The House of Representatives has held numerous information-gathering meetings in D.C. The House Committee on Education and the Workforce, Subcommittee on Workforce Protections, hosted a recent event on May 8.

Carlos Luna

The wide divide that exists between state and federal government was clear as the feds focused on the success that state workers’ compensation systems are having in the war on opioid abuse.

House Committee on Education and the Workforce

The committee hosted a distinguished panel that included Scott Dahl (inspector general of the Department of Labor), Scott D. Szymendera (acting section research manager of the Congressional Research Service), Joseph Paduda (president of CompPharma) and Ramona Tanabe (executive vice president and counsel of the Workers Compensation Research Institute).

Paduda and Tanabe did a good job ushering the committee through an impressive highlight reel of opioid-use statistics and state-enacted policies in the ongoing effort to reduce opioid abuse by states workers’ compensation systems. Some of the standout points included:

• State workers’ compensation systems have reduced drug spending by a third in the last two years and half in the last five years.
• Less than 4% of the State of Washington’s workers’ comp drug spend is for opioids.
• Since 2014 the California State Compensation Insurance Fund has reduced the number opioid prescriptions by 60%, and the number of patients taking high levels of opioids, from 1,458 to 186.
• Kentucky, Maryland, Michigan and New York have experienced large decreases (30%-40%) in opioids dispensed to injured workers.
• Sixteen states have adopted state-developed and nationally recognized medical treatment guidelines for chronic pain or opioid prescribing.
• Fifteen states have implemented or passed legislation for drug formularies.
• Eight states have implemented limits on quantities of physician-dispensed opioids.
• Twenty-one states have implemented a limit in days for which opioids may be prescribed.

The need for clinical controls

The panel’s introductory statements were overshadowed by commentary from Rep. Bobby Scott, D-Virginia, to Dahl. Scott focused on the system’s lack of clinical controls in place to facilitate “certification, or at least a representation” that specific medications were, in fact, medically necessary.

Scott’s impassioned commentary seemed to have been prompted by Dahl’s introductory testimony pertinent to the DOL’s focus to curb extreme costly billing for compound medications.

Scott questioned how a prescription can get filled without “someone along the line” certifying that the drug is medically necessary. Dahl responded, “I think that is incumbent upon that doctor to do that.”

Rep. Bradley Byrne, R-Alabama, echoed Scott’s indirect suggestion that clinical controls at the point of care may have slowed, or entirely prevented, the prescription, fulfillment and reimbursement of medications that are not medically necessary.

When asked by Byrne what should be done to make sure medical services provided to workers are in their best interest, Dahl suggested that the Federal Employees’ Compensation Act (FECA) program should implement controls to confirm that the “treatment of these opioid recipients is effective and medically necessary.”

Dahl informed the committee that the DOL has an ongoing audit evaluating such controls.

Legislators uneasy with intervening in medical process

While a sense of urgency to address the prescription of drugs that are not medically necessary appeared to be a common thread among committee members, there was also a clear sense of uneasiness about intervening in medical professionals’ ability to treat their patients as they see fit.

Expanding on his comments respective to clinical controls, Byrne stated, “So we have a government agency telling a doctor, a medical professional, ‘Hey, what you’re doing may not be good for your patient’ — the federal government has to tell a medical professional that?”

Dahl concurred and expressed that “this is the difficulty” in the government getting involved in the medical treatment of patients. “It appears that some doctors are motivated by other things than what’s in the best interest of their patients,” he said.

This is arguably the crux of the debate about the appropriateness of clinical controls and outside influences on the treatment of patients, particularly in the area of pain management. It became evident that there was representation from one stakeholder group missing from the panel: representatives from the medical community.

In my personal view, discussions about resolving flaws in a system, or process, are generally more effective with the right expertise and representation from that system. If a viable solution to address the inappropriate prescription of drugs is to be discussed and put on a realistic path to enactment at the federal level, collaboration efforts must include the medical community.

Paduda put it best when stating, “Physicians want to do the right thing. Getting their patients off opioids is absolutely the right thing.”

The most Important metric not being accurately measured

There is a public perception that government tends to move only when there are dollars at stake, either in the form of savings or extraordinary expenses. As a system, workers’ compensation has become very proficient at measuring the numbers associated with drug spend. These metrics are important, though they obfuscate the reality that there are grave losses to our society by way of human cost.

Equally important, cost savings do not tell the full story of the efficacy of policies being enacted in workers’ compensation.

Rep. Donald Norcross, D-New Jersey, challenged the panel and committee members to expand research areas of the opioid epidemic beyond dollar values. When questioned about the number of overdose deaths per year of those covered by FECA, panel members did not have a precise calculation. One panel member explained that there is a challenge with collecting accurate data on the precise number of overdose deaths due to inconsistent coroner reports.

Norcross doubled down, explaining that the system does not track lives lost, but it tracks the dollar values at stake. He concluded by urging the panel and committee members to improve the tracking of the human side of the opioid crisis.

“We are not tracking it, but we tracking the money,” he said.

House Committee on Ways and Means

The Committee on Education and the Workforce is not the only group in the House gathering information. In mid-March, the Committee on Ways and Means issued a request for information to insurers, doctors, prescribers  and other health care providers.

I was very fortunate to have been asked to submit input to the committee’s RFI. As may be expected, the general theme of my input was the urgent need of implementing, in collaboration with the medical community, clinical controls to guide prescribers to administer evidence-based care.

The idea of “guardrails” through evidence-based guidance seemed to resonate with legislators as my input, along with 109 other responses, were published in a white paper that summarizes key recommendations.

The opioid crisis in America is a great reminder of how far behind the federal government is in comparison to state-initiated efforts. It’s about time the feds focus on the success that state workers’ compensation systems are having in the war against opioid abuse. There are numerous important lessons to be gathered.

I applaud state legislators and regulators who tirelessly work on finding ways to solve this complex medical and social issue. May they continue to expand their point of view, pursue additional research on patient health outcomes, total health care costs and improve the measurement of the most costly loss of all: human life.

Carlos Luna is a consultant to the workers’ compensation industry, with subject matter expertise in government affairs, evidence-based medicine and return to work. This column is republished with his permission from his Carlos Luna News blog.