The 411 on HB2

I was in Frankfort KY yesterday (May 31) and I was impressed.

The new workers' compensation drug formulary for Kentucky is in very good hands.

The inaugural (open public) meeting of the Medical Advisory Committee discussed the process of complying with HB2, a bill that was signed into law by Governor Matt Bevin on March 30, 2018 and contained manifold substantial changes to the workers' compensation system for Kentucky. Among those changes were two that directly impact medical treatment:

• KRS 342.035 (8) (a) that requires "evidence based treatment guidelines for medical treatment ... including but not limited to chronic pain management treatment and opioid use ... on or before December 31, 2019." (on page 10 of 63)
• KRS 342.035 (8) (b) that requires the Commissioner to "develop or adopt a pharmaceutical formulary for medications prescribed for the cure of and relief from the effects of a work injury or occupational disease and promulgate administrative regulations to implement the developed or adopted pharmaceutical formulary on or before December 31, 2018." (on page 11 of 63)

I have been an advisor to 16 states on drug formularies since 2010 and each situation has been unique - the regulatory foundation upon which a drug formulary is being built, the history for how appropriateness of medical treatment and drugs are evaluated, the politics surrounding the process and decision, the leadership and advisors involved, the makeup and voice of stakeholders, etc. As has often been said, if you've seen one work comp drug formulary you've seen one work comp drug formulary. What Commissioner Bob Swisher is being asked to do is a daunting task with daunting deadlines. But I was impressed by what I saw ...

• The Medical Advisory Committee (MAC) is comprised of a variety of clinical specialties and thus perspectives - OccMed, pain management, orthopedic surgeons, chiropractor, pharmacist and physical therapist. NOTE: All clinicians! Their role is to determine the substance of the medicine for the treatment guidelines and drug formulary. There is a separate group (Regulatory Advisory Committee) that will be working in parallel on the legal / regulatory issues associated with implementing the treatment guidelines and drug formulary. Having experts focus on their expertise, while collaborating, makes a lot of sense.
• Given the timeframe their primary focus will be on the drug formulary, although Commissioner Swisher made it clear the 12/31/18 deadline includes having the process in place (choice, regulations) and not necessarily the "effective" date (to accommodate proper rollout). However, since treatment guidelines are the basis for the drug formulary (they answer "why" a drug is either preferred or not preferred and help determine whether a drug is appropriate for this person with this condition at this time), the selection will be inextricably connected. This synergy makes a lot of sense.
• Commissioner Swisher provided each of the MAC members a printed binder with the overview PPT he used during the meeting, helpful resources on the subject of work comp drug formularies (including "A Discussion on the Use of a Formulary in Workers' Compensation" from the IAIABC), and copies of various publicly available work comp drug formularies as examples. Commissioner Swisher had done his homework, not just with the binder but also in talking with leaders in other jurisdictions that have already implemented a work comp drug formulary. Preparation is key. Providing all of the participants an equal starting point for context on what they're being asked to do makes a lot of sense.
• Their goals and objectives included important standard items such as the need to properly transition "legacy" drug regimens, having fewer injured workers using opioids, and to reduce the friction between providers and payers. However, the first item resonated the most with me - better treatment outcomes by focusing on best practices on the "front end." In other words, creating an environment where better treatment choices are made on day one instead of needing to "rescue" them later. Several comments by the MAC members backed that up - "this is not about saving money" ... "we can't keep throwing opioids at people" ... "pain management is not just about drugs (before mentioning acupuncture, chiropractic, CBT)" ... "acute context determines chronic outcomes" ... "how can we ensure injured workers get faster access to the right treatment" ... "fundamentally change how pain is treated in the acute phase" ... "this is more than return to work - it's about returning to life." To hear unanimity on the need to provide the best treatment as quickly as possible definitely makes a lot of sense.

There is a lot to do over the next few months. More meetings, presentations, comparisons, deliberation, at-home reading. But from this inaugural meeting it appears that the right people are involved, with the right motivations, and the right process. And that makes a lot of sense.