UR Nation End of Month Regulatory News Summary

| | Utilization Review

California CURES to Become Mandatory

The California Department of Justice certified that as of April 2 it had sufficient staff and resources to run the Controlled Substances Utilization Review and Evaluation System (CURES) prescription drug monitoring program (PDMP). Therefore, the California Medical Association announced that starting Oct. 2, 2018, all prescribers must consult the PDMP before prescribing Schedule II, III or IV controlled substances to a patient for the first time. Thereafter, prescribers must check the PDMP at least once every four months as long as the patient remains on the treatment regimen.

Providers prescribing no more than a 5-day supply of medications will not be required to consult the PDMP when doing so would delay timely access to treatment or if the prescription follows a surgical procedure. Also, prescribers in emergency rooms are exempt from having to consult the database as long as prescriptions do not exceed a 7-day supply.

California Department of Industrial Relations Director Christine Baker Stepped Down

On Monday April 2 news broke that Department of Industrial Relations Director Christine Baker announced her retirement, effective immediately, from state service. The announcement came via a late afternoon email to Department employees. Obviously, the suddenness of her resignation caused system participants to ask why. Some believe it may have had had something to do with the audit performed by State Auditor Elaine Howle. Christine Baker strongly disagreed with Howle’s suggestion that injured workers should be sent Explanation of Benefit (EOB) forms. Presumably, the EOB forms would be compared with services rendered, and the injured worker could therefore act as a fraud detection mechanism. But at this point it’s really just speculation.

We believe there is no denying Christine Baker’s impact on several reforms, not the least of which was SB 863. Christine Baker worked tirelessly with labor and management to help bring about sweeping reforms such as Independent Medical Review (IMR), Independent Bill Review (IBR), reduction of liens, more permanent disability benefits for injured workers, the return to work fund, and other reforms, including fraud detection in the workers’ comp system. Her career spanned 34 years, including work as head of the Commission on Health, Safety and Workers’ Compensation. Baker has been described as a “bright light” in the Jerry Brown Administration.

Labor and Workforce Development Agency Secretary David Lanier tapped agency undersecretary Andre Schoori to serve as acting director of the Department. Andre Schoori joined the Labor and Workforce Development Agency in 2014 and before that served as deputy director at the Assembly Speaker’s Office of Member Services.

National Guideline Clearinghouse to be Discontinued

The National Guideline Clearinghouse (NGC) announced that it will discontinue all services by July 16, 2018. According to the announcement, the Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services decided to end support of the clearinghouse to save $1.2 million or more. NGC will continue to post summaries of new and updated evidence-based clinical practice guidelines until July 2. But it is no longer accepting guideline submissions.

Most system participants think this is probably a win for ODG. You may recall that back in 2016 NGC dropped ODG from its clearinghouse because ODG did not meet “more stringent requirements” that NGC began using in 2014. At the time, Work Loss Data Institute, publisher of ODG, worked for months to try to keep ODG in the clearinghouse. But eventually, ODG gave up and said they did not think NGC’s methodology was applicable to clinical guidelines.

Following ODG’s removal, ACOEM responded by submitting two guidelines that were accepted. But interestingly, ACOEM did not submit any additional guidelines as they previously stated they did not want to give away commercial product by having it listed in the clearinghouse.

Another interesting fact is that New York recently chose the ACOEM formulary, in part because it met the standards for inclusion in the NGC. A New Work Workers’ Comp Board spokeswoman said that discontinuation of the NGC would not impact formulary implementation.”

New Reports by Optum and Coventry Show Progress on Opioids in Workers’ Comp

A report by Optum and a report by Coventry show continued progress in the battle against the opioid crisis. For example, in the Optum report 49% of injured workers receiving a prescription drug in 2017 were taking an opioid. That was down 4% from 2016. And the morphine equivalent dose per claim fell 5.7% over the same timeframe. In the Coventry report, overall opioid use was down 10.7% from 2016 to 2017. Also, costs for opioids per claim was down 14.4%. Both reports noted that the cost for compounds was down significantly.

These reports follow on the heels of Express Scripts releasing their new report showing that opioid spending fell 11.9% in 2017 compared to 2016. As for compounds, spending on compounded medications fell 37.1% in 2017.  Express Scripts noted that this marks the third consecutive year that spending on compounds has decreased.

One of the things the Optum report said was that, going forward, Optum expects to see a continued drop in opioid use as well as a reduction in morphine equivalent dose. Optum also said medication-assisted treatments and the use of addiction treatments should continue to grow.

Pennsylvania Governor Tom Wolf Vetoed SB 936 Formulary Bill

Gov. Tom Wolf came up with his own alternative plan to the SB 936 formulary bill. At that point it appeared highly likely that he would veto SB 936. Indeed, that’s exactly what happened, as he vetoed SB 936 just hours before it would have become law without his signature.

In a statement Gov. Wolf said, “Make no mistake, Senate Bill 936 is not a bill designed to fight the opioid crisis. Senate Bill 936 threatens health care for millions of workers who could be injured on the job, including police, corrections officers and firefighters, who put their lives on the line every day.”

Kevin Shivers, state director of the National Federation of Independent Businesses, blasted the Gov. Wolf’s actions. “The governor’s plan does nothing to stop the rampant price gouging for drugs prescribed in the state’s workers’ compensation system … instead, the governor decided to create an expensive new bureaucracy that does nothing to ensure drugs prescribed to injured workers are effective.”

We believe it has been a very unfortunate reality that in Pennsylvania the idea of a drug formulary has become a political hot potato.

Texas DWC Adopted Rules Requiring Preauthorization of All Compounds Starting July 1, 2018

Texas Division of Workers’ Compensation adopted rules requiring preauthorization for all compounds prescribed after July 1, 2017. The rules were published in the Texas Register. To many system participants this comes as very good news. Historically, compounders could create compounds for injured workers as long as they contained “Y” ingredients on the Texas ODG based drug formulary. The problem is that these compounds were not FDA approved and some compounds cost nearly $1,000 per tube.

Brian Allen, vice president of government affairs with Mitchell, said “We commend the … division for their thoughtful and thorough approach as they evaluated the use and cost of compounds, and the evidence-based medical needs of injured workers in Texas.”

Texas DWC Commissioner Ryan Brannan Resigned

Texas Division of Workers’ Compensation Commissioner Ryan Brannan announced he resigned his position effective May 1. Commissioner Brannan’s term was set to run through Feb. 1, 2019, so this comes as a real surprise. Most system participants, including all of us who know Ryan Brannan, are likely disappointed by this news. Commissioner Brannan was level-headed, reasonable, and showed good leadership while at the division. His leadership during Hurricane Harvey, for example, was outstanding. Despite disruptions and dislocations to the workers’ compensation system in the aftermath of Hurricane Harvey, system participants knew what to do, thanks to Ryan Brannan’s strong leadership and excellent communication.

Governor Abbot will likely appoint someone to serve out Commissioner Brannan’s term with the title of “Acting Commissioner” until a new person is chosen in 2019.

Tom Swiatek

Tom Swiatek

As Assistant Vice President of Regulatory Services, General Counsel, and Editor in Chief of UR Nation, Tom Swiatek draws on his experience as an insurance attorney on both the general liability side, as well as on workers’ compensation matters. As a California Workers’ Compensation Section Member, Tom is leading the discussion with respect to the regulatory challenges and opportunities facing the workers’ compensation system.