My post earlier this week about the new opioid prescriber audit program recently announced by Texas’ Department of Insurance generated a rather interesting back-and-forth with TDI staff.
First, they were “disappointed” I didn’t post their entire response to the questions I emailed to TDI. There are a couple reasons for this:
1. TDI’s email response read like boilerplate, didn’t directly answer my five questions, and only indirectly answered three (I only figured this out after reading and re-reading the response several times; it was pretty convoluted).
2. I don’t post responses as a matter of course; if they are germane and responsive, I may well do so.
3. I received inconsistent guidance from TDI re the purpose of the audit – which is more accurately described as a peer review of 15 physicians’ prescribing patterns and comparison of those to guidelines. Nothing wrong with that audit, but as I noted in the original post, TDI’s reviewers will “have a good perspective on prescribing patterns for 15 docs, but…to what end?” The language in their email led me to believe the purpose was enforcement, but I was told that the purpose was actually “quality care for injured workers” (or words to that effect) – before I was told no, it was actually enforcement (in another communication). So, with no clear guidance, it was kinda tough to figure out the purpose of the audit.
Second, Amy Lee took me to task for neglecting to mention TDI had – in fact – published system-wide research on the types and usage of drugs in Texas. Lee was correct as I should have noted TDI has published results of two studies, one in 2011 and one here – (for some reason the embedded link doesn’t work) www.tdi.texas.gov/reports/wcreg/documents/Pharmaceutical_Prese1.ppt.
There was a lot more to the back-and-forth, but there’s no point in recounting the “he-said, she-saids”.
Instead, I’d suggest there are a couple take-aways.
1. I’ll continue to work to be more careful in giving credit where credit is due.
2. I never got an answer to my questions; why limit this to 15 docs?; and why not look at docs who prescribed meds for claimants with other prescribers? I’m still wondering, as are many others.
As I noted Monday, “payers have been required to report all manner of information to Texas for several years, with rather draconian penalties for failure to report. With this wealth of data, gathered at great expense and at no small cost to employers and their payers and vendors, it should be relatively simple to provide in-depth information on prescribing patterns around the entire Lone Star State. These data could be case-mix adjusted as well, something that isn’t mentioned in the TDI announcement on the current project.”
Now THAT would be helpful, and provide policymakers and other stakeholders with a wealth of information. While TDI did publish some research, in relation to controlled substances it was limited to system-wide script types, counts, costs, and number of claimants using (or more accurately billing for claimants dispensed) those drugs. There’s so much more that could be gleaned from the data; regional- or area-specific differences, scripts by type of injury, duration of care, case-mix adjusted comparison of claimants prescribed and not prescribed controlled substances, scatter plots or line plots of physician prescribing volumes by any number of variables…you get the picture.
Which leads me to point 3.
3. This all could have been avoided if TDI had responded to my query with direct answers. If that wasn’t possible, they could have called and said, hey, thanks for the query, but for reasons A, B, and C we can’t tell you that. Trying to get media – even we lowly bloggers – to play “find the answer in the vaguely-worded boilerplate” may sound like fun but in the end this hurts a lot more than helps.
You end up with a confused and frustrated writer, where you could have had another media outlet describing your yeoman efforts to improve things in your comp system.
FWIW, my original query, followed by TDI’s response is below.
my email –
Dr Patrick [TDI Medical Adviser] –
I write a blog on managed care issues and am working on a post re the opioid audit. I have several questions I’d like to get your thoughts on.
I’d like to understand why TDI decided to limit the audit to 15 providers.
Why is TDI not looking at multiple prescibers as part of this audit?
What does TDI expect to learn as a result of this audit?
When will the results be published?
Will physician names be included in the published report?
If there’s someone else I should be communicating with please let me know.
regards
Joe Paduda
——————————
Dr Patrick’s response
Mr. Paduda,
The Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) recognizes the abuse and misuse of prescription drugs, including opioids, is a serious issue in the Texas workers’ compensation system. To address this issue, TDI-DWC has adopted and implemented several rules that provide the tools necessary for system participants to monitor prescription drug utilization and curb unnecessary medical care including evidence-based treatment and return-to-work guidelines, a new closed pharmacy formulary, and enhanced medical data reporting requirements for insurance carriers.
Additionally, monitoring of doctors who prescribe opioids has been added as a required review category for the CY 2012 Medical Quality Review Audit Plan, the results of which may be utilized for enforcement purposes. Based on the results of these audits, as the TDI-DWC Medical Advisor, I may recommend specific penalties and/or other sanctions against selected prescribing doctors. This may include removal from the workers’ compensation system, other practice restrictions, monetary penalties, and/or referral to state licensing agencies. These audits consist of in-depth clinical reviews of multiple claims for each selected doctor in order to review that doctor’s prescribing patterns. Multiple doctors who have expertise in conducting these types of reviews are utilized by TDI-DWC to ensure that these clinical reviews properly identify instances of treatment which are below the standard of care in Texas. The results of these audits may become investigation files referred for enforcement actions. TDI-DWC will publish the outcomes of those enforcement actions in the same way it does with all enforcement actions against system participants.
