Supreme Court Saves Patient's Life

Monday, December 3, 2012 | 0

The Pennsylvania Supreme Court saved a patient's life last week. Interestingly, the court accomplished this great feat by doing nothing.

Linda Turner was injured on the job in December of 1987. She underwent two surgical procedures and was diagnosed, over a number of years, with arachnoiditis, failed spinal fusion surgery, small fiber neuropathy, chronic pain syndrome, discitis, osteomyelitis, spinal stenosis, and mood disorder.  Her treatment, in May of 2009, consisted of Fentanyl 125 mcg patch every three days and Fentanyl 600 mcg lozenge four times a day for breakthrough pain.  I'll save you the math... that's about 400 mg morphine equivalents per day.

Her employer conducted utilization review on the treatment and the lozenges were found to be unnecessary and unreasonable care. This finding was not based on assessment of functionality or objective clinical evidence of sources of pain (as is often the case), but rather on the addictive nature of the medication, its Food and Drug Administration-approved indications (palliative care for late stage cancer patients) and the risk to the patient.  A workers' compensation judge (WCJ) denied Turner's petition for review of the utilization-review decision.

The Workers' Compensation Appeals Board then reversed the WCJ, finding that the employer did not satisfy its burden of proving the Fentanyl lozenges were not reasonable and necessary.

On appeal, the Commonwealth Court of Pennsylvania reversed the board and reinstated the WCJ's denial of petition for review of the original UR decision.

Last week, the Pennsylvania Supreme Court declined to hear Turner's appeal, thus giving credibility to the UR process, leverage for employers in Pennsylvania to avoid payment for unnecessary and unreasonable care, and saving Linda Turner's life (despite the fact she probably doesn't realize it now).

The section of the Commonwealth Court's opinion I found most illuminating was on page 10: "Further, in determining the reasonableness and necessity of a prescribed medication, it is entirely appropriate for a UR reviewer to consider the risk to the patient. In other words, a UR reviewer may consider whether it is reasonable and necessary for a provider to expose a patient to the level of risk presented by a medication."

Funny... all of us are in the "risk management" business. Yet we often overlook the risks inherent in the treatment of these injured workers. I hope more states take the view that Pennsylvania has taken: risk to life and limb of the patient, even at the hands of a qualified physician, needs to be weighed when assessing the reasonableness of care.

Michael Gavin is chief strategy officer for Prium, a managed-care business based in Tampa, Fla. This column was reprinted with his permission from the firm's Evidence Based blog.