The capstone to an excellent NCCI AIS was provided by WCRI Exec Dir Dr. Rick Victor and his counterpart at CWCI, Alex Swedlow.
Rick led off with my LEAST favorite topic – physician dispensing of drugs to work comp claimants. The usually-very-circumspect Dr Victor said that “the evidence is pretty clear in terms of costs and likely benefits of physician dispensing.”
All the evidence indicates:
- physician dispensing is common in big states
- prices are higher than for the same drugs in retail pharmacies
- even after reforms, prices are about 30% higher
- docs write scripts for OTC meds when they dispense those meds
- dispensing docs prescribe unnecessary opioids
- the price focused reforms – eliminating the upcharge for repackaged drugs – will not deliver long term results.
As great as it was to see Dr Victor and NCCI focus so much time on an issue that I’ve been harping on/screaming about for about 8 years, I – as undoubtedly you – are sick to death of this subject. It’s time to kill the beast – ban physician dispensing and docs profiting from dispensing.
CWCI’s Alex Swedlow jumped full force into a quick review of utilization review in California.
The key takeaway is the decline in medical trend observed recently – which is leading to a reduction in rates – is very good news indeed.
Pharmacy is the fastest growing component of California’s work comp medical expense, now totaling 13.2% measured at 24 months maturity, or $1.2 billion. This despite two fee schedule reforms, implementation of chronic pain guidelines, and shortly opioid-specific guidelines and perhaps a formulary via legislation now under consideration. Yet 45% of UR involves drugs, and 45% of medical reviews do as well.
BTW doc dispensed drugs account for over half of drug spend in the Golden State.
Despite all that effort 29% of pharmacy spend is for Schedule II and II drugs.
That’s just appalling.
Which led Alex to the key question – why is California’s WC medical so much harder to manage?
Alex’ take – a fundamental lack of shared risk – no supply/demand controls, no contractual language that limits care, and a dispute process that features very high levels of litigation.
Which leads to the Independent Medical Review (IMR) process – intended to speed dispute resolution while increasing consistency. CWCI has done quite a bit of research into this area, most of which is available on their website.
Briefly – 95% of ALL treatment requests are approved. There is NO wholesale denial of care occurring in California.
Despite what you may have heard, the IMR process is working pretty well.
CWCI’s research (on their website) indicated that the average audit score for timeliness etc was 97%. And, IMR isn’t nearly as cumbersome as some would like to portray.
Here’s the real data…
75% of requests for initial treatment are immediately approved.
77% of the 25% that aren’t approved initially are approved after going thru UR. – that equates to 94.1% of all treatment requests are approved initially or after UR.
91.4% of IMRs agreed with UR that the UR-denied treatment was in fact not consistent with evidence-based medical guidelines.
44.7% of services going to IMR were for drugs; those decisions were upheld 92% of the time. And a lot of the IMR challenges are coming from one area – Los Angeles. Similarly, the top 1% of docs generated 44% of the letters; only 10 docs were responsible for 11% of ALL IMRs.
What does this mean for you?
Drugs are a big problem, and a relatively few docs are the ones contributing to this problem.
The IMR process is working pretty well – and would be much better if a very few docs weren’t flooding the system.