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Industry Insights

Paduda: Trigger Warning

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I love reading the California Workers’ Compensation Institute Bulletins, even if they make me want to tear my hair out and scream.

Joe Paduda

Joe Paduda

The latest from the brilliant analysts in Oakland, California, is an update on three unnecessary and wildly expensive drugs with no purpose other than Hoovering millions from employers' and taxpayers’ pockets. These three drugs account for 2% of anti-inflammatory scripts and almost half of anti-inflammatory drug costs.

wrote about fenoprofen calcium two years ago:

These meds aren’t wonder drugs that grow hair while curing low back pain and strengthening joints and rejuvenating shoulder cartilage. They are similar to aspirin, ibuprofen and naproxen.

OK, here’s how the scheme works.

Neither drug (fenoprofen calcium and ketoprofen) is on the California workers' comp drug fee schedule, so employers and taxpayers have to pay 83% of the “average wholesale price.” AWP is a number made up by the drugs’ manufacturers and can be anything they want it to be.

So, some smart schemers figured out that they could make a shipload of money by a) jacking up the price of a drug that costs pennies to make and b) convincing a few docs to prescribe it to workers’ comp patients.

The latest from CWCI shows that things have gotten worse.

  • Profiteers increased fenoprofen calcium’s reimbursement from $192 in 2016 to $1,479 five years later.
  • In four years, ketoprofen went from $107 to $1,073, a 1,000% increase.
  • Another drug, etanercept, went from $1,930 in 2012 to $7,716 in 2021.

So what are you going to do about this? Wait, this is the first you’ve heard about it? Well, this is not new news.

CWCI first reported this two years ago. WCRI did the same months ago.

What does this mean for you?

You have a fiduciary duty to stop this. If you have ignored this to date, you should be embarrassed, ashamed humiliated and:

  1. Get a report from your payer/PBM about your spend on these three drugs over each of the last three years.
  2. Find out what’s been done — or attempted — to address this.
  3. If you, the payer, haven’t done your part, do not blame anyone else.
  4. Regardless, identify the docs prescribing this stuff; kick them out of your MPN, require prior auth for these meds and work with your PBM — it probably has an on-the-shelf plan — but do not just dump it on the PBM and tell it to fix the problem.
  5. Put a process in place to make sure you are on top of this stuff long before it hits some blog.

Oh, and the CWCI bulletin identifies a bunch of other drugs that are, at best, questionable.

Joseph Paduda is co-owner of CompPharma, a consulting firm focused on improving pharmacy programs in workers’ compensation. This column is republished with his permission from his Managed Care Matters blog.

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