States are starting to study opioid prescribing patterns – and well they should.
Last week, WorkCompWire arrived with an update on Texas’ plans to assess opioid prescribing patterns for work comp claimants in the Lone Star State. Actually, this isn’t an assessment of prescribing patterns, but rather a very limited review/audit of the top 15 physician opioid prescribers – with some major exemptions.
The opioid audit plan [opens pdf] covers claims with dates of accident in 2010 where the initial opioid prescription was less than 10 days from the date of injury; there’s more than a 30 day total supply of opioids for the injured employee; and the physician audited was the health care provider prescribing opioids to the injured employee.
I asked TDI (via email) why the audit was limited to 15 physicians, when and if the names of the top 15 prescribers will be published, why they aren’t looking at multiple prescibers, and what they will do with the results. The initial response was boilerplate and did not address those questions.
If there’s more follow up (I asked again) I’ll let you know.
The very limited nature of the audit is puzzling; payers have been required to report all manner of information to Texas for several years, with rather draconian penalties for failure to report. With this wealth of data, gathered at great expense and at no small cost to employers and their payers and vendors, it should be relatively simple to provide in-depth information on prescribing patterns around the entire Lone Star State. These data could be case-mix adjusted as well, something that isn’t mentioned in the TDI announcement on the current project. It is entirely possible the Medical Quality Review Panel will do that, but the memo from TDI says the Panel will “assess the medical necessity and appropriateness of prescribing opioids incases selected for this Plan-Based Audit by using their professional expertise and knowledge…”
In fact, case-mix adjusting may be irrelevant, as it doesn’t appear this is a statistical analysis, but rather a kind of peer review.
I’m a bit puzzled as to the intent and outcome of this effort.
While it is admirable to evaluate opioid prescribing, it’s unclear what the reviewers or regulators or enforcement authorities or employers will do differently after the audit.
They’ll have a good perspective on prescribing patterns for 15 docs, but…to what end?
Perhaps this is intended to be a warning shot across the bows of prescribing physicians, letting them know that high prescribers may come under scrutiny at some point. That’s purely conjecture on my part, as I’m not sure I understand the utility of the audit as currently described.
California, for all their ills, has done a creditable job studying and reporting on the physicians’ opioid prescribing patterns. The multiple reports, discussions, and publications resulting from CWCI’s research have led to a much better understanding of the dimension of the issue in California, one that may well have been instrumental in the state fund’s decision to incorporate prescribing practices in network contracting requirements.
I look forward to more dialogue with TDI, and will keep you posted.
Jun
4
PRIUM submitted the following during the public comment period for the audit plan. We clearly share your concerns, Joe, regarding the limited scope and narrow focus of the audit.
To: Donald Patrick, M.D., J.D., Medical Advisor
Date: Thursday, April 26, 2012
As a utilization management company focused on the application of the Official Disability Guidelines to prescription drug utilization in the State of Texas, we appreciate the opportunity to provide input and suggestions on the development of the new Plan-Based Audit for health care providers prescribing opioids. We applaud the state of Texas for its efforts thus far in the area of narcotics control in workers’ compensation and hope that this new Plan-Based Audit will further limit the inappropriate use of prescription narcotics.
Regarding Section III: Scope and Methodology – We understand the budgetary limitations associated with any undertaking such as this. That said, we’re concerned that a focus on early prescribing of an opioid (within 10 days of the date of injury and >30 days supply) is too narrow to capture the broad nature of the problem. Often, injured workers only end up on grossly inappropriate drug regimens well after the initial injury, perhaps even years later. Dose escalations, tolerance, dependence, and addiction develop months and years down the road. While a focus on early prescribing behavior will alleviate a portion of the problem, our view is that the most intractable cases would not be identified with the criteria as currently proposed.
We suggest the Plan-Based Audit consider focusing on a measures much more likely to capture the most prevalent (and expensive) issue in the system – long term use of high dose narcotics. We suggest the following:
– Health care providers who have prescribed opioids to injured employees where the morphine equivalent dosage (MED) exceeds 120 mg per day.
Regarding Section IV: Selection Criteria – Again, we acknowledge budgetary constraints as a real issue in deploying a program such as the Plan-Based Audit. However, selecting a mere 15 physicians may not be sufficient to change or influence overall system behavior. The stated purposed of the Plan-Based Audit is to “focus attention on the issue of opioid utilization in the Texas workers’ compensation system.” We fear that the relatively small scope of the current proposed plan will fail to garner sufficient attention to guide future clinical decision-making.
Regarding Section V – Roles and Responsibilities – We suggest the following questions for the Medical Advisor’s consideration as he develops guidance for the MQRP experts (these questions would be in addition to the already stated objecting of ensuring “that health care providers adhere to the Official Disability Guidelines and medically accepted standards of care for prescribing pain management services including opioids”):
1) Has the patient signed an opioid treatment agreement or narcotics contract?
2) Does the provider have the patient undergo regular urine drug monitoring?
3) Did the provider consult a prescription drug monitoring database prior to writing the prescription?
4) Has an opioid risk assessment been completed to evaluate likelihood of abuse issues?
5) What are the specific treatment goals for this patient in terms of functional improvement?
These questions represent several “best practices” in prescription drug utilization management and we believe these questions provide a potential road map for evaluating the treatment patterns of selected physicians.
We appreciate of the opportunity to provide input and suggestions.
Regards,
Michael Gavin
Chief Marketing Officer
PRIUM