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State push to adopt workers comp formularies sees mixed results

Posted On: Jun. 21, 2017 7:00 AM CST

State push to adopt workers comp formularies sees mixed results

Recent state efforts to adopt drug formularies in workers compensation have experienced obstacles despite evidence that they can produce good results for states grappling with opioid addiction and reduce prescription costs, according to experts.

Louisiana, for example, ranked second in the strength of doses among 25 states studied for injured-worker opioid prescriptions, according to Cambridge, Massachusetts-based Workers Compensation Research Institute’s 2016 figures. Yet legislative efforts to pass a drug formulary failed in early June when the state Senate did not place the issue on its calendar for consideration before the end of the legislative session.

Despite the failure, Steve Bennett, Washington-based director of workers compensation programs and associate general counsel for the American Insurance Association, said Louisiana did make headway and expects to see another push in 2018 — there and in other states.

“Slow and steady, states will see the advantages to the treatment of injured workers and the workers compensation systems when policies are enacted,” he said. “We will keep trying to get drug formularies enacted in states where they do not have them.”

In Pennsylvania, ranked third in terms of the strength of doses in the WCRI study, lawmakers are now hammering out amendments for a bill that would create a workers comp formulary. H.B. 18 has yet to see a floor vote, but the House’s Labor and Industry committee voted on June 13 with revisions passing at 14-12 — along party lines with the exception of one Republican voting in favor.

Michael Gavin, president of Prium, a Duluth, Georgia-based medical cost management firm, said the struggle to enact drug formularies exists for two reasons: political and regulatory.

Regulatory issues arise if a state doesn’t already have a viable preauthorization and reviews process, he said.

“If those things are not in place, it’s hard to skip that step and go forth with a formulary,” he said, adding that Louisiana’s preauthorization program isn’t as developed as programs in other states such as Texas, which has had a successful formulary in place since 2011.

“Yes, some of the necessary dispute resolution process is in place (in Louisiana), but they don’t have the history that a place like Texas has,” he said.

Politics was also a major hurdle: when the Louisiana House of Representatives passed H.B. 592 by a 58-36 vote in May, all but six Democrats were against the proposal and all but two Republicans supported it.

In Pennsylvania, politics also seemed to be at play for H.B. 18, he said, as opponents in the pharmaceuticals and medical care industries framed a drug formulary “as potentially harmful to injured workers; they won’t be able to get the drugs they need.”

“There’s a lot of opposition,” said Ben Roberts, Prium’s Duluth-based executive vice president and general counsel, adding that the much of the opposition is coming from those who fill prescriptions for injured workers.

Meanwhile, two large states are in line to introduce formularies in the coming year: California and New York.

New York, ranked No. 1 in the WCRI report, included language requiring the creation of a workers comp formulary in its adopted budget for the upcoming fiscal year, and work is now underway. Details on the implementation are not yet available.

Meanwhile, the implementation of California’s formulary, which lawmakers approved in 2015, is being delayed six months to Jan. 1, 2018, giving stakeholders more time to prepare for the new regulations, the California Department of Industrial Relations confirmed early in June.

One of the key components of the California formulary is that no opioids are on the preferred list, meaning a prescription will always need to go through a reviews process.   

Some of the delay in California is related to long-term, legacy opioid prescriptions and how to wean patients off prescribed medications, said Mr. Gavin.

The California Department of Industrial Relations is still working on a timeline for another 15-day comment period and no date has been set, a spokesman wrote in an email Tuesday.  The department “is still considering all of the comments received during the comment period that ended May 1,” he wrote.

Mr. Gavin called the delays a good thing.

“Formularies are good, but they have to be implemented carefully, and speed is not a virtue when it comes to formulary implementation,” he said.