Q1 – 2019 – May 1, 2019

Research

Treatment Approval Rates After UR and IMR.  Preliminary data compiled by CWCI based on UR and IMR outcomes for services performed and reviewed between 2017 and April 2018 show that the approval rate for Calif WC treatment across all service categories was 91.3 percent, while the modification rate was 2.0 percent, and the denial rate was 6.7 percent.  Results by type of treatment request show significant variation among service categories, with overall approval rates after IMR ranging from a low of 77.2 percent for injections to a high of 99.5 percent for E/M services, which are primarily office visits and consultations.

Executive Briefing (3/29/19) (members only)

Off-Label Use of Gabapentinoids… JAMA Internal Medicine recently published a clinical overview of off-label use of gabapentinoids such as gabapentin and pregabalin.  The overview noted that these drugs were originally developed as anti-seizure meds, and that the only pain-related indication approved by the FDA for gabapentin is postherpetic neuralgia; and for pregabalin, the only FDA-approved pain indications are for postherpetic neuralgia, neuropathic pain associated with diabetic neuropathy or spinal cord injury, and fibromyalgia. Despite these limited indications, the authors state that gabapentin and pregabalin are being widely prescribed off-label for various other pain syndromes, which they surmise may be due to physicians searching for alternatives to opioids.  They conclude that physicians who prescribe gabapentinoids off-label for pain should be aware of the limited evidence and should acknowledge to patients that potential benefits are uncertain for most off-label uses. The overview is available at jamanetwork.com/searchresults?author=Allan+S.+Brett&q=Allan+S.+Brett.

Executive Briefing (3/29/19) (members only)

California Workers’ Comp Pharmaceutical Utilization & Reimbursement; Part 2:  Emerging Outcomes Under the MTUS Formulary.  CWCI research examines the impact of the MTUS Formulary on the mix of drugs used in California workers’ compensation and the distribution of prescription drug payments.  The results show that drugs listed as “Exempt” from prospective UR and those that are “Not Listed” in the formulary account for an increasing share of the prescriptions, while “Non-Exempt” drugs account for a decreasing share.  At the same time, Exempt and Non-Exempt drugs represent a dwindling share of the total drug spend, while Not listed drugs jumped from about a quarter of the prescription payments prior to the formulary to nearly 39 percent after it took effect.

Spotlight Report (3/20/19) (members only)

Bulletin (3/20/19) (members only)

News Release (3/20/19) (public)

Dermatological Drug Shift.  CWCI data found a shift away from custom compounded creams and gels in California WC after medical billing changes and unit price controls enacted under AB 378 took effect, requiring more detailed itemization of the NDCs associated with pharmacy-compounded drugs, and price caps for physician-dispensed compound drugs.  A 2013 CWCI study found increases in the average number of ingredients per compound and the average cost per ingredient, resulting in a 68% increase in the average cost per compound drug immediately following the passage of AB 378.  While AB 378 failed to reduce the unit cost of custom compounds, it did make it easier for payers to flag these drugs, while high-profile indictments of drug wholesalers who offered kickbacks to doctors to prescribe custom compounds raised public awareness and helped reduce the use of custom compounds, which in turn reduced the total amount paid for them. But, after custom compounded drug abuses were exposed, some of the promoters switched to marketing different dermatologicals, including mass-produced, high-cost private label topicals and dermatological products containing an NSAID such as diclofenac, some of which are exempt from UR under the formulary.  Both are now driving up WC dermatological costs.

Executive Briefing (2/25/19) (members only)

California Workers’ Comp Prescription Drug Utilization & Payment Distributions, 2009-2018: Part 1.  CWCI’s analysis of changes in the types of drugs used in California workers’ comp over the past decade. The report looks at the breakdown of prescriptions and payments by therapeutic drug group by service year, as well as the generic utilization rates for the different drug groups and how the average amounts paid for drugs within each group changed over the 10-year study period. Among the key findings: non-steroidal anti-inflammatories (NSAIDs) have supplanted opioids as the most common therapeutic drug group prescribed to injured workers in California, while the payment data show that both dermatological medications and anticonvulsants now rank ahead of opioids in terms of total reimbursements.

CWCI Research Update (2/15/19) (public)

Bulletin (2/15/19) (members only)

Executive Briefing (1/24/19) (members only)

Regional Variations in Post SB 863 WC Experience in L.A., the Bay Area, San Diego County and Statewide.  A comparison of the claims experience in the state’s 3 largest metropolitan regions derived from the recent updates to CWCI’s On-Line Regional Data Application.  The summary provides AY 13-AY 17 claims data for each region, valued through 12/31/17, and compares results across multiple metrics to identify both the existence and the extent of regional differences in claimant demographics, benefit mix and average payments, attorney involvement, claim closure rates, and average employer & carrier notification time lags for the 5-year post-reform period. 

Bulletin (1/4/19) (members only)

Statutory/Regulatory

Calif Consumer Privacy Law Raises WC Concerns. Last year, in order to forestall a threatened ballot initiative, Calif lawmakers hastily enacted a comprehensive but complex data privacy law (SB 1121 & AB 375) which will take effect 1/1/20.  Dubbed the Calif Consumer Privacy Act (CCPA) of 2018, the measure, gives “consumers” the right to know what personal information is being collected on them; access that information and request that it be deleted; know whether their information is being shared, and if so, with whom; and to opt out of the sale of their information.  The statute will also allow consumers to file civil suits against companies that fail to abide by the law, and will allow the state to impose a $7,500 fine for any violation that is not addressed w/in 30 days.  The CCPA has raised red flags in WC, as the current statutory definitions of “consumer” and “personal information” would likely include WC; there is no provision to ensure WC insurer access to medical data needed to process claims and deliver timely benefits; it is unclear what impact it might have on an insurer’s ability to report fraud; and claims organizations that fail to disclose privacy rights to patients could face suits, fines and enforcement actions.  Existing statutes already ensure the confidentiality of injured workers’ medical data, so the insurance lobby has introduced clean-up legislation (AB 981 – Daly) to exempt WC from the CCPA privacy requirements.  Calif led the way in enacting such a sweeping consumer privacy law, so other states are keeping an eye on how the clean-up legislation and the regs related to the measure play out.

