PA Lawmakers Must Recognize Importance of Workers’ Comp Drug Formularies

By: Brian Allen, Vice President of Government Affairs at Mitchell

The Pennsylvania General Assembly is currently considering legislation (SB936) to require the Department of Labor and Industry to develop a prescription drug formulary to help guide the prescribing of medications for injured workers. There has been much political rhetoric, on both sides of the issue, and some has unfairly mischaracterized a formulary’s purpose and utilization.

Namely, there are two major misconceptions surrounding workers’ compensation drug formularies that must be put to rest. Otherwise, Pennsylvania lawmakers risk making a poorly informed decision that may risk the health and safety of more than 150,000 Pennsylvania workers who are injured each year and rely on the care received through workers’ compensation. 

Patient Safety is Top Priority

First, formularies aim to prevent the prescribing of dangerous or inappropriate medications that would deter the injured workers’ recovery; they do not prevent injured workers from receiving the appropriate medications they need. A properly constructed formulary provides evidence-based information to physicians treating injured workers, serving as a very necessary and helpful “best practice” guide to prescribing. 

In cases where a medication is not recommended, the formulary can suggest recognized optional medications that can be prescribed without special authorization. If the treating physician still determines that a particular drug not recommended by the formulary is necessary, the physician can seek authorization for the medication by demonstrating that the desired drug is medically necessary. This authorization request is akin to seeking a second opinion with the sole intention of keeping patients safe.

Addressing Opioids

Another common misconception about the Pennsylvania drug formulary is that it only addresses opioids. This is not true. While opioids are a part of the equation, the drug formulary covers a number of medications. Additionally, the formulary recommends those medications that have demonstrated the best results with the fewest side effects. Similar to a non-effective surgery, a non-effective medication would not be recommended; the potential side effects can be dangerous. 

Most importantly, the use of a drug formulary is not about denying care to an injured worker. A drug formulary is there to make sure that individuals get the right medication for their work-related injury or illness. In rare cases, where there is a unique need and the treating physician can show medical necessity for a particular drug or compound that isn’t recommended by the formulary, these medications would still be allowed. 

Formularies Can and Do Yield Positive Results

Drug formularies, when done correctly, yield positive results. We need look no further than to other states for proof. Ohio uses a specific preferred drug list for its injured workers. Last month, the Ohio Bureau of Workers’ Compensation reported they have experienced a 59 percent reduction in opioid dependence among their injured worker population since the introduction of their drug formulary in 2011. They have also seen an overall decrease in the use of all prescription medications. 

Texas, which introduced its formulary in 2011, reported in July 2016 that the use of non-recommended drugs had decreased by over 80 percent, overall prescribing rates for all other drugs combined were down, and lost-time days due to injury have been reduced. The report also showed that patient satisfaction levels over that same time-period remained constant.

These positive results from formulary early adopters have prompted many other states to move in that direction, including: Oklahoma, Tennessee, Washington, California, Montana, Arkansas, New York, Indiana, Kentucky, Massachusetts and Arizona. What’s most important to note is that these states vary in their political makeup and yet all have seen the value of a drug formulary to protect their injured workers. 

Providing the best pharmacy care to injured workers is the primary goal of a drug formulary.  Clearly the results in Ohio and Texas demonstrate the positive effects for injured workers when providing them the most effective medications and eliminating unnecessary or unproven drugs.  There is also a financial benefit as claim costs go down.  The Pennsylvania legislation ensures that any cost savings realized don’t benefit the insurance company but are passed on to Pennsylvania employers in the form of premium reductions. 

What Will Pennsylvania Do?

The General Assembly is at a critical crossroads. They can take a number of paths to develop this formulary specifically for injured workers. One path is to use an already established formulary, such as one crafted by physicians and pharmacists who are nationally recognized for their expertise in treating injured workers. The physicians and pharmacists work with groups such as the American College of Occupational and Environmental Medicine (ACOEM) or the Work Loss Data Institute (WLDI). 

Another path some states take is to develop their own formularies. In this case, the formulary is developed by a Pharmacy and Therapeutics Committee comprised of local physicians and pharmacists. Finally, some states have a hybrid of the two options. It is important to note that, in all cases, medical professionals develop the workers’ compensation drug formulary; not insurance companies.

What’s not an option is to sit back and do nothing. Pennsylvania must work to develop an evidence-based, medically-driven workers’ compensation formulary. 

In the end, what matters most, and what should matter to everyone, is the quality of care being delivered to the injured workers. Drug formularies have proven to enhance outcomes in both quality care and getting injured workers back to good health. Pennsylvania’s injured workers deserve the safest, most appropriate pharmacy care that is ensured by an evidenced-based drug formulary.  

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By: Brian Allen, Vice President of Government Affairs at Mitchell

As the Vice President of Government Affairs at Mitchell, a workers’ compensation pharmacy benefit manager, Brian is in the unique position to see firsthand how a drug formulary impacts injured workers as it is implemented and managed over time. In every state where a formulary has been approved and activated, Brian has seen a reduction in the use of opioids and other dangerous medications.