LeFevre: Confusing the Role of Treatment Guidelines and Formularies

Thursday, March 8, 2018 | 0

Clients and partners have asked for an official ODG response to the latest blog by Carlos Luna of Reed Group (Wednesday) questioning the research of the Workers Compensation Research Institute in its analysis showing considerable benefit available for states following the Official Disability Guidelines model, and outcomes from ODG states including Texas.

Phil LeFevre

Luna suggests that the massive cost savings attributable to ODG guidelines and formulary adoptions may not equate to improvements in health outcomes. The position of ODG and our regulatory partners is the opposite: We believe the only way to achieve real and lasting cost savings in workers’ comp is through the delivery of quality and timely care resulting in improved patient outcomes. The best measure of success for workers’ comp reform efforts is time away from work.

When average lost-time duration due to illness and injury declines, the lives and livelihoods of workers injured on the job are changed for the better.

Thankfully, in large part due to the hard work of the workers’ comp agencies and stakeholders — third-party administrators, pharmacy benefit managers, managed care organizations, employers, carriers, and providers charged with ODG implementation and concurrent reform measures — outcomes in ODG states have improved dramatically, including average lost time reductions of 34% (Texas) to 65% (Tennessee).

Further, that cases receiving opioid doses of 90 morphine milligram equivalent or more are down by 97%, with total opioid usage down 58% in Texas, is a testament to the safeguards put in place using the ODG Formulary to protect patients. Claim-cost savings (indemnity, medical and administrative) through better outcomes have resulted in premium reductions of 64% (Oklahoma), 63% (Texas) and 36% (Tennessee) post-ODG.

Luna’s approach tries to elicit fear in the marketplace, painting the ODG Formulary as “draconian” because it’s “binary,” advocating instead for a diagnosis-based formulary. But Luna confuses the role of treatment guidelines and formulary.

A formulary adoption is a preauthorization rule, making it more difficult to prescribe the most dangerous drugs (by requiring preauthorization). But all medications, including both preferred and non-preferred drugs in the ODG Formulary, open complete evidence-based care guidelines in ODG, where diagnosis, duration, dose and contraindications are discussed and outlined. It’s through the formulary-guideline linkage that patient selection criteria are applied in the clinician’s office and on the backend through utilization review.

Luna either does not understand how successful formulary implementations work or is intentionally misleading the industry. Either scenario is alarming. However, given the track records of WCRI, ODG and our regulatory partners, stakeholders can see his agenda through the obfuscation.

In closing, thanks to WCRI for the excellent research, to stakeholders for your leadership implementing ODG, and to WorkCompCentral.com for the opportunity to respond to criticism.

Phil LeFevre is managing director of the Official Disability Guidelines, published by the Work Loss Data Institute.