State Compensation Insurance Fund (SCIF) will learn this week how many — if any — physicians opt out of its medical provider network (MPN) to protest new controls in its network agreement to prevent overuse and abuse of opioids and compounded drugs. Both classes of pharmaceuticals have been among the fastest-growing expense items in California’s workers’ comp system, and the quasi-governmental carrier is not alone in looking for ways to get a handle on the issue.
State Fund is approaching the problem by requiring all network physicians to get prior approval before prescribing any compounded medication to injured workers. It’s also limiting prescriptions for opioid medications to a 60-day supply unless the physician can show cause as to why the worker needs a longer regimen. And it is also clamping down on in-office dispensing of medications, limiting the handouts to a 72-hour supply.
“These changes are designed to further improve patient outcomes and ensure that injured employees receive optimal treatment. Working with Dr. Bernyce Peplowski, our interim medical director, we have followed the ACOEM guidelines and Medical Treatment Utilization Schedule in revising our MPN contract,” State Fund spokeswoman Jennifer Vargen tells Workers’ Comp Executive.”We worked closely with the administrators of Blue Cross and Kaiser Permanente, our MPN partners, in rolling these out and have their full support.”
These policies, among others, were outlined in a letter that State Fund sent every physician in its MPN earlier this month. Physicians who fail to return a signed copy of the letter by June 30 will be booted from the network. Violations of the agreement’s terms can also result in expulsion. Kaiser doctors, of course, must follow Kaiser rules.
The quick turnaround, along with some of the individual conditions, causes the California Society of Industrial Medicine and Surgery (CSIMS) to be concerned about the fallout. While its members will have to make their own decision about whether to sign the agreement, CSIMS lobbyist Steve Cattolica maintains that State Fund’s policies are at odds with other guidelines for pain management and prescribing opioids.
He says the policy appears to be an attempt by State Fund to reduce the size of its network and gain more influence over doctors who remain.
“You have to think that’s part of their desire because there are going to be some of the physicians who don’t sign the letter, and they must have thought that would be the case,” Cattolica says. As of late last week, he says, State Fund had not responded to CSIMS’ concerns, which were outlined in a letter to the carrier.
Workers’ Comp Executive will follow the story to show you how the final network numbers play out, as well as the long-term impact on use of opioids and compound medications.
(Filed by Brad Cain in San Francisco)