Texas’ Work Comp pharmacy reporting – too much information?

The Texas Division of Workers Comp (DWC) recently released proposed rules for work comp pharmacy billing. Along with the rules are what can perhaps best be described as an ‘extensive’ list of data elements DWC is looking to collect, a list that includes information that – in the view of most PBMs, retail pharmacies, and chains – is extremely sensitive and proprietary.
This effort is driven by provisions within the Texas Labor Code that, according to DWC, require DWC to adopt CMS’ most current reimbursement policies etc.
The draft – and I want to emphasize the form is still a draft – form requires submission of a comprehensive list of data elements, including the actual price paid for the script.
There are a number of concerns with this requirement. Here’s a quick list.
– revealing prices paid for individual scripts would potentially enable PBMs – and others – to determine the PBM’s contracted reimbursement rates with specific chains and retail stores. This is highly proprietary, extremely sensitive information.
– pharmacies will be quite concerned about release of data that would enable outside parties to find out what they charge specific PBMs. Many, if not most, PBM – pharmacy contracts employ a single rate nationwide, thus any entity that can access the Texas reporting information will quickly be able to determine reimbursement rates not only for that state, but likely all states.
– PBMs are not the only managed care entities that make their margin on the delta between what they receive from the payer and what they pay the service provider. Imaging and physical/occupational therapy networks, durable medical equipment/home health care vendors, designated doctor firms – all are reimbursed by the payer at one rate and pay their service providers – imaging centers, PTs/OTs, suppliers, physicians – another.
Given DWC’s current interpretation of the Labor Code, it would not be surprising if these other entities were required to reveal their pricing.
Anyone looking to provide comments on the proposed regs can do so by emailing rulecomments@tdi.state.tx.us. Of course, make sure you read the material on DWC’s website and consult counsel before taking up the virtual pen.