This page contains a Flash digital edition of a book.
“I recommend doctors get very familiar with this rule.”


the rate and expense of opioid prescrip- tions decreased by 10 and 17 percent, respectively. Dr. Swift saw similar outcomes in the dozen or so Texas MedClinic urgent care clinics he runs as chief executive of- ficer, where workers’ compensation pa- tients make up about 25 percent of the caseload. While N-drugs make up only 1 percent of all clinic prescriptions, that number still dropped by 40 percent in the last six months or so. As a primary care facility that does


not treat long-term pain, for the 52 lega- cy claims in his clinics, “it behooves us to look at why those prescriptions are being written,” Dr. Swift said. The closed formulary includes all


Food and Drug Administration-approved drugs with the exception of:


• Drugs with “N” status identified in Appendix A of the Official Disability Guidelines — Treatment in Workers’ Comp (ODG);


• Compounds that contain an “N” drug; and


• Any investigational or experimental drugs.


The list of N drugs includes certain


antidepressants, antiepileptic drugs, asthma medications, muscle relaxants, nonsteroidal anti-inflammatory drugs, opioids, sedative-hypnotics, topical an- algesics, and more. Physicians can view the most current list and DWC closed formulary rules at www.texmed.org/ CompFormulary.


Despite some initial confusion over 42 TEXAS MEDICINE February 2013


the list, Round Rock pain management specialist Graves T. Owen, MD, says he encountered no problems finding al- ternatives to excluded drugs. Workers’ compensation officials “have not limited a whole class of drugs. What they did was change access to ‘not recommended’ drugs, by requiring preauthorization.” Some of the nonformulary medica- tions, for example, may have unproven effects or even be dangerous. The mus- cle relaxant Soma (carisoprodol) was excluded because it lacked sufficient scientific proof of medical efficacy and because it carried added risks of abuse due to a euphoric effect when mixed with other drugs. Dr. Graves has since seen fewer new patients referred to him on the questionable drug. The pain medication oxycodone, also


prone to abuse, was excluded, too, while morphine, a potential substitute, was not.


“The sooner we prepare, the better, because this is not about just getting people off addictive drugs, it’s about making sure people are obtaining a ther- apeutic benefit [as defined by ODG] on the drugs they are prescribed,” said Dr. Owen, president of the Texas Pain Soci- ety, part of TMA’s House of Delegates.


Next steps That could take time and help from in- surance carriers in managing the rough- ly 15,000 legacy claims in the system, which DWC factored into the bifurcated implementation schedule and the transi- tion rules, Mr. Zurek says. The regulations require physicians


and carriers to formally discuss the pharmacological management of these patients. Ideally, the two parties would agree before Sept. 1 on how to proceed. That agreement could include a weaning schedule, a plan to continue the patient on the N drug, or other alternatives. “We didn’t want to get into prescrib- ing what the agreement should be, and there is very broad language in the closed formulary rules that leaves it in hands of professionals,” Mr. Zurek said. To initiate that process, insurance carriers must notify physicians, injured workers, and pharmacies in writing by March 1 of any legacy patients for whom an N drug was prescribed after Sept. 1, 2012.


Physicians should expect those letters, and possibly phone calls, and contact carriers, who are obligated to provide a physician peer, such as a medical direc- tor or utilization review representative. For the physician and carrier to agree


to continue a patient on an N drug for any length of time, doctors will have to verify the medical necessity of the medi- cation. The agreement would prevent doctors from having to produce proof repeatedly and ensure payment for the drug based on the agreed-upon plan and timeframe, Mr. Zurek says. Beginning in October 2012, Texas Mutual Insurance Company, the state’s largest workers’ compensation carrier, reached out to physicians by phone and by mail. As of December, it had sched- uled roughly 400 peer-to-peer discus- sions between prescribing doctors and the company’s medical director. Of those conversations, more than 90


percent ended in agreements, says Kim Haugaard, vice president of network and medical operations.


He called the negotiations “multifac- eted,” adding that they ranged in scope and duration, depending, for example, on the patient’s condition and other drugs he or she was taking. Such com- plicated treatment decisions “can’t be considered in a vacuum.” In some cases, patients were weaned


off narcotics right away, while for others that process did not work and the physi- cian and carrier remain in conversation. Still others agreed to test an alternative


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68