UR Nation End of Month Regulatory News Summary

| | Technology & Integration, Utilization Review

CO Health Initiative ColoradoCare Goes Down in Flames

ColoradoCare (also called Amendment 69) was a ballot initiative that would have created a state health care system. The system would have absorbed the medical portion of workers’ comp. However, Colorado voters soundly defeated Amendment 69 by a whopping 80 to 20 percent.

Interestingly, 2016 tracking showed ColoradoCare gaining momentum until about three months ago. Also, many thought that with the massive rate hikes seen on the ObamaCare exchanges (many health care plans going up 40 percent) Coloradans would vote for ColoradoCare to simply get some relief. Small businesses could have also benefited from ColoradoCare because they would have been able to offer the same health benefits as Fortune 500 companies, which generally get better health care rates due to their better negotiating leverage.

CA DWC Analysis Shows Almost Half of Providers Fail to Properly Document RFAs for Opioids

In November, CA DWC issued a report on the state of IMR. During 2015 and 2016, IMR had been improving in several areas, including turn-around times. But based on DWC analysis, another interesting fact has come to light. Nearly half of the IMR decisions on opioids failed to include documentation needed to determine if the painkillers were medically appropriate. Specifically, the chronic pain section of MTUS requires providers to document four key areas when seeking to maintain an opioid regimen. These includes evidence of relief of pain, improvement in functionality, the presence of side effects and evidence of addiction. Interestingly, when looking at IMRs for opioids, DWC found that only about half the time were all four of these criteria satisfied. Put another way, providers included adequate documentation in only half of their requests for opioid treatment.

NC Has Announced Workplace Injuries Have Plummeted 51 Percent in 15 Years

In a recent press release, the Department of Labor announced that workplace injuries and illness rates have dropped 51 percent over the past 15 years. Specifically, in 2015 the number of cases dropped to just 2.6 per 100 full-time workers. That was down from 2.7 per 100 full-time workers in 2014. For construction workers, the rate dropped to 2.7 per 100 full-time workers in 2015, down from 3.3 per 100 full-time workers in 2014.

The agency said that the Tar Heel state is one of the safest states to work, adding that the national average rate is 3.0 claims per 100 full-time workers. Labor Commissioner Cherie Berry said “Good employers understand that a good workplace safety program pays for itself, but at the end of the day it’s really about making it [safely] home to family and loved ones that matters most.”

This trend follows a national trend of fewer workplace related injuries and illnesses, due to many factors including more information technology jobs and improved safety measures in the construction and manufacturing industries.

NY Launches New Hearing Process for Opioid Weaning

In an announcement in November, the NY WCB alerted system participants that they were 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. An administrative law judge will then conduct a hearing to determine if the claimant should go through a weaning process to stop taking 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. Pew said, “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 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.

A Report by Optum Shows Compound 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% (one half of one percent).

Tron Emptage, chief clinical officer in Optum’s workers’ compensation division, said workers’ comp saw a rapid rise in compound medications prescribed 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. Emptage states, “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 use opiods for just a few days post-injury, in addition to those using the drugs long term.

Surgeon General Vivek Murthy Released a New Report on Drug and Alcohol Addiction

United States Surgeon General Dr. Vivek Murthy has 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 percent of those suffering from substance abuse will get treatment. One of the findings in the report is that addiction treatment in the US 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.

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.