Thursday, January 26, 2012

TX Formulary Showing Early Success, Raising Questions

Much of the discussion both in this blog and the industry in general in the past year has been about prescription drug abuse, the growing awareness of this problem and what various states are doing about it.

A study by Washington's Department of Labor & Industries shows that state's recent policies as proving effective in combating the problem.

Now a utilization review company says it's data shows that Texas' efforts, with its "closed formulary" rules, is proving effective too.

Texas' formulary uses the Official Disability Guidelines (ODG) to determine which drugs require preauthorization. Preauthorization is required for drugs designated as “N” under the ODG, meaning those drugs are considered experimental, investigational or not recognized for use in treating a particular injury or condition.

Drugs on the “N” list include potentially addictive and expensive Class II narcotics, hypnotics, and compound drugs that contain “N” ingredients. The federal Drug Enforcement Administration classifies drugs based on their medical uses and potential for addiction or dependency.

The formulary, which was mandated by the Texas Legislature through House Bill 7 in 2005, was drafted by the Division of Workers’ Compensation and became effective Sept. 1, 2011 for new claims with a date of injury on or after that date. Legacy claims come under the formulary two years later.

Mark Pew, senior vice president of business development for Atlanta, Ga.-based Prium, a utilization review company specializing in prescription drug claims, said one of Prium’s pharmacy benefit manager partners provided data on its Texas drug transactions, which he says show that since the formulary took effect last Sept. 1, “there appears to have been a significant decline in the prescribing of drugs that would qualify for…preauthorization for new claims.”

The data show 18,359 prescriptions for drugs dispensed within 90 days of the date of injury between Sept. 1, 2010 and Aug. 31, 2011. Those prescriptions included 1,355 “N” drugs, accounting for 7.38% of the total. From Sept. 1 through Dec. 22, 2011, there were 1,825 prescriptions for drugs dispensed within 90 days of injury, which included 64 for “N” drugs, representing 3.51% of the total.

That's a big drop in just one year for the limited class of claims being studied - 90 days post injury.

The next measurement will occur once legacy claims fall under the formulary, which occurs starting September 1, 2013.

Research indicates there are a lot of “N” drugs being prescribed for legacy claims.

The Texas Department of Insurance Workers’ Compensation Research and Evaluation Group published a report last October showing that legacy claim prescriptions for injury years 1991 through 2005 averaged $3,636 in 2010 compared to $266 per prescription for injury years 2006 through 2009.

Prescription drug issues are getting attention through out the nation - the states that have implemented rules and regulations all have taken different approaches, but each of them appears to be effective at least in addressing the numbers issue; i.e. reducing the number of prescriptions and/or number of people receiving large doses of potentially lethal opium-based pharmaceuticals.

There are some questions left unanswered that should be addressed in the future: 1) What is the impact on the injured worker population? Death rate? Disability and return to work statistics? Benefit impact? 2) Will some other cost component experience unnatural inflation (i.e. the whack-a-mole experience)? 3) Was one state's approach more effective than another state's approach?

And, to me, the most obvious question is one of causation - the rise and fall of the prescription drug bubble has been very rapid (relatively speaking of course). So exactly what inflated the bubble and why were the various state responses so effective in deflating the bubble (i.e. looking for the "follow the money" investigation)?workers compensation, work comp, injured worker 

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