MEDICAL ECONOMICS
Closed formulary, part two Workers’ comp to require preauthorization for “legacies” BY AMY LYNN SORREL Legislation aiming to reduce over-
use of pain medications and other addictive and expensive drugs within the workers’ compensation program appears to be achieving that goal through stepped implementation of a closed formulary. With phase two of the process set to take ef- fect this September, leaders at the Texas Medical Association and the Texas Department of Insurance Division of Workers’ Compensation (DWC) say physi- cians should prepare now for what could be the more challenging part of the transition.
Under the closed formulary, mandated by the legislature in 2005, physicians must obtain pre- authorization from workers’ com- pensation insurance carriers be- fore prescribing roughly 90 differ- ent medications. The so-called “N drugs” not in the formulary include mostly opioids, analgesics, muscle relaxants, and antidepressants. Until now, the preapproval pro- cess applied only to patients injured on or after Sept. 1, 2011. Part two of the schedule kicks in on Sept. 1 of this year, when physicians also must obtain N-drug preauthoriza- tion for patients with workplace injuries before Sept. 1, 2011, the so-called “legacy patients.” That next step likely will involve meeting with carriers to move injured patients already tak- ing N drugs to alternative therapies, says Bernard T. Swift Jr., DO, chair of TMA’s Council on Socioeconomics. That means doctors and carriers must prepare and collaborate sooner, not later.
“It all sounds great from a policy perspective to get people
off narcotic pain medications. But the fact of the matter is, as treating physicians, it is in some cases very difficult when confronted with patients who may be very angry if asked to discontinue a drug they believe they need,” the San Antonio occupational medicine specialist warned.
“This is not us telling
Despite the added administrative hoop, however, the sys- tem appears to be working “pretty well” so far, Dr. Swift says. “Given the high level of abuse of prescription drugs across the state, this was a step in the right direction toward get- ting the problem under control, and it makes [physicians and patients] think twice about prescribing a potentially addic- tive drug over a long period of time,” he said. “The question is, Is this an administrative burden we want to keep? And I think the answer is yes. This is a purposeful administrative burden and probably one that is not entirely inappropri- ate, given the situation.”
doctors what they must do. We know that won’t work.”
TMA and DWC officials do not expect the process to be overly bur- densome, but are working together to ensure that it’s not. Over the past several months, agency representa- tives met with stakeholders, includ- ing TMA, the Texas Pain Society, and insurers, to discuss the rules and ed- ucational outreach so both doctors and carriers involved can help each other transition injured patients. “The intent of the rule isn’t to say everybody has to be off these N drugs, but [for doctors and carriers] to have peer-to-peer discussions and come to an agreement, if possible, on the continued coverage of that N drug,” said Matt Zurek, DWC execu-
tive deputy commissioner for health care management. Come Sept. 1, however, “if patients are still on those drugs, and phy- sicians have not reached an agreement with the carrier, those drugs will require preauthorization.”
So far, so good Recent DWC statistics show that from September to Novem- ber 2011, N-drug costs dropped by 75 percent, or $841,000. When compared with the same period in 2010, total prescrip- tion drug costs fell 26 percent, or $1.4 million. The frequency of all N-drug prescriptions also decreased 65 percent, while
February 2013 TEXAS MEDICINE 41
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