CA Formulary Rule-Making Slated for January
The California Division of Workers’ Comp plans to start formal rule-making for a prescription drug formulary in January, according to DWC spokesman Peter Melton. This is less than six months prior to the scheduled implementation date of July 1, 2017. Key to the formulary is the list of 257 medications that are designated “preferred.” Under the proposal, preferred drugs would be prescribed to injured workers without preauthorization. Non-preferred drugs, including opioids, would require utilization review. The proposed formulary rules include a “first fill” exception where a treating physician can prescribe a 4-day supply for such drugs as tramadol, morphine sulfate, or hydrocodone – within the first 7 days following the injury. Other states, such as Florida and New York, are now considering creating a drug formulary, so expect this formulary development trend to continue in 2017.
Telemedicine Services Launched by Concentra and Others To Expand in 2017
Concentra will begin offering telemedicine services early next year through a partnership with telehealth company American Well. The telemedicine service will give injured workers access to medical care 24 hours a day, 7 days a week. The addition of the new telemedicine service will allow employees to connect with Concentra physicians via computers, kiosks and smart mobile devices. Concentra is a division of Select Medical, and provides occupational medicine, urgent care, physician therapy and wellness services from more than 300 medical centers in 40 states. Expect to see more companies adopting telemedicine services in 2017.
CWCI Has New Report on Implications of Legalized Cannabis
The California Workers’ Compensation Institute published a white paper analyzing the implications of legalized recreational cannabis. In 2016, voters in California, Nevada, Massachusetts and Maine made recreational marijuana legal. Voters in Arkansas, Florida and North Dakota approved medical cannabis. So look for cannabis to be a significant issue in workers’ comp going forward.
Focusing on the California law, the law prohibits employers from having to reimburse injured workers for cannabis. It also precludes employer liability for injuries caused by marijuana intoxication. However, the report notes that proving marijuana intoxication could be an “insurmountable hurdle” since marijuana stays in the system much longer than alcohol. The report suggests that California employers have a clear written anti-marijuana policy. For example, many work campuses are “tobacco free” and could potentially be “tobacco and marijuana free” as a company policy.
Interestingly, on page 14 of the report it talks about the medical efficacy of marijuana. It said that while many have found marijuana effective for controlling chronic pain, the scientific community does not share a universal view on the effectiveness of marijuana as a medical treatment. For example, neither ACOEM nor AMA support marijuana use, and ODG guidelines expressly preclude marijuana as a treatment for pain.
Get Ready for Futuristic Treatments
During a webinar in December, Dr. Michael Choo, chief medical officer for Paradigm outcomes, discussed some interesting technological innovations. The most interesting was “electronic skin” that could be wrapped around prosthetics to give the patient feeling in an artificial limb. For example, while the human hand has about 17,000 touch sensors, a prosthetic hand or foot has none. The technology is currently under development at Stanford University.
Another interesting technology Choo discussed was called a neuro-spinal scaffold. This helps the spinal cord heal after injury. The product, under development by In-Viro Therapeutics, is inserted in the damaged area of the spinal cord. The scaffold is intended to provide support to the surviving spinal tissue and promote healing. It is made of the same material as dissolvable sutures and degrades over several weeks. In clinical trials, In-Viro reported that patients treated with the neuro-spine scaffold showed improvement in function.
Dr. Choo also discussed 3-D skin printing for burn wounds. This technology is currently being developed at Wake Forest School of Medicine. The treatment involves scanning the patient’s burn wounds to determine size, shape and depth. Next, a printer designed to print skin cells prints skin with a similar depth to natural skin. A much smaller patch of human skin is needed to grow the cells used in the printing process.
Gov Jerry Brown Signed SB 482 Requiring Doctors to Check PDMP Cures
Governor Jerry Brown has signed SB 482. The law requires that starting in 2017 doctors must check the CA PDMP database CURES before prescribing most controlled substances. Specifically, the measure will require providers to check the database before first prescribing any Schedule II, III, or IV drug. This of course is a classification that includes almost all opioids. If a doctor learns that a patient has a current prescription of a controlled substance the provider will not be allowed to prescribe the additional controlled substance. The only exception is if the doctor can determine that there is a legitimate medical need for the additional controlled substance. After initially checking the CURES database doctors are required to check it again every four months.
Dr. Robert Goldberg, chief medical officer of the work comp PBM Healthesystems, said he thinks requiring doctors to check CURES is an important step in curbing opioid prescriptions. He analogizes it to a “speed bump” that will require providers to go through one more step before writing a controlled substance prescription. He said it’s comparable to a computer pop-up notice asking if you’re sure you want to delete a file. Another benefit is that it will give doctors a defensive tool when patients are pushing for an opioid prescription. Doctors can tell the patient that they have no choice but to check with the database and see what else that person is taking. The doctor will also be able to get a bird’s eye view of the complete record of all controlled substance prescriptions a patient has received. “Net, net it’s a good thing,” Goldberg said.
