In the following guest post, Carlos Luna, Director of Government Affairs for Reed Group’s MDGuidelines, explores the experience of other states in implementing formularies and why the details of Louisiana’s system make it a poor fit for a Texas-style formulary.
Rep. Talbot’s HB 592, which will be heard in a House Labor and Industrial Relations Committee meeting on Thursday, would establish the Work Loss Data Institute’s “Official Disability Guidelines” (AKA ODG) closed pharmacy formulary as the law of the land. ODG is the formulary Texas has used for years with significant system savings that some say are the result of cost-shifting from the insurers to the social safety net.
The Proverbial Broad Brush
Generalities plague the workers’ compensation industry. From indirectly typecasting opioid-using patients as drug addicts to characterizing physicians as narrow-minded profit-driven narcissists – and former state officials suggesting a single binary drug list can have similar cost-saving effects in multiple jurisdictions. The proverbial broad brush is a potent distraction from the specific issues needing attention in order to improve the quality of care to injured workers.
Louisiana’s Need of a Drug Formulary
Former Texas Workers’ Compensation Commissioner, Rod Bordelon, has represented Work Loss Data Institute and their ODG Treatment Guidelines and Drug Formulary in a number of jurisdictions. In November of 2016, he made a stop at the Louisiana Association of Self Insured Employers (LASIE) annual conference.
Armed with the usual workers’ compensation cost savings statistics from Texas, Bordelon made a case suggesting that Louisiana can experience similar savings if they adopted the same formulary as Texas – the ODG binary drug list. The presentation overlooked two critical differences between Louisiana and Texas:
- Louisiana recognizes the Colorado Treatment Guidelines as the presumptively correct standard of care and not the ODG Treatment Guidelines, which is the standard in Texas.
- Louisiana does not have a legislative mandate to use Return-To-Work Guidelines.
The Colorado Treatment Guidelines and ODG Treatment Guidelines have very different levels of rigor in their development methodology. As an indication of the differences in their scientific basis, the Colorado Guidelines are listed in AHRQ’s National Guideline Clearinghouse for being trustworthy clinical guidelines aligning with the Institute of Medicine’s Standards for Developing Trustworthy Clinical Practice Guidelines. After it was determined that ODG did not meet critical standards of evidence-based medicine such as transparency, study inclusion/exclusion criteria, the ODG Treatment Guidelines were removed from the National Guideline Clearinghouse in June of 2016. As a result, Louisiana stakeholders should expect to experience friction and disconnect resulting from using the ODG drug list, purportedly based on the ODG Treatment Guidelines, and the Colorado Guidelines in concert.
Perhaps the most underestimated component of the Texas workers’ comp system that has supported its reduction in prescription drugs is their legislated mandate to use Return-To-Work guidelines to help injured workers return to productivity as soon and safely as possible. Texas’ efforts to keep workers employed while recovering from work-related injuries and illnesses has resulted in a drop in lost-time claims from 165,000 in 2000 to fewer than 90,000 in 2014. The success of the Return-To-Work program is preventing the pathogenic effects of job loss such as decreased physical and mental health and higher treatment utilization, and thus driving down medication consumption.
On Monday, May 1st, the California Division of Workers Compensation (DWC) held a public hearing required by statute in order to collect feedback on its proposed regulation package for the enactment of its formulary (which is based on the ACOEM standard). California’s journey to adopting a trustworthy drug formulary started with a comprehensive independent report from the RAND Corporation, Implementing a Drug Formulary for California’s Workers’ Compensation Program.
Several assumptions regarding how California’s DWC would design and implement the drug formulary underpinned RAND’s methodological approach and policy analyses. The first assumption was that the DWC intended to adopt a formulary designed to maximize quality-of-care, health, and work-related outcomes; this has also been a guiding principal behind Louisiana’s HB 592 according the bill’s sponsor, Representative Kirk Talbot and the Louisiana Association of Self Insured Employers. To accomplish these objectives in California, RAND recommended the formulary drug list and drug classification scheme to be evidence-based and as consistent with the California’s Medical Treatment Utilization Schedule (i.e., California’s treatment guidelines) as possible.
The RAND report identified that while the ODG formulary would be easier to implement, methods used to develop the guidelines used as the formulary’s basis have been less rigorous than its counterparts in the workers’ compensation arena (Nuckols et al., 2014).
Further, due to fact that very little of California’s treatment guidelines were based on ODG, the adoption of the ODG formulary would represent a major departure from the current California Treatment Guidelines. Similar to California, a departure from Louisiana’s presumptively correct standards (the Colorado Treatment Guidelines) will create an environment governed by disagreement.
In addition to Louisiana, Montana, Nebraska, New York and Pennsylvania have ongoing legislative conversations pertaining to the adoption of a drug formulary. As with Louisiana, the Colorado Treatment Guidelines are adopted in part or in whole, in Montana and New York providing the content source presumptive weight. The question of what formulary will work best in concert with the Colorado Treatment Guidelines will also need to be answered in these jurisdictions.
Time Will Tell
While most stakeholders in Louisiana feel an evidence-based drug formulary can be a useful tool to support other state measures to curb opioid prescriptions, not many believe the ODG binary drug list is the right fit for injured workers in the state.
Louisiana Representative Chris Broadwater, author of this year’s HB 529 calling for the Louisiana Office of Workers’ Compensation Administration to create a drug formulary, pulled a similar bill introduced in 2016 requiring the use of the ODG binary drug list. What does Rep. Broadwater know that Rep. Talbot, Bordelon, and LASIE do not?
Comparing the Texas workers’ compensation system to Louisiana’s system is like comparing apples to oranges. The expectations for similar outcomes is a stretch, to say the least, at the expense of injured workers.