XCVI I Am the Law

By: Publius

A buzz has been created about the use of formularies. A formulary is a listing of medications acceptable for use by an insurer – whether Medicare or private insurer. In the recent (June 8, 2009) hearing on California workers’ comp rates, Insurance Commissioner Steve Poizner was told both the pros of having a formulary and, at least from a legal standpoint, the cons, as articulated by the Division of Workers’ Compensation (DWC). The latter position so clearly summarizes the frustration many stakeholders feel with delays in implementing various aspects of the 2003-2004 reform laws.

To be fair, DWC has successfully undertaken an enormous rulemaking agenda over the past five years. This comes at a time when its leadership has changed and key personnel have left. But that should affect when a reform can be implemented, not whether it can be implemented.

The Medical Treatment Utilization Schedule (MTUS) is supposed to “…address, at a minimum, the frequency, duration, intensity, and appropriateness of all treatment procedures and modalities commonly performed in workers’ compensation cases.” It is reasonable, is it not, to assume that “all treatment procedures and modalities” include prescribing drugs?

Furthermore, as was pointed out at the hearing, DWC has yet to set forth guidelines on development of pharmacy networks, a reform enacted in 2001 with passage of Assembly Bill 749 (Calderon). In other words, there is much work to be done.

A formulary is not simply a cost-saving device. If it is viewed as such there will be resistance from the medical community – and we have seen what resistance to treatment guidelines has already done to erode reforms. A formulary also can address issues such as compounding, off-label use and appropriate use of compounds for treatment not covered by the official medical fee schedule. As we see more opportunities for use and abuse of pain medications, there should be a heightened sense of urgency in developing guidelines to limit – or eliminate – high-powered opioids whose clinical value must be measured against their potentially devastating effects.

But none of these sound public policy justifications will move the system along unless and until the guardians of the rulemaking process – DWC staff attorneys – jump on board. As is already happening in Texas, it is clear that developing an acceptable formulary is no easy task. But it is made more difficult, and well nigh impossible, if unnecessary hurdles are put up to stop the process from even starting.

Consider this a nudge.


PUBLISHERS' NOTE: Publius is written by a consortium of writers, sometimes internal, most frequently external. Workers' Comp Executive believes that it has the responsibility to air most viewpoints and welcomes the comments of its community on any subject. Publius does not necessarily represent the views of this publication.