The California Medical Board contends that opioid restrictions proposed by State Fund could violate its treatment guidelines for pain management and are an “unwarranted intrusion” into the physician-patient relationship.
The medical board is California’s regulator in charge of physician discipline. It issued the guidelines in 1994 amid a national debate over physicians’ alleged failure to properly manage pain for fear of running afoul of federal drug laws. The guidelines were last updated in 2007.
State Compensation Insurance Fund (SCIF) “respectfully disagrees” with the medical board’s contention that proposed changes to its medical provider network (MPN) rules could put physicians between an ethical rock and a hard place. It maintains that the controls it is placing on prescribing of opioids and compound drugs are not only good policy but also in full compliance with the rules of the workers’ comp system.
State Fund executive vice president of claims Julie Jenkinson and State Fund medical director Bernyce Peplowski outlined the carrier’s position in a response letter to the medical board, which questions the proposed changes.
State Fund is moving to adopt prescribing limits that require prior approval to prescribe a compound drug or issue a prescription exceeding 60 days for opioids as part of a member requirement while reconstructing its MPN.
“The board strongly urges physicians and surgeons to view effective pain management as a high priority in all patients, including children, the elderly, and patients who are terminally ill. Pain should be assessed and treated promptly, effectively
and for as
long as pain persists…For some types of pain, the use of medications is emphasized and should be pursued vigorously; for other types, the use of medications is better de-emphasized in favor of other therapeutic modalities,” the guidelines state. “Medications, in particular opioid analgesics, are considered the cornerstone of treatment for pain associated with trauma, surgery, medical procedures, or cancer.”
“[The contract] merely requires the physician to obtain utilization review approval or follow a Judge’s order before prescribing controlled substances beyond 60 days,” State Fund says in its response letter. It also points out that under Labor Code section 4600(d)(5) it can require prior authorization of any nonemergency treatment or diagnostic service and conduct any necessary utilization review.
It also disputes the medical board’s contention that the restrictions are an “unwarranted intrusion” into the physician-patient relationship.
“The workers’ compensation laws define what is ‘reasonable’ and necessary.’ All physicians who treat an injured worker within the statutory scheme of workers’ compensation law are always subject to having their treatment recommendations reviewed by the insurer and workers’ compensation Judges…The Judge may order the treatment or find that the treatment is not reasonable or necessary and deny it,” the SCIF letter states. “Accordingly, [the contract provision] is consistent with the Medical Board’s Intractable Pain Guidelines’ requirement that a physician must comply with federal and state regulations when issuing controlled substances.”
State Fund’s Peplowski says that doctors need to take advantage of functional restoration rather than relying on opioids to treat injured workers, thus by setting a limit they are incentivized to do so. According to one month of data from SCIF’s pharmacy benefits manager, it had 10,000 prescriptions for narcotics, and only 1,500 prescriptions for anti-inflammatories.
“Given that most of our injuries are soft tissue/musculoskeletal, and very few, thank goodness, are catastrophic, these numbers are literally backwards,” Peplowski says.
Both the medical board and the California Medical Association were still reviewing State Fund’s response when contacted by Workers’ Comp Executive and were not ready to comment.
Click here for a copy of State Fund’s response letter.
(Filed by Brad Cain in San Francisco)