UR Nation End of Month Regulatory News Summary

| | Evidence Based Medicine, Utilization Review

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announcement-updated_4-1-15
CA DWC Launches Online MTUS Education Module for Physicians Treating Injured Workers

CA DWC launched a free online education course for physicians treating patients in the California workers’ compensation system.  CA DWC Medical Director Dr. Raymond Meister said “All medical providers who treat injured workers are required to understand and follow the MTUS.  The online course is a convenient tool for providers to learn how to use the treatment guidelines designed to improve medical outcomes for injured workers.”

The module is available on the DWC Website and will be available by module app soon. Medical doctors, chiropractors and nurses who take the course will receive one hour of free CME credit.  QMEs may report up to one hour of credit for QME reappointment.  The course is also available to anyone else wishing to learn about the MTUS, and a completion certificate is available.

The module specifically covers (1) What the MTUS is and how to use it, (2) how to navigate MTUS treatment guidelines and apply recommendations via case scenarios, (3) when to consider recommendations outside of the MTUS for the care of your patient, and (4) the role of UR and IMR.

DEA Slashes Opioid Production Quota by 25 Percent

The Drug Enforcement Agency (DEA) issued a press release stating that it has reduced by 25% its quota of opioids that can be manufactured in the U.S. in 2017.  As you may know, the DEA has a quota system whereby they try to ensure enough controlled substances are available each year to meet medical demand, while at the same time limiting the amount available (the fear is that excess amounts will be used for illegal purposes).

Silvia Sacalis, vice president of clinical services for Healthesystems, said the decrease opioid production quota was a positive move.  “It’s another step in the right direction, as federal and local agencies bring more awareness to the opioid epidemic and public health crisis we face due to the overuse and abuse of opioids.”  For workers’ compensation, Sacalis said she hoped this action signals a shift toward helping injured workers get treatment for their injuries rather than just treating the pain of the underlying injury.

Joe Paduda, principal of Health Strategy Associates called the DEA action more symbolic than meaningful.  “It is an indication that the DEA is heading in the right direction, but to make a dent in opioid overprescribing a 60% to 70% reduction in the quota would be needed.”

WCIRB Amends CA Pure Premium Rate Due to SB 1160 and AB 1244

The WCIRB said they would amend their pure premium rate filing if California passed SB 1160 and AB 1244.  True to its word, with the passage of those bills WCIRB has announced that it is now proposing a pure premium rate 4.3% less than what was approved on July 1.  Specifically, WCIRB is recommending a rate of $2.22 per $100 of payroll, compared to the current rate of $2.32.

WCIRB made it clear that they liked SB 1160’s changes to UR (in the first 30 days) and particularly liked the new lien rules – identifying significant savings from fewer liens as the bill prohibits the assignment of liens.  WCIRB also liked AB 1244 because it gives the DWC the power to suspend any medical provider from participating in the state workers’ comp system who has been convicted of a felony or misdemeanor involving fraud.

Ten Indicted in Alleged Pain Cream Scheme

A Federal Indictment has named 10 people from Texas and Arizona for their roles in a $100 million drug-compounding scam allegedly perpetrated against Tricare.  The defendants, who include doctors, pharmacy owners and marketers, were charged with 35 counts including conspiracy to commit health care fraud and aiding and abetting payment of illegal remunerations.

Prosecutors allege that the participants paid Tricare beneficiaries “grants for participating in a medical study” for obtaining and filling prescriptions for compounded pain creams, scar creams, migraine creams, and vitamins.  The allegations are that the grants were part of a sham medical study ostensibly used to evaluate the efficacy of compounded drugs.  The indictment alleges that from October 2014 to June 2015 Tricare paid more than $102 million for compounded drugs generated by CMGRX.  CMGRX was a Dallas based company that was owned by Richard Cesario of Plano Texas, and John P. Cooper of Southlake; two men named in the indictment.

In addition to payments to Tricare beneficiaries, the scheme involved payment of kickbacks to prescribing physicians, including Dr. Walter Neil Simmons, of Mesa AZ, and Dr. William F. Elder-Quintana, of El Paso TX.

Recent WCRI Webinar Shows PA, NY and LA Dispense More Opioids More Frequently

In an October webinar WCRI went over their recent study showing physicians in Pennsylvania, New York and Louisiana tend to prescribe injured workers higher dosages of opioids more frequently and see more injured workers become long-term opioid users.

The webinar compared opioid use across 25 states workers’ compensation systems, with a special focus on the outliers PA, NY, and LA.  Between 2012 and 2014, physicians in those states prescribed a disproportionately large amount of opioids to injured workers. WCRI used number of prescriptions, quantity of pills, and strength of the narcotics, as metrics.  WCRI defined “long term users” as those who refill their opioid prescription three or more times between the 7th month and 12th month post-injury.  The most severe outlier was LA.  The average claim in LA contained 250% more opioids than did a “low opioid state” like Missouri.

The webinar provided an overview of common tactics to reduce opioid over-prescription.  This includes mandating the use of a prescription drug monitoring program (PDMP), implementing a closed formulary, and requiring the use of treatment guidelines.  One example cited during the webinar was Texas.  During the WCRI’s study period, Texas adopted their closed formulary based on ODG and WCRI noted that opioids per claim dropped 20%.

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.