EK HEALTH

It has become apparent that pharmacy and medication reviews are becoming the dominant UR issue in California. In particular, opioids (morphine, codeine, and methadone, etc.) are increasingly used to manage non-malignant chronic pain. Medication reviews may make up as much as 40% of UR reviews and the medications for chronic pain are some of the most difficult for UR physicians to review. Why is this? Let me suggest a few reasons:

1) There is a disparity from what MTUS medication treatment guidelines recommend and what is being prescribed, i.e. duration of treatment, dosage indications. Many of the prescribed treatment regimens are egregiously beyond MTUS recommendations.

2) In order to evaluate a treatment request, specific documentation is needed, however, clinical documentation from the treating physician is almost always inadequate.

3) In order to make rational decisions, a UR doctor needs to have information re: work status and specific work restrictions. If it is not available, the UR doctor (or the adjuster) need to attempt to obtain it, either from the doctor's office, the medical records or by direct communication with the treating doctor.

4) Rational decisions regarding the appropriateness of medical treatment can only be made in the context of the patient's clinical and psychosocial history and characteristics. Hence, when a particular treatment has been associated with a positive effect on functional capacity and RTW in a given patient, it may be wise to continue with the treatment course even if the published guidelines cast doubt on the efficacy of the requested treatment.

5) Very few doctors treating chronic pain will communicate with the UR physician.

6) The treating physician does not describe functional improvement to meet the MTUS definition. More often, it is placed only in subjective terms, i.e., the patient reports they feel better.

7) MTUS is often too general and doesn’t allow the UR physician or the adjuster to demand specific procedures, i.e. urine drug testing, CURES report.

8) The real efficacy of the medication is not known. An “indicated” medication does not necessarily imply a beneficial medication.

9) Powerful opioids, in combination with other medications and alcohol, may produce additive effects including sedation and impaired work performance. UR doctors don’t want the responsibility for approving medications that may be extremely dangerous and deleterious to the patient.

10) While the UR doctor may be told there is a pain contract, they hardly ever know the specifics. Frequently, the UR doctor would like to know the consequences of nonadherence. MTUS is quite specific regarding the contents of a pain contract. 11) Is the patient being closely monitored for side effects of the medications?

It is essential the UR physician not cross the line and become involved in, or suggest, treatment. So, what can be done? Well, EK Health and many of our EK Health UR doctors are changing the way they do some things. Here are a few ideas:

1) We have added 2 new pharmacist reviewers to our EK Health professional team. We want to give our UR physicians the most accurate information, beyond MTUS, for multiple drugs that are often taken in huge amounts and in combinations that are poorly understood.

2) UR physicians should work closer with adjusters/claims examiners to document communication with treating doctors and raise the level of medical documentation expected from treating doctors that manage patients on multiple, powerful medications for chronic pain. The claims staff can be of tremendous help by demanding improved documentation of functional improvement, work restrictions, and all medications being taken by the patient including the dosage and frequency.

3) UR physicians should work closely with adjusters/claims examiners to develop a process and protocol to deal with cases that create concern for overuse (or escalating use) or inappropriate use of medications, prescription drugs, urine drug screens, physical therapy and other passive treatment modalities.

4) Require treating physicians to deliver meaningful, legible clinical information. Lack of this information is grounds for denial!

We hope to change the model of reviewing requests for opioids and other medications being used for chronic pain. If we have an effective, consistent approach to treating chronic pain that is based on MTUS and demand treating physicians document the specific medical care and the progress and functional status of the patient, we may just impact the care of injured workers in a very positive way.

I hope you will work with EK Health and our reviewing doctors on this.