SESSION SUMMARY: Exploring the Impact of SB 1160 (and new Formulary and MTUS Guidelines)
California Coalition on Workers' Compensation (CCWC) 16th Annual Conference - JULY 2018
- Doug Benner, MD. Chief Medical Officer of EK Health Services, Inc.
- Roman Kownacki, MD, MPH, FACOEM. Chief of KaiserPermanente On-the-Job
- Rajiv Das, MD. Medical Director for Safeway Inc., VONS and Albertsons
- Alex Swedlow. President, California Workers’ Compensation Institute (CWCI)
Panelists discussed what they have observed since the changes of SB1160, Drug Formulary and MTUS Guideliness updates in 2018 compared to predictions they made in 2017. Highlights included:
- Will the formulary result in a significant change in the prescribing of opiates? Consensus was no. The 8-year decline in opiate prescriptions has continued at the same rate, but no noted bump from these changes.
- Will the formulary resolve issues with those receiving long term or long term and high dose opiate treatment? Again, the consensus was no. Most have not seen many letters from treaters justifying continuing use of Non-Exempt Drugs that were required to be submitted by April 1, 2018.
- Getting UR reviewers up to speed on updates in ACOEM and getting them to get online access to it. This did take a lot of work but is happening.
- Getting Reviewers to go to MTUS first. Many old habits of just using ODG. Few reviewers still quote ODG first instead of CA MTUS.
- Getting Reviewers to document their reasons for deviating from MTUS. This happens more and more but could still improve.
- One item not predicted last July but now is good reason to go to other guidelines is that several treatments in ACOEM/MTUS are summarized with “ NO RECOMMENDATION”, therefore ODG should be consulted next.
- Another issue not predicted is many treaters still submitting RFAs with Exempt drugs on older cases.
- There is still education needed to remind all that Exempt drugs still must be prescribed in accordance with the MTUS guidelines.
- Although UROs were required to accredited by URAC, a significant number have not completed this.
- Also unpredicted is that the DWC has not released draft regulations to implement the 2018 changes required by SB 1160.
- Also noted that effective October 2, 2018 the CA Medical Board has mandated that all health care professional prescribing, administrating or furnishing a Schedule II-IV controlled substance must consult CURES first (CA Controlled Substance Utilization Review and Evaluation System).
Alex Swedlow, President of CWCI, presented data on the new Formulary's impact on UR and IMR so far in 2018.
The findings show:
- The proportion of UR decisions involving prescription drug requests fell from 44.5% in the pre-formulary period to 40.7% in the first five months of 2018, a relative decline of 8.5%.
- At the same time, the percentage of UR decisions in which a prescription drug request was denied was unchanged at 14.6%, while 85.4% were either approved as submitted or approved with a modification.
- UR decisions involving opioid requests showed little change, edging down from 30.6% in the pre-formulary period to 30.0% after the formulary took effect, though the UR approval rate for opioids showed a sharper decline, falling from 72.3% to 68.8%.
- Meanwhile, the percentage of IMR decisions involving UR modifications or denials of opioids increased from 29.2% prior to the formulary’s implementation to 33.6% under the formulary, while the IMR uphold rate for opioid modifications or denials showed a modest increase, rising from 90.1% to 91.4%.
- Doug Benner, MD
EK Health Chief Medical Officer