California: What's Working? What's Not?

Thursday, December 19, 2013 | 0

I spent some time recently visiting Prium's customers in California, a state that might as well be its own country when it comes to workers' compensation (and lots of other things). Some specific observations based on my interactions with carriers, self-insured employers, third-party administrators and attorneys around the issues of chronic pain management and prescription drug utilization:

The independent medical review (IMR) backlog is as frustrating as it is predictable. While the Division of Workers' Compensation has recently called for a public meeting to gather input on process optimization, the case load continues to mount at Maximus. My own reading of the publicly available IMR decisions has uncovered some disturbing results (like Maximus case number CM13-0000947, the summary of which states that Valium, Duragesic and Norco are all "medically necessary and appropriate." 

Read further into the detail of the report, however, and each of these three drugs is actually deemed NOT medically necessary and appropriate. A typo, yes... but a pretty critical one). The results of the medication-related cases that are being acted upon appear favorable amongst PRIUM's customers that have used our peer review, oversight, and utilization-review services. Until the process is somehow changed, it's incumbent upon payers to have an airtight process to avoid procedural errors and ensure predictable, accurate results that are in the best interest of injured worker health.

Payers are spending way too much on ineffective urine drug-monitoring services. I see broad-based intellectual acknowledgement by payers that drug testing should be a part of any chronic opioid therapy regimen. But there remains confusion around implementation, pricing and what to do with the results. Best practice here is not just to secure a contracted rate with a national drug-monitoring vendor, but to develop a process to ensure optimization of the testing process. This means that injured workers are tested at the right time, in the right place, using the best technology and that the results are communicated to the provider and payer as actionable intelligence that informs treatment decisions (not just a diagnostic test that gets thrown in a file). We have a long way to go before this kind of methodical approach is commonplace.

The use of independent medical exams allowed under Labor Code Section 4050 varies widely, but should be used more often. If Prium is unable to engage the prescriber in a peer-to-peer conversation, we ask ourselves, "Is there another way to gather information about the injured worker's care? Without having to go directly to UR/IMR and all of its timelines, technicalities and backlogs?" Several payers in California use these 4050 exams to do just that. What's more, the results of a 4050 exam may be used in the UR/IMR process later and may (under certain circumstances) be admissible in the AME/QME process (if applicable).  We're always looking for ways to inject independent, objective, evidence-based views on complex cases, and this is another tool available to payers in California more of whom, in our opinion, should be using 4050 exams.

"Functional Restoration Programs" in California are fast becoming a routine, expensive and ineffective answer to prescription drug overutilization. Some payers talk about these programs with such disdain and disappointment that it's downright depressing. I asked every customer we met with, "Who do you like? Where should we send them?" I got a few suggestions, but not many. The few I got are probably familiar to most payers, but in a state with as big an issue as California, there's a dearth of effective alternative treatment centers for injured workers.

By the way, should anyone disagree with that last point and wish to share other treatment programs in California that have great outcomes... I'm more than willing to listen. 

Michael Gavin is president of Prium, a medical cost-containment firm in Duluth. This column was reprinted with his permission from his Evidence Based blog.