After reviewing the available pharmacy data reported to TDI-DWC by insurance carriers as well as stakeholder input on a draft of the audit plan, TDI-DWC adopted criteria for this initial audit of doctor’s opioid prescribing practices that would target cases of opioid abuse and misuse. During this initial audit plan, TDI-DWC will focus on those prescribing doctors who prescribed opioids early in the claim before exhausting other health care options and continued to prescribe opioids beyond evidence-based recommendations found in its adopted treatment guidelines. Other opioid audits will be planned in the future focusing on doctors treating chronic cases.
Joe –
It was apropos to ask the TDI-DWC what was the purpose of the audit. Keep it up.
Having said that, I am struck why anyone would wait for a regulator to take steps to address the apparent excessive prescription of opoids. Surely a regulator who is so far removed from the scene, and so late in recognizing the problem, cannot be expected to effectively deal with the abuse. It seems to me that insurance companies – their adjusters in particular – can deal with this issue on a contemporaneous basis and not have to wait for a regulator to acknowledge that a problem exists and then issue off-the-mark remedial regulations. The adjusting community needs to explain why they continue to pay providers for services that apparently do not serve or meet the patient’s needs and interests.
“The adjusting community needs to explain why they continue to pay providers for services that apparently do not serve or meet the patient’s needs and interests.”
If only denying opioid prescriptions was as easy as “ralp” seems to think is the case. He apparently isn’t familiar with the fact that the treating physician is considered to be “God” in many WC jurisdictions. He also apparently isn’t aware also that adjusters (or their employer) could be fined in some states or sued by the claimant for failing to authorize medication prescribed by the treating dr.
To point the blame solely at the adjusting community as “ralp” has done here is flat out wrong. This individual clearly doesn’t have enough grasp of how the WC system actually works to have an informed opinion on this subject.
Jeff – I think Ralph’s statement was more of a general one; while there are indeed myriad challenges in combating opioid overuse, the adjusting community does need to do more to intervene in and address this issue.
While there are always jurisdictional hurdles, hassles, barriers, and realities, the problem is of such a dimension and the costs – human and financial – so large that the “adjusting community” has to re-evaluate how it deals with opioids and the prescribing and dispensing of same.
I agree that there are lots of problems from a regulatory perspective, but perhaps one of the ways the adjusting community can effect change is to join together to ensure regulators and legislators are aware of the dimensions of the problem and how regulations hamper effective management of opioids.
Mr. Knipper must not be familiar with the workers comp system in Texas. Here, it is the adjuster that is considered God. Treating doctors have very little power and our state Supreme Court has recently given very strong indications that they will do away with the cause of action for breaching the duty of good faith and fair dealing in workers comp.
My guess as to the answers to Joe’s questions is related to the demographics of Texas. Houston, Dallas & San Antonio dominate the system. Major players in those three cities dominate those cities. I would bet that most or all of the 15 are in those three cities and comprise the majority of opiate prescriptions in the state. However, TDI has to be careful because some of those 15 may be affiliated with one of the large hospital systems — Baylor in Dallas or Memorial-Hermann in Houston, That could get a call from the Governor.
As a Texas WC attorney, my opinion of the problem is that it is caused by incentivizing poor care. Adjusters always have too many files and so it is too easy to deny care than to examine the file. Doctors can’t get their patients the treatment they think they need, so, they prescribe opiates to help patients deal with pain, they see a ton of patients, and they are a revolving door to the next opiate prescriber, aka pain management specialist. And unfortunately, the problem will never be fixed in Texas because the solution — quality care — would cause rates to go up. And we can’t have that in Texas, y’all.
It may surprise Mr. Knipper that the significant reform of the Texas workers’ compensation regulations back in 1992, among other changes, authorized (meaning “empowered”) the payor community to review the treatment of claimants, and thus the attending physician, through a new-fangled system called “utilization review”. In fact, I believe the reforming statue granted the payor time to investigate the medical appropriateness of the treatment, including getting statements from the attending physician, and then ask a third-party medical review entity for an opinion.
In all the conversation about opoid misuse or abuse I have not seen much discussion about this feature of the Texas system!
Ralph: My apologies if your initial comments were intended to only address the WC opioid problem in TX. Per my reference above to “many WC jurisdictions” I was not limiting the discussion to only the state of TX.