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By John Stahl, Esq.
The latest report on Florida from the Workers’ Compensation Research Institute (WCRI) is a trifecta in the sense that it addresses topics that arguably are the current “top three” workers’ compensation drug-related issues:
· Overuse of opioids by workers’ compensation claimants;
· “Pill mills” in the form of doctors liberally (and profitably) dispensing prescription medicines from their offices; and
· The impact of legislative reforms on workers’ compensation practices.
The report, “Impact of Banning Physician Dispensing of Opioids in Florida,” written by Vennela Thumula, analyzes the impact of the July 2011 effective date of Florida House Bill 7095 (HB 7095), which is known as the Florida pill mill bill. The relevancy of that legislation to workers’ compensation relates to it prohibiting physicians who practice medicine in Florida from dispensing Schedule II and Schedule III controlled substances, which include “strong opioids,” to patients. The very narrow exceptions include providing free samples and prescribing a single two-week supply of those drugs to ease surgery-related pain. Florida law considers violating the prohibition a third-degree felony that can result in at least a six-month suspension of a license to practice medicine.
The research specifically compares the usage rate of opioids among newly injured workers before and after July 2011.
Overview of Study
The report defined “Schedule II controlled substances” as prescription drugs with a “high potential for abuse;” the relevant definition of “Schedule III controlled substances” was the subset of prescription drugs with reduced, but still serious, “potential for abuse.” The research revealed that most physician-dispensed prescriptions were for Schedule III opioids.
The statistics regarding a period that ended a few months before the reforms’ effective date demonstrated that 3.5 percent of injured workers received strong opioids from physicians during the initial three-to-six months after their accidents. That percentage fell to .5 percent of the newly injured workers in the immediate post-reform period.
Sixty-nine percent of the workers who received strong opioids in the post-reform period obtained those drugs during the aforementioned two-week post-surgery period. Out-of-state physicians dispensed most of the remaining 31 percent of strong opioids in the relevant period.
These figures indicated a high compliance rate with the reforms’ provisions that were directed at physician-dispensed opioids. They also suggested that the reform’s effects might have included some patients choosing out-of-state doctors that were not subject to the new law.
The specific timeframes for the periods that the study included were that the pre-reform statistics reflected injured workers who experienced the relevant underlying harm between July and September 2010 and had prescriptions filled up to the end of the 2010 calendar year. The injured workers in the post-reform group sustained the relevant underlying harm between July and September 2011 and were issued prescriptions up to the end of the 2011 calendar year.
The impact of the reforms extended beyond physician-dispensed strong opioids. The pre-reform statistic was that 26.7 percent of all pain medications that were prescribed during the three-to-six-month period after an injured worker’s accident were strong opioids. That percentage fell to 22.6 percent after the reform’s effective date.
Most workers’ compensation jurisdictions authorized physician dispensing of prescription drugs. It added that some jurisdictions that generally prohibited that practice allowed some limited exceptions to that ban. One example was a Massachusetts law that allowed a physician to “dispense drugs only when necessary for the immediate and proper treatment of the patient until it is possible for the patient to have a prescription filled at a pharmacy.”
Analysis of Results
According to the report, the overall reduction in prescriptions for strong opioids prompted speculation that many pre-reform prescriptions for those drugs were unnecessary. The more specific reasoning was that the fact that physicians did not issue the same number of prescriptions for those drugs post-reform and merely have pharmacies fill them indicated that the pre-reform level at which physicians and pharmacies had been dispensing them was unduly high.
[Author’s Note: The study’s findings that the reforms may not have reduced the total number of physician-dispensed prescriptions and that those medical-care providers may have simply substituted other pain medications for strong opioids suggested that the reforms may have supported the objective of reducing abuse of stronger opioids but may not have affected the practice of some physicians operating “pill mills.”]
The report further suggests that most physicians who treated injured workers complied with the restrictions under the reforms; however, the report noted that it did not examine physicians who operated on a cash-only basis.
Additionally, the report observed that the potential consequences of prescribing higher doses of weaker opioids included physical and psychological dependence.
The report pointed out that most prior analyses of “pill mills” had focused on the premium that physicians charged for office-dispensed prescriptions compared to the prices for identical pharmacy-dispensed prescriptions. Those studies did not examine whether the economic benefits associated with “pill mills” prompted physicians to prescribe and dispense unnecessary drugs for the purpose of increasing the sales of those higher-priced medications.
The results from the current WCRI study that directly indicated a link between an economic advantage and prescription practices included a finding that those reforms may have influenced many physicians who dispensed drugs from their offices to substitute prescriptions for strong opioids with prescriptions for weaker opioids that physicians could still dispense from their offices in the post-reform period.
Related conclusions included that the reforms did not affect:
· The rate at which physicians prescribed non-pain medications that they dispensed; or
· The quantity or potency of physician-dispensed weaker pain medications.
The WCRI study also presented indirect proof that economic factors motivated issuing unnecessary prescriptions that included evidence related to the practice of self-referral. For example, evidence indicated that surgeons who owned surgery centers performed more operations than surgeons who lacked that economic incentive.
Additionally, the WCRI study expressed concern related to a profit motive leading to unnecessary prescriptions for opioids included proof that prescribing excessive quantities of those substances increased the risks of addiction and death related to taking them.
Any reform-related progress regarding reduced economic premiums and claimants’ improper use of strong opioids that are associated with pill mills is commendable. Avoiding diluting those benefits requires carefully administering fee schedules and diligently monitoring prescription practices because of the probability that dispensing physicians will adopt policies that offset reform-related revenue losses.
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