The good folks at CWCI just published a research report (The Cost and Utilization of Compound Drugs, Convenience Packs and Medical Foods in California WC) documenting the rise in spend on medical foods, repackaged drugs, and compound drugs from 2006 – 2009; the highlight is these categories accounted for almost 12% of drug spend in California in Q1 2009.
A couple of the findings that jumped out at me…
– the average amount paid per compound drug as $728 in Q1 2009.
– medical food reimbursement hit $233 per script that quarter
– a new category, ‘co-packs’ has emerged as a significant therapy; these are combinations of drugs with medical foods dispensed as a single unit.
The story of drug costs and attempts to address same in California is fascinating, with lessons aplenty for regulators and payers.
– A drastic reduction in the fee schedule was followed by explosive growth in repackaged drugs.
– Regulatory changes finally addressed that issue, but meanwhile the use of narcotic opioids increased six-fold, likely negatively impacting disability duration as well as increasing cost.
– New entrants into the therapeutic armamentarium, entrants that are foreign to many adjusters, case managers, and work comp execs alike, are growing in importance, requiring regulators and payers alike to understand their impact and develop policies for coverage and reimbursement.
The list of medical foods includes Theramine, Gabadone, Sentra, Apptrim, Trepadone, and others, with Theramine (pain) and Sentra (sleep aid) accounting for over half of the volume in California. Medical foods are pretty new to me; according to the Orphan Drug Act (1988 Amendment), a medical food is “a food which is formulated to be consumed or administered enterally (orally) under the supervision of a physician, and which is intended for specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.”
I’m no pharmacist or clinician, and am certainly not able to comment on the efficacy of medical foods or specific medications. For a primer on medical foods, click here.
There does appear to be evidence supporting the use of medical foods for treatment of pain, osteoarthritis, and other conditions, with one medical food, Limbrel, the subject of large, double-blind, placebo-controlled clinical studies in the United States and Japan. According to one source, “Limbrel administration has resulted in statistically significant improvement in all primary clinical endpoints (functional mobility, functional stiffness and functional joint discomfort).”
What does this mean for you?
If your P&T Committee hasn’t looked at medical foods yet, you may want to add it to the agenda for the next meeting. It is highly likely we’re going to see more of these scripts, and far better to be ready than to have your adjusters making decisions completely unprepared.
Aug
18
