed formulary will apply to those legacy claims.

The idea in staggering the application was so that patients who have become addicted to opioids not be forced cold turkey into using alternative medications.

Not that there aren't plenty of pain relievers available. "The physician is not handcuffed, there are plenty of drugs to choose from, "Andrews said.

On Sept. 1, 2013, between 12,000 to 15,000 legacy claims in Texas will come into the controlled formulary, but companies had better start preparing now, Pew said. And many are.

"It's going to happen, people need to prepare for it," Pew said.

Texas isn't the only state that is making progress in the war on opioids. Utilization review has been put to good effect in California, Ohio and other states.

Pew and Andrews pointed to the drop in the percentage of pharmacy spending as a component of the overall workers' compensation spending in those states that are using utilization review.

November 12, 2012

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