Beyond Pennsylvania Politics

Pennsylvania, ranked 2nd in Average MEA per Claim with Opioids according to Workers’ Compensation Research Institute’s (WCRI), Interstate Variations in Use of Opioids, 4th Edition, will not adopt a nationally recognized evidence-based medicine drug formulary. Is this the outcome of Pennsylvania politics taking precedence over enacting policy that would materially change prescribing behavior protecting injured workers in the state?

Governor Tom Wolf’s letter to the Senate of the Commonwealth of Pennsylvania contains several statements that deserve closer scrutiny:

Outcomes and the Tide of Opioids

Governor Wolf – “The implementation of a drug formulary as prescribed by this legislation will not improve overall health outcomes for Pennsylvania’s injured workers and will not stem the tide of the opioid crisis that is ravaging every area of our society.”

Carlos Luna News (CLN) Analysis – Let’s separate the Governor’s claims: 1. The drug formulary as defined by SB 936 will not improve overall outcomes and 2. The drug formulary defined by SB 936 will not stem the tide of the opioid crisis.

I have recently expressed concerns over the lack of quality independent research available that measures overall health outcomes among injured workers in states that have adopted drug formularies for workers’ compensation. If proponents of drug formularies seek to shed the perception that these tools are more than mechanisms of cost savings, they must urge researchers to make this a priority. While I personally believe overall health outcomes are achieved through the use of formularies, at this point the claim is mostly anecdotal.

Governor Wolf’s claim that the formulary defined in SB 936 will not stem the tide of the opioid crisis is inaccurate. While we have little to no objective data that suggests formularies are efficacious in the improvement of overall health outcomes, there are numerous reports that have been devoted to measuring the sharp decline in opioid prescriptions and use in states where drug formularies have been used.

As an example, it is reported that Ohio has experienced a 40% decrease in opioid prescriptions between 2011 and 2015. The drug formulary, which is based on recommendations from a pharmacy and therapeutics (P&T) committee, is one of the numerous initiatives the state has enacted to combat the local opioid crisis. Complimenting the use of the state drug formulary is the 2016 Opioid Rule that among numerous safeguards holds prescribers accountable for failure to follow best practices. These policies have not only decreased the number of pills being dispensed, additionally, earlier this year Ohio reported a 59% drop since 2011 in injured workers considered to be clinically dependent to these dangerous drugs.

Cost Savings at the Expense of Injured Workers?

Governor Wolf – “The formulary proposed in this bill runs counter to the compact we have made with the injured workers and does so to save money for insurers and businesses.”

CLN Analysis – Thorough research and measurement of overall health care cost impact in states that have adopted drug formularies is another gaping hole in workers’ compensation. Studies published to date focus mostly on drug spend, and sometimes more specifically opioid spend. As a result, the debate about cost savings created by adopting a drug formulary is very narrow and mostly not relevant. Research that has not made its way to the public domain is the measurement of cost impact for alternative pain treatment such as mental health, physical therapy, etc.

Specific to Pennsylvania SB 936, bill text states, “Within eighteen (18) calendar months following the effective date of the prescription drug formulary selected under this subclause, the Pennsylvania Compensation Ratings Bureau shall calculate the savings achieved through the implementation of the prescription drug formulary. For the calendar year immediately following this calculation, the amount of savings shall be used to provide an immediate reduction in rates, equal to the savings, applicable to employers’ workers’ compensation policies.”

Provided the uncertainty of cost impact by way of alternative pain treatments, post drug formulary adoption, insurers could have very well been left in the red due to their willingness to share cost savings attributed to the adoption of the formulary via “immediate reduction in rates, equal to the savings…”

Steering to Less Expensive Treatment

Governor Wolf – “Since the bill’s drug formulary is designed to steer physicians towards prescribing less costly drugs, it will not likely accomplish the often-stated objective of the bill’s promoters – curbing opioid over-prescription.”

CLN Analysis – One of the drug formulary options that would have met the bill’s requirements of being “nationally recognized” and “evidence-based” with a basis that “is readily apparent and publically available” (i.e., transparent development methodology), focuses on therapeutic agents, not “less costly drugs”. This allows healthcare providers to choose the most appropriate medication therapy for their patients.

Evidence-based medicine (EBM) inherently suggests that the more costly the test/intervention, the more caution to be used before ordering the test or treatment and the stronger the evidence of efficacy should be. In other words, EBM recommends closer scrutiny of more costly care to ensure efficacy for the cost. This focus does not always result in the less expensive treatment option being recommended.

Perhaps a lost fact among opponents of SB 936 is that the formulary would serve as a “guardrail” ensuring appropriate pharmacological care stays on course. In cases where a physician runs into a non-recommended agent or bumps against the rail, they are able to select an agent that is recommended (and may not always be the least expensive) or choose to investigate the appropriateness of non-pharmaceutical treatment options. In either case, the physician remains in the driver’s seat helping their patient to get from point A (injury) to point B (recovery).

Pennsylvania Politics reported in March that Governor Wolf’s campaign for reelection had one PAC leading in contributions – by a lot! Fairness PA donated $1M during the second half of 2017. The PAC contributed twice as much money as any other committee for the year.

According to the report, Fairness PA has become a channel for owners of compound pharmacies (doctors and lawyers) to put their campaign contributions to use. The donations came at a time when legislature heavily debated SB 936 that would have put an end to the controversial practice of these pharmacies billing insurers for unproven, non-FDA approved pain creams that cost upwards of $4,000 per tube.

Governor Wolf offered an executive and regulatory action plan that focuses on the development of prescription guidelines for opioids, training for providers and judges, better use of the state’s PDMP, and more. The plan has numerous issues with it, beginning with a state agency being tasked with developing prescription guidelines (I’ll dig deeper on this subject in a future post), as well as, omitting specific timeframes for implementation. To proponents of SB 936, the Governor’s plan rings hollow.

Time will tell whether Governor Wolf’s decision to veto SB 936 and take the reins over solving Pennsylvania’s opioid crisis was a well-placed political move in hopes of re-election. For the sake of the state’s commonwealth, I hope the effort goes beyond Pennsylvania politics.

Categories: Evidence-Based Medicine (EBM), State Workers' Compensation Standards

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