Texas’ efforts to control WC Rx

In the very narrow world of work comp managed care, there’s an even skinnier slice focused on managing pharmacy. As pharma accounts for almost a fifth of all medical dollars spent in comp, its an area that certainly deserves attention – from employers, insurers, legislators and regulators.
There’s a lot going on in work comp pharmacy:
– the basis for fee schedules in 33 of the 34 states with fee schedules for comp will change within a year;
– the use of potent and potentially addictive narcotic opioids is rapidly increasing;
– price increases on brand drugs has raised the price per pill rather dramatically; and
– drug testing and the use of opioid contracts are gaining traction.
Interestingly, there’s only one state that currently has a somewhat restricted formulary in place – Washington, which actually prohibits the use of several controversial drugs for work comp claimants.
Texas has been working on a ‘closed’ formulary for a couple of years now, and has made significant progress. Basing their list of drugs on the ODG guidelines, Texas will be the first non-monopolistic state to require payers’ authorization of a number of drugs before they can be dispensed.
While the review and regulatory drafting process has taken a while, involved many parties, and required many meetings, sources indicate it is getting close to completion. The length of time it takes to get this done is not surprising, as this is new ground for regulators, payers, and clinical personnel as well.
The formulary will allow most drugs commonly used in work comp to be dispensed without any prior authorization (PA) or review (just as they are today) but a relatively few drugs will have to be specifically authorized by the payer. Among the drugs requiring a PA is my old favorite Actiq(r), a very, very expensive, very potent narcotic lollipop that is only FDA approved for breakthrough cancer pain for patients already using a narcotic opioid.
I’ve locked horns with the good folk from Texas’ DWC in the past over their managed care reporting methodologies; I’d be remiss if I didn’t applaud their efforts to address one of the most significant problems in workers comp – the inappropriate use of expensive drugs.
It isn’t just the cost of the pill that’s the issue. Patients taking narcotic opioids for extended periods are at high risk for addiction; are severely limited in their ability to return to work; and often suffer from significant and highly problematic side effects (depression, constipation, erectile dysfunction are just a few).
This is one of those issues that isn’t easy to address. Managing pain can be highly controversial, is a very patient-specific and not-well-understood aspect of medicine, and often puts physicians in a difficult position. If they don’t treat the pain as the patient desires they may be subject to sanction, but if they overtreat they may harm the patient or contribute to abuse or diversion.
Adoption of state-approved prescription medication guidelines will go a long way to helping resolve these issues, and kudos to Texas’ DWC for the thoughtful, careful way they’re going about it.