Dr. William Hopper: Utilization Review — Focus on Cost Effectiveness and Patient Safety in the Management of Pain
By Dr. William Hopper, CMO, MediCall
"MediCall's William Hopper, MD is an invited industry expert and contributor to workcompwire.com and their "Leaders Speak" series addressing key industry challenges"
There is growing concern about the increasing cost of unnecessary health care services.1 The rate of cost increases is being driven by acuity and severity of service categories2, and one of the most accelerated areas is pharmacy services. In addition to cost, the impact on patient morbidity and mortality needs to take a more important place in the queue of concerns. The growth of "pain medicine", the development of more potent (and much more expensive) long–acting opioids, the use of multiple medications with synergistically dangerous side effects, and a failure to follow well developed Federal. state and nationally recognized evidence–based guidelines for using controlled substances in treating non–malignant pain have all contributed to an increase in mortality and morbidity.
A study in Spine3 studied all Washington State claimants who underwent spinal fusion between January 1994 and December 2001 found that "Analgesic–related deaths were responsible for 21% of all deaths and 31.4% of all potential life lost. The risk of analgesic–related death was higher among workers who received instrumentation or intervertebral cage devices compared with recipients of bone–only fusions (1.1% vs. 0.0%; P = 0.03) and among workers with degenerative disc disease (age and gender–adjusted mortality rate ratio, 2.71) (95% confidence interval, 1.17–6.28)."The authors concluded that "Analgesic–related deaths are responsible for more deaths and more potential life lost among workers who underwent lumbar fusion than any other cause. Risk of analgesic–related death was especially high among young and middleâ€“aged workers with degenerative disc disease."
The use of controlled substances in the Workers' Compensation patient continues to increase. This trend places the patient at even more risk of morbidity (overdose) and mortality (death). A recent study4 into long–term opioid therapy found that fatal overdoses have occurred, and the likelihood of these fatalities increased 8.9 fold with more potent dosages of opioids.
These studies and trends should give us all pause to consider the path and endpoint implied herein. It is not news to anyone in health care, especially Workers' Comp, that the marketing of opioids has been found suspect.5 An additional issue is the diversion of controlled substances which can and does also result in overdoses and death. Nevertheless, increasing prescribing continues unabated.
There is more rather than less need for focused and robust utilization review and management of controlled substances and other medication categories. All but 2 states6 (Illinois and Indiana) have developed or adopted guidelines designed to address the professional expectations and obligations involved in the assessment, treatment and monitoring of patients with non–malignant pain using controlled substances. These guidelines are reasonable and were created to maximize patient safety, minimize physician legal risk and ensure that patients obtain a scientific basis for alleviating much if not all of their pain. Too often these guidelines are ignored or disregarded by the prescribing physician(s) in treating patients for their pain.
While PBMs have been involved in Drug Utilization Review analysis, too often prescribing physicians minimize or ignore these pharmacist–based intervention efforts. The use of physician reviewers and the application of the jurisdictional state and other guidelines has led to more effective UR tools in presenting prescribing physicians with ineffective or potential abusive prescribing patterns, and offering patients a safer treatment pathway.
It is time to consider and implement a more effective approach to this growing and unsafe situation.
Biography for Dr. William Hopper
Dr. Hopper's clinical experience includes solo family practice, medical groups, including Sutter Medical Group of Santa Rosa, the Permanente Medical Group of the Northeast, the Vancouver Clinic, Lifelong Medical Care (Berkeley, CA), US Healthworks ,Concentra and has expertise in clinicâ€“based occupational, urgent care, family and addiction medicine. He has developed and managed utilization and quality management programs for hospitals, medical groups, IPAs, MSOs and health plans in California, New York, North Carolina, Washington State, and Oregon. He has extensive experience in the development and application of electronic health records, quality and practice performance improvement programs, evidence–based medicine, billing fraud, practice protocols, and regulatory compliance.
Posted: January 26, 2011