Tuesday, January 17, 2012

Drugs, Whack-a-Mole and Transparency

While a National Conference of Insurance Legislators (NCOIL) committee will take "a hard look" at physician dispensing of repackaged drugs to injured workers when the organization meets in Biloxi, Miss., on Feb. 25, legislation placing limitations on restrictions on opioid prescriptions for injured workers could surface as stand-alone legislation or as part of a comprehensive bill to reform the workers' compensation system in California.

Problems associated with prescription drugs in health care, and in particular in workers' compensation, has grown to epic proportions, with many interest groups jumping in and sounding alarms about excess overdose death rates and out of control costs.

Mark Sektnan, president of the Association of California Insurance Companies (ACIC), said the increased awareness might be sufficient to attract the attention of lawmakers this year.

"Opiates are a growing concern and an issue in both workers' compensation and the prescription world," he told WorkCompCentral News. "The growing drum beat of opiate cases and stories seems to be getting to the level it needs to be to address this."

Jordan Estey, NCOIL director of legislative affairs and education, told WorkCompCentral that the committee is responding to a resolution passed at the organization's meeting last November in Santa Fe, N.M., instructing the panel to "investigate medical cost trends and related state cost-containment strategies, including state efforts on physician dispensing and drug repackaging."

NCOIL reports that "central to the issue are concerns that drugs are being repackaged using more expensive reimbursement codes than the originals - up to 300% more costly in some cases."

A number of states with some success stories are being highlighted in this national debate about prescription drugs.

Five medical boards and commissions in the state of Washington passed measures requiring a provider to perform a full assessment of a patient's health history and past treatment of pain when prescribing opioids. Doctors are required to prepare a treatment plan, and also seek a consultation for any prescription that exceeds the equivalent of a 120 mg dose of orally administered morphine per day. The Washington Department of Labor and Industries, which administers the state's monopoly workers' compensation system, is working on incorporating the new standards into its treatment guidelines.

Arizona Gov. Jan Brewer signed a bill on Feb. 29, 2011, requiring doctors to provide written justification in their reports when prescribing high dosages of painkillers or controlled-release drugs for acute pain. Additionally, a doctor must consult with the state's Controlled Substances Prescription Monitoring Program, a database of prescriptions created in 2008 to prevent patients from doctor shopping to obtain multiple prescriptions. A carrier is not required to pay for office visits if a physician fails to provide justification for a prescription or check with the drug-monitoring database.

In 2007, California approved capping the price of repackaged drugs based on the Medi-Cal schedule.

South Carolina approved price caps on repackaged drugs under a new pharmacy fee schedule in December, and Florida legislators have proposed legislation intended to curb the cost of such drugs.

But the way I see it, the bigger problem is that government's attempt at regulating this activity is like the carnival game, "Whack a Mole". Closing a loophole that allows providers to profit from one practice can lead to providers exploiting other profitable loopholes.

The bigger issue I think is that in workers' compensation and health care in general there is no transparency. The consumer of health care services and goods does not know what the cost of services or goods is, does not have statistical or empirical evidence of a provider's outcomes for comparison, nor does the consumer generally even care because the consumer (particularly in the case of workers' compensation) has no financial stake - "don't worry, it's covered by your insurance."

As a consequence there is no real market competition for medical services and goods at the consumer level. The health consumer counts on the government to regulate this activity, but as we have seen throughout the history of health care governmental regulation is in general too little too late - it takes a lot of momentum for the government to take action and by the time action is taken the profit incentive has shifted to another unforeseen medical component.

While the national debate should continue with conversations about regulating undesired behavior, the bigger conversation should be about how to bring transparency to the medical market. Good providers should see no problem with good, comparative, open-market competition. Those that desire to shelter activities for unreasonable motives will oppose efforts to institute true market reform.workers compensation, work comp, injured worker 

1 comment:

  1. David excellent article. The problem is apparent on so many levels. The medical community often throws drugs at the patient as a bandaid solution because they don't know what else to do with the patient. The payor community allows for it as they believe there is no other option. The patient wants it because they don't know how deal with their condition. We do need transparency and better solutions.

    My organization has refined an approach that addresses the issue on those levels. Pain management does not have to be about drugs, injections and more surgery. The pain may be with the patient for the rest of their life. We provide a program that teaches the patient how to manage their pain in a healthy way and take ownership of their health. The end result is decrease medical and PD costs for the payor and improved quality of life for patient.