In a statement released on June 7, 2016, the National Alliance of Medicare Set-Aside Professionals (NAMSAP) announced the 2nd in a series of webinars focused on opioid drugs in the Medicare Set Aside. The release can be found at NAMSAP Presents “Opioids in the Life of the MSA” Webinar on June 21
Since the creation of NAMSAP’s Evidence Based Medicine Committee in 2014, opioid use has been in the forefront of attention within NAMSAP. As a member of NAMSAP’s Board of Directors, I have participated in our organization’s efforts to collaborate with experts on this critical issue, to educate our members as to what is happening when opioid involved MSAs are reviewed by CMS, and now to advocate to entities outside of workers’ compensation.
Our goal is to publicize the conflict between the WCMSA review process and CMS’s own criteria for opioid addiction triggers, prior authorization requirements and mandatory weaning. This release explains the rationale and basis for our request: NAMSAP has called for CMS to limit opioids in the MSA review;
The easy answer
Many say the answer to the inconsistencies in the WCMSA review process as it relates to opioids is to stop submitting the MSA to CMS. “Why feed into a broken system?” is the question I’ve heard. If opioids aren’t appropriate for life expectancy, if addiction is imminent, if weaning is appropriate, then include this in the MSA and just don’t submit.
I absolutely endorse CMS non-submission as an option. Where I may differ from others is that I believe it should be decided based on the facts of the case as compared to the objective and subjective nature of CMS’s review and approval process. Unfortunately, I fear a corporate non-submit strategy is a slippery slope down the path of massaging the MSA to ‘fit’ the needs of the moment. That is not its intent of the MSA, nor will it be left unchallenged in the long term.
I believe the prevalence of opioids in workers’ compensation indicates something is broken, but the break is much further up the food chain. Can and should CMS ‘fix’ a problem that we have allowed and enabled over the life of the claim? Can an excise tax on opioids fix the problem?
What if we looked at things differently?
- What if we identify the physicians who don’t write for opioids as first line treatment for pain?
- What if we know and use the physicians with a proven track record of getting patients back to work
- What if we implement triggers to identify initial onset and changes in opioid dosage and frequency?
- What if an increase in Morphine Equivalent Dosage was measured and addressed immediately with the physician?
- What if we leverage PBM reports and tools to block opioids based on corporate designated criteria, and then execute an action plan?
- What if we use jurisdictional options like UR, IMR, challenging treatment to force dispute resolution and state options to allow the carrier to control physician choice where these options exist?
Working both sides
Every company has its own strategies to address the opioid issue. Our policy at Tower is to ask every ‘what if‘ question possible as we work with clients throughout the claim and settlement process. Whatever the answer, whether it’s physician follow up to track weaning, a formal physician peer review to challenge inappropriate treatment, or negotiating a Conditional Payment Notice to dissociate unrelated treatment, our MSP Automation Suite drives and tracks every step in the process. We push the claim to optimize outcomes and acknowledge when the MSA is ‘ready‘ to submit.
The result of the combined efforts of all stakeholders in workers’ compensation, according the WCRI report on opioids released on June 9, 2016 is that the industry has made positive strides to address opioid issues. Now NAMSAP is challenging CMS to modify the WCMSA review criteria so that it more closely mirrors its own Part D approvals process.
I hope you will join the webinar as we look at the policy side of the opioid issue within the MSA and that you join our advocacy efforts.