Executive Briefing (3/29/19) (members only)

2019 WC Bills Introduced.  It appears that in his first year Gov. Newsom will have other issues to deal with other than a WC overhaul, though several WC-related bills have been introduced this year:  

• AB 5 (codification of Dynamex: applies the ABC test in defining what constitutes an “employee”)
• AB 71 (codification of the multi-pronged employment test from Borello, which would end Dynamex for labor disputes including wage orders)
• AB 233 (which would exempt licensed insurance agents from the ABC test under Dynamex)
• AB 981 (a bill to exempt insurance companies from the Calif Consumer Privacy Act
• SB 731 (CAAA’s attempt to ban apportionment based on race, age, gender, marital status, sexual orientation, and genetics)
• AB 932 (a bill mandating WC coverage for firefighters working out of state – drafted in response to the denial of benefits for Calif public safety officers who responded to the 2017 Las Vegas terrorist attack)
• AB 1400 (expansion of the cancer presumption to all fire service personnel with exposure to active fires or health hazards resulting from firefighting operations)
• SB 542 (a measure to grant a PTSD presumption for police and firefighters)
• SB 416 (a bill to establish hernia, heart, and pneumonia presumptions to an expanded class of peace officers)
• SB 567 (a bill to establish presumptions for cancer, musculoskeletal injuries, and a wide range of injuries and illnesses for acute care hospital workers for up to 10 years)

Lyrica Allowed in WCMSAs for Off-Label Use.  CMS has announced a new policy that will allow Workers’ Comp Medicare Set-Aside plans to allocate funds for off-label use of the anticonvulsant pregabalin as a painkiller in cases involving radicular pain stemming from a spinal cord condition.  Currently, pregabalin is only available as the high-cost brand-name drug Lyrica, so the National Alliance of Medical Set Aside Professionals (NAMSAP) calculates that including Lyrica in a WCMSA plan of an injured worker w/a 20-year life expectancy will add nearly $200K in cost.  NAMSAP expressed its concerns to CMS, which elicited an explanation of the change in a CMS reference guide last month. But NAMSAP is still trying to get the policy overturned and sent letters to every member of Congress explaining the issue and why it can be problematic to require WCMSA allocations for off-label use of RX drugs.  As of now, however, the policy change still stands.

Executive Briefing (3/29/19) (members only)

Heads Up For Employers on OSHA Forms.  If they haven’t already done so, employers need to complete and post their Form 300A summary of job-related injuries and illnesses from 2018, and from Feb. 1 – April 30 post it in a common area where notices to employees are usually found. 0. Employers do NOT need to post their work injury and illness log (Form 300), only the summary (Form 300A.  Companies that had no recordable injuries or illnesses last year should post the summary with zeros on the “total” line.  A company executive must certify all establishment summaries.  Employers also must make a copy of the summary available to employees who move from worksite to worksite (such as construction workers) as well as to employees who do not report to any fixed establishment on a regular basis.  In addition, emergency regs adopted by Cal/OSHA require employers w/250 or more employees per establishment (unless exempted by the regs) and employers in high-hazard industries (noted in the regs) that have 20-249 employees to electronically submit Form 300A information to Fed-OSHA by March 2. Those who report electronically are also still required to keep & maintain their OSHA 300A Summary and other injury and illness recordkeeping forms, available on OSHA’s website.

Executive Briefing (2/25/19) (members only)

Medical Treatment Utilization Schedule.  CWCI’s 30-day public comments on the proposed MTUS guideline updates.

30-Day Public Comment (2/15/19) (public)

New Laws Affecting Opioid Prescriptions in California Now in Effect.  A reminder to members that two new laws affecting opioid prescriptions took effect January 1.  The first (AB 1753 Low) requires providers to use new prescription pads offering more detailed information when prescribing controlled substances; the second  (AB 1760) Wood requires that opioid prescribers offer a prescription for the overdose-reversing drug naloxone concurrently with the opioid prescription in three specified situations.

Executive Memo (1/16/19) (members only)

2019 Reg Update…The state kicked off the new year w/ regulatory activity on several fronts, including collecting forum comments on proposed changes to UR/IMR & the treating physician’s report form; a public hearing on public self-insured reporting requirements; and a  February hearing on MTUS updates (including new PTSD and Acute Stress Disorder guidelines). Other areas where there may be regulatory activity in 2019:  benefit notice (access to treatment notification); Cal-OSHA electronic injury reporting (not coming from DIR, but still outstandingst Report, Request for Authorization and Progress Report revisions); Home Health Care Fee Schedule; Independent Medical Review (electronic submission of records requested by Maximus); Interpreter Fee Schedule; Medical-Legal Fee Schedule; MTUS Guideline Updates; nurse case manager immediate support for victims of terrorism; Pharmacy Fee Schedule revisions; RTW Supplement Program; Utilization Review (electronic reporting of data); Utilization Review (“fast pass” treatment w/in 30 days); Vocational Expert Fee Schedule; WCIS FROI/SROI reporting; WCIS penalty schedule.