Problem-Solving Perplexity for California and New York

| | Technology & Integration, Utilization Review

Jaelene April Article on California and NY
Regulations often provide an opportunity to solve problems. For example, California and New York are working to solve the problems associated with abuse of opioids and other prescription drugs, such as benzodiazepines, through creation of a drug formulary. Determining how to implement regulations and achieve desired outcomes, however, can be perplexing. This is especially true when there is a short time window between publication of an adopted rule and the rule’s effective date. This shortened time frame can be a direct result of statutory directives.

California regulators and stakeholders have had ongoing dialogue since AB 1124 was adopted in October 2015. The Division of Workers’ Compensation (DWC) utilized their Rulemaking Forum to gather feedback and published proposed rules earlier this spring. The public comment period ends May 1, leaving less than two months between publication of the adopted rules and the July 1, 2017 statutory deadline for adopting a formulary, a small window indeed.

On April 10, New York Governor Andrew Cuomo signed into law a state budget that includes a fast track drug formulary implementation. Page 161 of S2009/A3009 (see Sec. 13-p) directs the chair of the Workers’ Compensation Board to establish a comprehensive prescription drug formulary on or before December 31, 2017. Prior to adoption of the budget bill, the New York Workers’ Compensation Board initiated discussion of a formulary by releasing a Pharmacy Benefit Plan Discussion document, which included a workers’ comp drug formulary. Though the dialogue has already begun, the rulemaking schedule will need to be very aggressive to meet the statutory deadline.

With limited time between publication of an adopted rule and the rule’s effective date, it is necessary to think through the workflow options for compliance by system participants on an accelerated basis. It is also prudent to anticipate changes that may be made as a result of public comment or known future changes. For example, one future change is California’s utilization review turnaround time requirement for “formulary” requests effective January 1, 2018. The new rules will allow a worker only 10 days to request IMR. That’s a major change from the current 30 days seen in non formulary reviews. This exercise of identifying changes is crucial, but it’s made much more difficult when the time window is small.

As an analogy, think about why most college quarterbacks never make it to the NFL. Hall of Famer Kurt Warner was recently asked “What’s the most important attribute of an NFL quarterback prospect?” He said a good prospect has to be accurate with his throws. “The windows are much tighter in the NFL. Miss a receiver by two feet in college and it’s probably still completed. Miss a receiver by 2 feet in the NFL and the ball is probably coming back the other way.”  In the case of California and New York, their time windows are “NFL caliber,” and that is very challenging.

In this article I also wanted to raise awareness of where California, New York and other states looking to solve problems via a formulary can get help. The plethora of information presented during the 2017 Rx Abuse and Heroin Summit may provide valuable insights into what works and what doesn’t. Important topics for the Summit include Clinical, Prevention, PDMP and Treatment. For those who missed the 2016 RX Summit, presentations and videos are posted here:

Jaelene Fayhee

Jaelene Fayhee

Jaelene Fayhee, AVP, Client Solutions for UniMed Direct, is a regulatory expert who works hand-in-hand with clients and the technology department to deliver technology and medical solutions to clients. Jaelene is focused on using technology to ensure compliance with current and upcoming regulatory requirements and delivering prompt and appropriate decisions to expedite medical decisions for injured workers.