The House of Representatives has held numerous information-gathering meetings in DC. The House Committee on Education and the Workforce, Subcommittee on Workforce Protections, hosted the most recent event on Tuesday, May 8th, 2018 (recording found here; hearing introduction begins at minute 16:31). The divide that exists between state and federal government was clear as the feds focused on the success state workers’ compensation systems are having in the war on opioid abuse.
House Committee on Education and the Workforce
The Committee hosted a distinguished panel that included Scott Dahl (Inspector General of the Department of Labor), Scott D. Szymendera (Acting Section Research Manager of the Congressional Research Service), Joseph Paduda (President of CompPharma, LLC) and Ramona Tanabe (Executive Vice President and Counsel of WCRI).
Paduda and Tanabe did a good job ushering the Committee through an impressive highlight reel of opioid-use statistics and state-enacted policies in the ongoing effort to reduce opioid abuse by states workers’ compensation systems. Some of the standout points included:
- State workers’ compensation systems have reduced drug spending by one-third (1/3) in the last two years and one-half (1/2) in the last five years;
- Less than 4% of the State of Washington’s workers’ comp drug spend is for opioids;
- Since 2014 the California State Compensation Insurance Fund has reduced the number opioid prescriptions by 60% and the number of patients taking high levels of opioids from 1458 to 186;
- Kentucky, Maryland, Michigan, and New York have experienced large decreases (30-40%) in opioids dispensed to injured workers;
- 16 states have adopted state-developed and nationally recognized medical treatment guidelines for chronic pain or opioid prescribing;
- 15 states have implemented or passed legislation for drug formularies;
- 8 states have implemented limits on quantities of physician-dispensed opioids;
- 21 states have implemented a limit in days for which opioids may be prescribed.
The Need for Clinical Controls
The panel’s introductory statements were overshadowed by commentary from Full Committee Ranking Member Representative Bobby Scott (D-VA) to DOL Inspector General, Scott Dahl. Rep. Scott focused on the system’s lack of clinical controls in place to facilitate “certification, or at least a representation” that specific medications were in fact medically necessary.
Rep. Scott’s impassioned commentary seemed prompted by Mr. Dahl’s introductory testimony pertinent to the DOL’s focus to curb extreme costly billing for compound medications. Rep. Scott questioned how a prescription can get filled without “someone along the line” certifying that the drug is medically necessary. Mr. Dahl responded, “I think that is incumbent upon that doctor to do that…”
Subcommittee Chair, Representative Bradley Byrne (R-AL) echoed Rep. Scott’s indirect suggestion that clinical controls at the point of care may have slowed, or entirely prevented, the prescription, fulfillment, and reimbursement of medications that are not medically necessary.
When asked what “should be done” to make sure medical services provided to workers are in their best interest by Chairman Byrne, Mr. Dahl suggested that the Federal Employees’ Compensation Act (FECA) program should implement controls to confirm that the “treatment of these opioid recipients is effective and medically necessary.” Mr. Dahl informed the Committee that the DOL has an ongoing audit evaluating such controls.
Legislators Uneasy with Intervening in Medical Process
While a sense of urgency to address the prescription of drugs that are not medically necessary appeared to be a common thread among Committee members, there was a clear sense of uneasiness about intervening with medical professionals’ ability to treat their patients as they see fit.
Expanding on his comments respective to clinical controls, Chairman Byrne stated, “So we have a government agency telling a doctor – a medical professional – ‘hey what you’re doing may not be good for your patient’ – the federal government has to tell a medical professional that?”
Mr. Dahl concurred and expressed “this is the difficulty” in the government getting involved in the medical treatment of patients. “It appears that some doctors are motivated by other things than what’s in the best interest of their patients,” he shared.
This is arguably the crux of the debate of the appropriateness of clinical controls and outside influences on the treatment of patients, particularly in the area of pain management. It became evident that there was representation from one stakeholder group missing from the panel – representatives from the medical community.
In my personal view, discussions about resolving flaws in a system, or process, are generally more effective with the right expertise and representation from that system. If a viable solution to address the inappropriate prescription of drugs is to be discussed and put on a realistic path to enactment at the federal-level, collaboration efforts must include the medical community.
Joe Paduda put it best when stating, “Physicians want to do the right thing. Getting their patients off opioids is absolutely the right thing.”
The Most Important Metric is Not Being Accurately Measured
There is a public perception that government tends to move only when there are dollars at stake, either in the form of savings or extraordinary expenses. As a system, workers’ compensation has become very proficient at measuring drug spend. These metrics are important but tend to deemphasize the reality that there are grave losses to our society by way of human cost. Additionally, the cost savings that are regularly reported do not tell the full story of the efficacy of policies being enacted in workers’ compensation.
Representative Donald Norcross (D-NJ) challenged the panel and Committee members to expand research areas of the opioid epidemic beyond dollar values. When questioned about the number of overdose deaths per year affecting those covered by FECA, panel members did not have a precise calculation. One panel member explained that there is a challenge with collecting accurate data on the precise number of overdose deaths due to inconsistent coroner reports.
Rep. Norcross doubled down explaining that the system does not track the number of lost lives, but it tracks the dollar values at stake. He concluded by urging the panel and Committee members to improve the tracking of the human side of the opioid crisis – “We are not tracking it, but we tracking the money.”
House Committee on Ways and Means
The Committee on Education and the Workforce is not the only group in the House gathering information. In mid-March, the Committee on Ways and Means issued a Request for Information (RFI) to insurers, doctors, prescribers, and other healthcare providers.
I was very fortunate to have been invited to submit input to the Committee’s RFI. As may be expected, the general theme of my input was the urgent need of implementing, in collaboration with the medical community, clinical controls to guide prescribers to administer evidence-based care. The idea of “guardrails” through evidence-based guidance seemed to resonate with legislators as my input, along with 109 other responses, were published in a whitepaper that summarizes key recommendations.
The opioid crisis in America is a great reminder of how far behind the federal government is in comparison to state-initiated efforts. It’s about time the feds focus on the success state workers’ compensation systems are having in the war against opioid abuse; there are numerous important lessons to be gathered.
I applaud state legislators and regulators that tirelessly work on finding ways to solve this complex medical and social issue in workers’ compensation. May they continue to expand their point of view, pursue additional research on patient health outcomes, total healthcare costs, and improve the measurement of the most costly loss of all – human life.