SB 482 contains an exemption for doctors in a hospital emergency department to allow them to prescribe a controlled substance up to 7 days without checking CURES. In addition, doctors in non-emergency situations would be allowed to prescribe controlled substances up to 5 days if the drugs cannot be refilled. Some oncologists wanted another exemption for those suffering from cancer, but ultimately that exemption did not make it into the bill.
California joins 32 other states that require doctors to check drug monitoring databases when prescribing certain controlled substances. Look for all 50 states to have a PDMP program, or plans for one, by the end of 2017.
NY Launches New Hearing Process on Opioid Weaning
In late 2016 the NY WCB alerted system participants that they are starting a new hearing process for opioid weaning. Here’s how it works: Carriers and Employers concerned about a claimant’s long term opioid use can now file Form RFA-2: Request for Further Action by Carrier/Employer, and check box “k.” Box “k” says “opioid weaning under non-acute pain guidelines.” At that point the claimant will be allowed to submit a medical report generated by the prescribing physician. Then an administrative law judge will conduct a hearing to determine if the claimant should go through a weaning process to get that claimant off of opioids.
Mark Pew, senior vice president with Prium, said New York’s approach seems promising. However, he was concerned about a judge making the medical decisions on what’s potentially a life-and-death issue for the injured worker. Ideally, the judge would be presented with quality information, and the two sides would be able to reach some agreement. “New York is definitely taking the lead on this, but as usual, the devil is in the details.” Pew suspects there will be an initial wave of opioid-wearing hearing requests, as payers look to this process as a way to make progress on claims that have dragged on for years. He said savvy payers can now approach providers about the possibility of a hearing and potentially reach an agreement on appropriate treatment without necessarily going through with the hearing. Don’t be surprised to see other states adopt a similar scheme in 2017.
Per Optum Compound Drug Use Has Fallen by Half in 2016
A report by Optum shows that in addition to the average prescription drug cost falling 4.6% percent in the first 7 months of 2016, compounded drugs as a percentage of total spend dropped 56 percent. By way of comparison, in the first 7 months of 2015 .9 percent of injured workers were using compounded medications. In the first 7 months of 2016 that number dropped to just .5 percent (one half of one percent).
Tron Emptage, chief clinical officer in Optum’s workers’ compensation division, said workers’ comp saw a rapid rise in prescribing of compounded medication in 2012. But the high cost of compounds grabbed payers’ attention quickly, resulting in what he described as a “full court press” to educate case managers, update treatment guidelines, and take the position that compounds are simply not a first-line therapy for injured workers. “Our industry continues to be challenged by compounded medications and therefore a multifaceted approach to managing their use, inclusive of regulatory reform, remains important to achieving better outcomes.”
Optum also saw progress on reducing the use of opioid painkillers. The number of injured workers using opioids fell from 58.2 percent in the first 7 months of 2015 to 55 percent during the first 7 months of 2016. Keep in mind that these numbers include patients who used opiods for just a few days post-injury in addition to long term use. Look for this trend to continue in 2017.
Surgeon General Vivek Murthy Released New Report on Drug and Alcohol Addiction
United States Surgeon General Dr. Vivek Murthy released a report on drug and alcohol addiction. The report discusses misuse of alcohol, illicit drugs and prescription medications including opioids. It includes sections on the science of substance abuse as well as the role of prevention, treatment, recovery and health systems. Dr. Murthy describes, in great detail, how addictive substances “hijack” the brain’s reward systems (see page 2-19 for a discussion on how opioids attach to opioid receptors in the brain).
According to the report, one in seven people are expected to develop substance abuse at some point in their lives. Interestingly, only 10% of those suffering from substance abuse will get treatment. One of the findings in the report is that addiction treatment in the U.S. is largely separate from the rest of health care and serves just a fraction of those needing treatment. As such, the report recommends recognizing substance misuse earlier, and expanding access to treatment. Don’t be surprised to see the incoming Surgeon General in 2017 promote similar programs to thwart drug and alcohol addiction.
Look for Conferences in 2017 to Focus on Election Impact for Comp
The Workers’ Compensation Research Institute will structure its 33rd annual conference in Boston around the theme “Persistent Challenges and New Opportunities: Using Research to Accelerate the Dialogue”. Specifically, the conference will analyze the impact the Donald Trump presidency will have on healthcare (including the Affordable Care Act, Medicare, and workers’ comp). The question will also be asked “Is the workers’ compensation system still fulfilling its mission or does it need revisiting?” Also, the question will be asked, “With opioid use decreasing what alternatives exist to treat pain?”
UR Nation believes that the election of Donald Trump is a boon for workers’ comp conferences since it will generate so much discussion about the future of workers’ comp. Look for “Trump’s Impact on Workers’ Comp” to be a hot topic throughout 2017.