Medical Director Year in Review

| | Evidence Based Medicine, Physician Peer Review, Utilization Review

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Medical Director 2016 Year in Review V 3
As the Medical Director at UniMed Direct, I have the unique opportunity to share my thoughts and insights here on URNation.org. I have taken an inventory of the more significant regulatory events from 2016. Specifically, looking back at 2016, we experienced many changes that affected the workers’ compensation industry. And many important areas specifically impacted utilization review. Here’s a recap of some of the highlights.

Guidelines In Flux

  • National Guideline Clearinghouse (NGC) dropped ODG. This came as a surprise as ODG is the most widely used collection of guidelines. I tend to think that once NGC and ODG revisit this and ODG presents their evidence based medicine, NGC will accept ODG back into the Clearinghouse.
  • Effective 2/28/16, Tennessee adopted ODG for chronic pain and the ODG drug formulary for medication requests. I believe this was a good decision by Tennessee. The ODG chronic pain guidelines are user friendly in that they are easy to understand and easy to use. ODG guidelines are updated regularly ensuring that they stay at the forefront of advancing medical technology.
  • Colorado adopted new utilization review standards effective 1/1/17. The standards include a requirement that reviews must use Colorado guidelines if they are addressed by the guidelines. If they fail to do so, CO DWC can impose possible penalties. Colorado guidelines are well written. For the conditions they address, they are very thorough and comprehensive.
  • As of 10/1/16 Arizona adopted ODG for the management of chronic pain and opioids for all states of pain management. As I previously stated, adopting these guidelines was a prudent decision. This also makes me wonder if Arizona will adopt other portions of ODG in the years to come.
  • CA adopted new MTUS Chronic Pain Medical Treatment Guidelines, effective 7/28/16. This applies to pain that persists more than three months. It consists of Part 1 which is an introduction, and Part 2, which consists of a reformatted version of ODG from 4/6/15. Part 1 includes definitions and pain models and also addresses Functional Restoration programs. Part 2 includes procedures and medications. CA also adopted a 2-part Opioid Treatment guideline, also effective 7/28/16. Part 1 contains the opioid treatment guidelines and Part 2 contains a discussion of medical evidence supporting the guidelines in Part 1.
More States Made Checking a Prescription Drug Monitoring Database (PDMP) Mandatory
  • I generally support the enforcement of checking these databases prior to prescribing controlled substances. This is because PDMPs help curb doctor shopping for controlled substances. It also helps keep patients honest about reporting other controlled substances they are taking that could have adverse effects in combination with other medications. Although as clinicians we often pride ourselves in knowing our patients, I have been humbled to learn on more than one occasion that a patient has deceived me and other prescribers. The states recently adopting PDMPs were California, Pennsylvania, New Mexico, Massachusetts and Maine.

More States Considering Drug Formularies

  • Some states, such as Texas, Washington, North Dakota, Ohio, Delaware, Oklahoma, Tennessee and Nevada have drug formularies, and other states are now considering or are in the process of developing drug formularies. These include California, Florida and Louisiana.
  • The states that currently have these drug formularies report significant cost savings. In my opinion, the benefit of these formularies go beyond that. Unfortunately, there are physicians who exploit the system by prescribing or dispensing expensive medications, sometimes for their own gain, that are not supported by evidence based medicine. Drug formularies can significantly reduce these unsupported medications. I have no doubt that other states will also adopt drug formularies.

California Changed its UR Process

  • CA SB 1160 passed and goes into effect 1/1/18. It states that no utilization review is required within first 30 days of injury if the provider is in the MPN or is a pre-designated provider. 
  • To avoid utilization review in first 30 days, treatments shall be consistent with MTUS. Pharmaceuticals, non-emergency surgery, psychological treatment, home health care, imaging and radiology, DME more than $250, and electrodiagnostic medicine all require utilization review.
  • This will likely be beneficial to the initial treating providers, such as occupational medicine doctors. This measure will unlikely be of much benefit once a patient has been referred to a specialist.

We Are All Eagerly Following King v. CompPartners

Lastly, in California the case of King v. CompPartners is waiting to be heard by the California Supreme Court. This case involves injured worker Kirk King who had been taking Klonopin for anxiety. A request for Klonopin was sent to utilization review, managed by CompPartners. Dr. Sharma was the utilization review physician reviewer. He recommended a denial of the drug based on MTUS guidelines. King ceased taking Klonopin and allegedly suffered seizures from the abrupt withdrawal. He sued Dr. Sharma for failing to warn. The CA Court of Appeal ruled that he had viable cause of action against CompPartners and Dr. Sharma for failing to warn him that immediate cessation of Klonopin could cause seizures. One of the crucial outcomes of this case will be the determination if a doctor doing utilization review is practicing medicine. The outcome of this case could have a huge impact on how Utilization Review is done in California. We will continue to follow this and other changes that may come our way in 2017.

Zenia Cortes, MD, Orthopedic Surgeon

Dr. Zenia Cortes brings her combined expertise in sports and orthopaedic medicine to UniMed Direct, along with insights from her experience in peer and utilization review.