Workers Comp Drugs: Paying too much...For the Wrong Medicines!

We have long been intrigued by a number of conundrums relative to drug prescriptions in the workers comp system. Why are exotic brand name drugs prescribed so frequently, when effective generics are readily available? Why are doctors so quick to adopt "off line" uses for exotic drugs, endorsing unconventional applications for very expensive medications? What accounts for the remarkable success of pharmacy companies in getting doctors to do what they want them to do? And why do insurers simply pay the bills, without asking doctors the rationale for what appears to be a very odd and problemmatic decision-making process?

Paying Too Much...
Our esteemed colleague, Peter Rousmaniere, principal of Rousmaniere Associates, has delved long and deep in these issues. He has two intriguing articles in the current issue of Risk and Insurance (available here). In the first article he presents a study done by a Cleveland area Pharmacist, Phillip Parsons, in conjunction with the Ohio State Fund and Archestral, a data analysis firm. They analyzed a number of prescriptions written in Ohio, Michigan and Pennsylvania. The study found that of the total $179 million in payments for the two million prescriptions, about $25 million were questionable. Overall, 20 percent of prescription payments contained at least one error.

Among the problems uncovered were:

8 percent to 15 percent of drug purchases conflicted with the compensable diagnosis.
7 percent to 10 percent of prescriptions were for brand names when generic substitutes were available.
As many as 11 percent of prescriptions were incorrectly priced.
All told, about 9 percent of prescriptions, or $16 million of total paid prescriptions, had no evident relationship to the work injury. For example, payments were made for Lotrel, used to reduce high blood pressure, which would rarely be appropriate for treating a work-related injury.

A second major type of error was failure to price the drug at the lowest available price. In all, about $4 million, or about 2 percent of total payment, was due to incorrect pricing.

Perhaps the most alarming finding of the study is in the area of painkillers. Exotic brand-name drugs were routinely prescribed, rather than less expensive generic equivalents. Paying for brand names added $11 million, or 6 percent of total payments. Beyond that, the study found that the ratio of brand to generic purchases was significantly higher for the more powerful pain medications, such as Oxycontin. In one egregious example, $12,000 was paid for one year of Oxycontin, for a 1990 workers' compensation claim of "neurotic depression." Yikes!

For all cases with both brand and generic alternatives, 8.6 percent of generic opportunities were missed. For pain medications, 12 percent of generic opportunities were missed. For the federal Drug Enforcement Administration's "schedule II" pain drugs – those with highest known abuse– more than 20 percent were brand instead of generic. I suspect that this one study is truly indicative of a national problem.

The Wrong Medication...
In a second article, Rousmaniere explores what may be an even more important issue: the heavy reliance of the medical community on pain killers to treat work-related injuries. Rousmaniere cites the treatment guidelines of the American College of Occupational and Environmental Medicine, which state: "Pain medications are typically not useful in the subacute and chronic phases [of injury] and have been shown to be the most important factor impeding recovery of function." [Emphasis added.] Get that? Pain medication slows down recovery! And in the world of workers comp, slower recovery translates into significantly higher costs.

The article goes on to challenge readers to analyze the root causes of over-medication. Rousmaniere offers a long menu of interesting options for getting control of pharmacy costs. The menu includes:

Aggressively enforce generic substitution rules; promote the availability of drug-detox vendors; screen for possible illicit usage and refer cases for investigation; promote among employers substance abuse/EAP services; contact high-volume pain-med-prescribing doctors to discuss treatment philosophy; promote alternative, non-drug-focused treatments for chronic-pain issues; require prior approval and peer review of all narcotic prescriptions ongoing for more than 90 days; require claimants receiving narcotics to participate in a drug education program; and promote pain-management treatment guidelines.

There is plenty of food for thought here. It's not only a list of what needs to be done, but it raises the issue of who should do it. Pharmacy management has become an industry buzz word. Everyone seems to be doing it, but are they doing it effectively? Are we really getting to the core issues: too many doctors are routinely prescribing expensive, highly addictive medications for work-related injuries. The entire medical community is relying much too heavily on pain medication to solve problems. To put it bluntly, we appear to be paying too much for the wrong medications. And that's certainly no prescription for success.