Additional licensure and certifications aren’t unheard of in the world of occupational health. In 2016, the Federal Motor Carrier Safety Administration implemented a new rule that only doctors on their registry can perform DOT Physical Examinations for truckers and other professional drivers. This reduced the number of doctors who can perform those examinations.
When I testified on LB 408, a bill that would have implemented drug formularies for opioids under the Nebraska Workers’ Compensation Act, some doctors were testifying that there was little training in regards to prescribing opioids. Though an opioid prescription registry like the DOT examination registry wasn’t proposed, you could certainly see it proposed as a solution to the opioid problem.
But that article also shared studies that state that pain pill prescriptions are not driving the opioid epidemic. Patients with pre-existing addiction issues are more likely to become addicted to opioids and 75 percent of those who develop opioids start taking opioids in a non-prescribed manner. Furthermore, only 12 to 13 percent of ER patients who are treated for opioid overdoses are chronic pain patients.
My topic will focus on working with non-English speaking clients. As we all know, non-English speaking immigrants come to this country for many different reasons, but the vast majority end up in labor jobs: jobs that cause work comp injuries. Personally, I have represented clients from over 20 countries; in Nebraska we have a surprising number of immigrants and refugees who relocate to Nebraska for plentiful jobs and cheap housing.
As a result of this melting-pot of injured workers, my seminar presentation will focus on the Ethics of representing non-English speaking clients. Specifically, I will explain what lawyers should do when a non-English speaking client contacts the lawyer; what issues may arise during litigation; and how to handle non-English speaking clients and interpreters during legal proceedings.
I recently wrote a post about immigration status and workers compensation. You can read that post here.
I will present on opioids in workers’ compensation. I plan on spending some time discussing opioid addiction as a work-related medical condition and some of the factual and legal challenges that come with opioid use in a workers’ compensation case. I will also address digestive and bowel issues that arise with opioid use and how those injuries can be covered by workers’ compensation.
Opioid addiction is a major public health and even political issue. Drug formularies are being pushed as a way to combat addiction by reducing the prescription of opioids in workers’ compensation cases. I plan on discussing why drug formularies should raise serious concerns not just from doctors, but from employees and employers. You can read my blog posts about formularies here, here and here.
Rod Rehm will be presenting on the topic of deposition preparation for plaintiffs in workers’ compensation cases. Rod is a Fellow in the College of Workers’ Compensation and has prepared hundreds of injured workers for their depositions in his long legal career. Earlier in his career Rod worked both as a prosecutor and criminal defense lawyer so he can draw on 40 plus years of litigation experience when it comes to witness preparation.
Drug formularies are touted as a way to fight prescription drug abuse and contain prescription drug cost. But one major Nebraska employer appears to be questioning whether drug formularies really contain prescription costs.
The City of Omaha was echoing widespread concerns about the possibility of conflict of interests in drug formularies. Those concerns were explained by me in a blog post published last December. In short, drug formularies are administered by pharmacy benefit managers. Pharmacy benefit managers make money by negotiating discounts from drug manufacturers. This gives pharmacy benefit managers incentive to put more expensive drugs on drug formularies because they can negotiate a more lucrative discount than they could for a less expensive generic drug.
LB 408 was held in committee by the Business and Labor committee so it is unlikely it will be considered in this legislative session. Opioids abuse is a topic of high interest for political leaders so drug formularies as a way to reduce opioid use will likely be discussed further in Nebraska.
The City of Omaha has a workforce this is more heavily unionized than most other workplaces in Nebraska. In some instances, labor and management will collectively bargain how some aspects of a workers’ compensation program is to be administered. Supporters of organized labor originated the idea of “labor pluralism” during the New Deal and Post-War era. (4) Labor pluralism means that government should minimize interference between the labor-management relationship. In a unionized workplace, labor and management have a complicated relationship that is both cooperative and confrontational depending on the circumstances. A mandate from the state requiring the use of drug formularies could be as undermining labor-management relations when a labor and management have bargained about the administration of workers’ compensation benefits.
While drug formularies are a relatively recent development in workers’ compensation, they are well established in the larger world of health insurance. Drug formularies have long been criticized for increasing costs in health insurance plans by reducing prescription usage because costs are shifted to insureds, which forces insureds to seek more expensive care, because chronic conditions go untreated. Overall costs are increased. The costs are also shifted onto insureds who have to pick up the costs for more expensive procedures that could have been taken care of through medication. Cost shifting from the employer onto the employee, other forms of insurance and the government is already a serious problem in workers’ compensation. Drug formularies in workers’ compensation could exacerbate the issue of cost-shifting.
Do Drug Formularies add up? Cost = Price * Utilization
When you study drug formularies for any amount of time, you run across the equation that drug costs equal price multiplied by utilization. Proponents of drug formularies tout that they can decrease both the utilization and the price of prescription drugs. Ohio has provided detailed information about the decrease in the utilization of certain drugs like opioids because of formularies. However, the decrease in the utilization in opioids cited by proponents of drug formularies coincides with an overall long-standing decrease in the frequency or number of workers’ compensation claims. Fewer overall claims mean less overall utilization, which could explain some of the cost decrease. A better measure of the effectiveness in drug formularies in controlling costs would be measured by looking at prescription cost per claim. So far, drug formulary proponents have been unable to show that data. Even if drug formulary proponents could show that data, there is still the issue of whether reductions in prescription drug costs lead to increases medical costs by forcing injured employees to seek more expensive care that could have been taken care of by prescriptions.
On the price end of the equation, drug formularies are thought to control costs by having pharmacy benefit managers negotiate bulk discounts on prescription drugs. But pharmacy benefit managers have come under fire with allegations that they actually increase drug prices or at the very least are powerless to stop the increases in drug prices. The issue of drug formularies, pharmacy benefit managers and drug prices is complicated and will be addressed in Part 2 of this series.