California
has defined how medical networks in Workers’ Compensation should be structured
and managed. Part I and Part II of this series described how
California’s SB 863 LC 4616 (b) (2) and LC 4616 (b)(3) takes medical provider
network directives to a new level. The key imperative is, “Every MPN must
establish and follow procedures continuously to review the quality of care,
performance of medical personnel, utilization of services, facilities, and
costs. However, a few additional key points should be considered when
selecting and monitoring medical providers for the California MPN or any
network.
Beyond legislation
Escalating
problems in the industry with Opioid
overuse and abuse, as well as physicians who are dispensing medications from
their offices are additional factors that must be considered. While the
California SB 863 legislation does not address these issues, the data should be
scrutinized to identify physicians who demonstrate unfavorable prescriptive
practices. Analyzing the data to evaluate physician performance in that regard
is essential to vetting physicians for membership in a network. It is also
crucial to monitoring networks going forward.
Opioid over-prescribers
Workers’
Compensation literature is replete with information about Opioid overuse and
abuse with its disastrous human and resource waste. Unfortunately, measures
taken to curb inappropriate prescribing behavior are few and vary widely across
the country.
Simply stated, the best way to reduce Opioid
abuse is to avoid Opioid over-prescribers. Analysis of the data will identify
the perpetrators. They should never be a part of a Workers’ Compensation
medical network.
Back to California - CURES
California
has a program that approaches the problem by monitoring patient utilization of
prescribed Schedule II drugs and making that information available to
authorized prescribers and distributors (pharmacies) of controlled drugs.
California’s
program is called CURES (Controlled Substance Utilization Review and Evaluation
System, and PDMP (California Prescription Drug Monitoring Program). [1] The California Department
of Justice, has a Prescription Drug Monitoring Program (PDMP) system which “allows
pre-registered users including licensed healthcare prescribers eligible to
prescribe controlled substances, pharmacists authorized to dispense controlled
substances, law enforcement, and regulatory boards to access timely patient
controlled substance history.
The California Attorney General's Office said that if doctors and pharmacies have access to controlled substance history information at the point of care it will help them make better prescribing decisions and cut down on prescription drug abuse in California. The role of the CURES/PDMP entrusts that well informed prescribers and pharmacists can and will use their professional expertise to evaluate their patients’ care and assist those patients who may be abusing controlled substances.
The state’s database known as the Controlled Substance Utilization Review and Evaluation System (C.U.R.E.S) contains over 100 million entries of controlled substance drugs that were dispensed in California. Each year the CURES program responds to more that 60,000 requests from practitioners and pharmacists. The online CURES/PDMP system will make it much easier for authorized prescribers and pharmacists to quickly review controlled substance information via the automated Patient Activity Report (PAR) in an effort to identify and deter drug abuse and diversion through accurate and rapid tracking of Schedule II through IV controlled substances.”
Submission of
Controlled Substance Data
Pursuant to Health & Safety Code Section 11190, and
Business & Professions Code Section 1170, all licensees who dispense
Schedule II through IV controlled substances must provide the dispensing
information to the Department of Justice on a weekly basis in a format approved
and accepted by the Atlantic Associates Inc.(AAI),and the DOJ. Similarly, pursuant to
California Health and Safety Code Section 11165(d), dispensing pharmacies and
clinics must provide weekly dispensing reports to the DOJ on Schedule II, III,
and IV prescription drugs.
For purposes of creating an intelligent MPN, insure any physician under consideration for an MPN in California is a member of CURES/PDMP. That notwithstanding, the data should be monitored continuously to determine actual performance.
Physician-dispensed
medications
Another prescription abuse issue not
addressed by the California legislation is physician-dispensed medications.
While it is portrayed as a patient convenience, and probably is, the
medications are prepackaged and extraordinarily costly. Once again, this
practice can be monitored in the data. Bills reflecting drugs dispensed by the
treating doctor are not monitored by Pharmacy Benefits Managers (PBM), rather,
they appear in normal provider billing.
Networks
with Intelligence
All medical provider networks serving
any jurisdiction should analyze integrated data, meaning all data associated
with claims. Integrated data is sourced from claims level systems, bill review
systems, PBM systems, and other such as utilization review to understand the
broad spectrum of claims and all individuals, organizations, and events
touching them. The goal is to select best-in-class doctors by objectively
identifying excellent provider performance.
Margaret Wagner is President and CEO of Signature Networks Plus, Networks with Intelligence™. She is considered an expert in network selection, monitoring and management, thereby creating Networks with Intelligence for clients. MWagner@signaturenetworksplus.com
Karen Wolfe is President and CEO of MedMetrics®, LLC, a Workers’ Compensation analytics company. MedMetrics scrubs and enhances provider data in systems, integrates the data from organizations’ disperse systems, then analyzes, scores, and monitors medical provider performance. MedMetrics also offers online “apps” that link medical analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org
No comments:
Post a Comment