Kentuckiana Formulary

Two weeks ... Two meetings about drug formularies in the adjacent states of Indiana and Kentucky. Similar timeframes, similar choices, different approaches. But come January 1 this "flyover" area of the country will have a new approach to Rx drugs in workers' compensation.

August 24 - Crown Point IN

I was on a panel to talk about the upcoming Indiana work comp drug formulary to attorneys (of both "sides") and the Work Comp Board Chairman. Senate Bill 369 made rapid progress - Senator Randy Head introduced the bill on January 4; Governor Eric Holcomb signed it into law on March 25. My role in this presentation was to cover the trends in regards to prescription opioids, alternative pain management techniques, guiding principles of drug formularies, what has occurred in other states and how Indiana compares. It was an interesting dialogue as most had heard about the drug formulary but very few understood the details (and none had begun working on it yet). Which is important since the drug formulary is effective on January 1, 2019 (there is a one year transition period for 'N' drugs). Here's one of my PPT slides with some details ...

Obviously there is a lot that needs to happen in the next four months, including guidance from the Work Comp Board on the process nuances beyond what was included in the legislation. But the die is cast ...

August 30 - Frankfort KY

You may recall my June 1 blogpost, "The 411 on HB2," that recapped the initial meeting of the Medical Advisory Committee in regards to Kentucky's work comp drug formulary. This follow-up meeting was to talk through what the Regulatory Advisory Committee has determined to-date on how to implement the drug formulary and treatment guidelines (starting at 11am) while the MAC discussed what to choose (starting at 2pm). The what discussion (including both the RAC and MAC) was joined by Dr. Bob Snyder, Medical Director for the Tennessee Bureau of Workers' Compensation. He recently (2014-2016) has been down the path of deliberating, deciding, implementing and managing a drug formulary so his input was invaluable to the Kentuckians present. Some observations:

• There were lots of good questions about how the prior authorization / pre-authorization / utilization review process should work. How to handle disagreements on whether a medication is medically appropriate is a key component to implementation.
• There was an interesting dialogue about how KY ALJ's can make medical decisions without medical training. Ultimately it was agreed they needed to be educated on the selected treatment guidelines, after which they can focus on their role of weighing the evidence submitted by the medical experts. Just like they already do.
• Dr. Snyder outlined how the primary cost reduction in TN has been in lower use of compounds and topicals (an approximately 50 percent drop). He could not document - yet - the total dollar savings because of the drug formulary + treatment guidelines. However he could confirm savings from streamlining the system and getting care to injured workers faster.
• There was a long discussion about the difficulties in transitioning "legacy" claims / drug regimens ("moving an elephant"). That included whether it's even possible because patients don't want to change / prescribers don't want to change / claims adjusters don't want to pay for alternatives. (That's my daily battle)
• Dr. Snyder pointed out that quality of care should be better since all stakeholders are using the same guidelines. The treatment guidelines should also be educational. Interestingly, however, he said they are still "largely ignored" by providers.
• Dr. Snyder pointed out the number of opioid prescriptions are down but that is not solely due to the drug formulary but also to societal forces external to work comp (that should sound familiar if you've been reading / listening to me).

Here's how they currently plan to get to the finish line:

• End of September - Decision on vendor for drug formulary
• Early October - First draft of regulations ready
• January 1 - Go!

Bottom line

January 1, 2019 is an important date for both states but they have different paths. One is focused on stakeholder education of what has been decided while the other is still deciding. So when it comes to opioids and work comp, the Ohio River is more of a uniter than a divider as both states continue to figure out ways to #CleanUpTheMess.