State of Minnesota Medical Services Review Board Oct. 13, 2005 443 Lafayette Road N. St.

Paul, MN
MSRB members present: Lynn Ayers Beth Baker, M.D., Chairperson Barbara Baum, P.T. Jeffrey Bonsell, D.C. Michael Goertz, M.D. Charles J. Hipp, M.D. Reed Pollack Andrew Schmidt, M.D. John Talsness, M.D. Philip Bachman, M.D. Sharon Ellis, R.N. Gregory J. Hynan, D.C. Margaret Kasting Robin Peterson, P.T. Andrea Trimble Hart Ronald Groat, M.D. William Martin, Esq. Kate Berger Rosaland Hoffman William Lohman, M.D. Julie Marquardt Philip Moosbrugger Patricia Todd Carolyn Blodgett, State Fund Mutual 1. Call to order, introductions, announcements Chairperson Beth Baker called the meeting to order at 4:08 p.m. Members introduced themselves. Dr. William Lohman introduced the department’s new Assistant Commissioner, Patricia Todd, who was the previous director for the Minnesota OSHA program for four years. Prior to coming to the department, Todd has worked in industry and at various manufacturing facilities throughout the metro area. She has a bachelor’s degree in electrical engineering and a master’s degree in business and administration. She has been with the state for four years.

MSRB members excused:

MSRB members not present:

Staff members present:

Others present:

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Todd gave an overview of the recent organizational changes within the Workers’ Compensation Division. Todd also said the medical request and medical response forms now include a section in regard to treatment parameters. The new forms are available on the Web site at www.doli.state.mn.us. Lohman said there has been a long-term concern about whether the parameters have been used to the fullest in decisionmaking, both by physicians and insurers, and by decisionmakers. The new forms will encourage the application of treatment parameters in medical disputes. Approval of minutes – action item A move was made to approve the Jan. 20 and April 21, 2005, minutes. Baum seconded the motion and the motion carried. 3. Pharmacy rules update Lohman introduced the most recent draft of the pharmacy rules, dated Oct. 6, 2005. These are changes to the fee schedule with regard to the payment of medications. Lohman and members discussed the changes and additions to the draft. A member asked whether the injured worker would always have a workers’ compensation claim number when presenting a prescription. Lohman said that when the pharmacist cannot use the electronic transaction because the insurer was not identified, then they could bill on paper and get the higher rate. This may encourage insurers and employers to deliver information to injured employees as rapidly as possible, so they can get the lower rate. He noted they tried to balance the incentives here as much as possible. Goertz noted that currently the denial rate for new claims is approximately 18 percent. So this isn’t the equivalent to general health care, where you have your insurance card and you know whether you are covered or not and you can have that confirmed. Lohman noted this is why they are keeping the paper billing system. So all of the situations where there may be a denial or the insurer is not known or hasn’t made up their mind yet, then the pharmacy would proceed the way they currently do. They would dispense the medication, bill it on paper and, in those situations, they would get paid the higher rate if it were found compensable. The lower electronic rate will only be applied when it is an admitted claim and the insurance company has been identified, so the pharmacist can directly contact the insurance company in real time to get a determination back in real time about whether the insurer intends to pay for the medication. That is a firm commitment and, after an insurance company has electronically transmitted an agreement to cover the medication, they can’t take it back. Someone asked if there was any feedback from the pharmacists. Lohman noted there were two issues still being reviewed with the Pharmacy Association: the definition of “usual and customary” and the amount of time needed for a pharmacist to set up electronic billing with an insurer (14 days versus 30). Lohman noted the timeline for the rules is to get them published sometime in December. Baker asked if the members needed to vote on the rules or if they were just for information. Lohman noted they are presented to the members for their information and if the board would like to render an opinion, the department would be happy to hear it.

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Bonsell asked Lohman that if the proposed rules go forward as written, what is the anticipated percentage of cost savings. Lohman said it should be at least 12 percent. There would also be other savings included that are a little harder to measure. Martin questioned whether the proposed rules require use of generics and whether they deal in any way with therapeutic equivalence. Lohman said it does not include therapeutic equivalence, but it does deal with generics. There has always been a workers’ compensation rule requiring the use of a generic equivalent, unless the doctor writes “dispense as written.” The changes that have been made leave that intact. There is not a rule for therapeutic equivalence, but that is something the board can address through treatment parameters. Baker asked members if anyone wanted to make a motion regarding the pharmacy rules or if members would like to let it stand. No motion was made. 4. Task-force report about NSAIDs Lohman presented the task-force’s final report about NSAIDs. Lohman asked Baker to give an overview of the report. Schmidt made a motion to accept the recommendations put forth in the report. Baum seconded the motion. Talsness noted he has some concerns regarding the statement that ibuprofen is associated with the lowest risk of gastrointestinal side effects. He was concerned about the studies being done with relatively low doses of ibuprofen. Lohman noted the risk goes up with the dose for all NSAIDs and said all the data is on the Web site. He noted the studies are done comparing people who are taking the lowest recommended dose for each of those medications. Ayers asked Lohman how to keep the rules up-to-date when new evidence becomes available. Lohman said by coming back to the board to review the data and make new recommendations if needed. Lohman did note that in this case the recommendations in the report would have been no different based on the data that was available before 1985 and the data after 1985, or before 1995 and after 1995, except for some of the information about COX2 inhibitors and their effect on cardiovascular health. Baum asked if there was a process for monitoring developments. Lohman said that monitoring medical evidence related to treatment parameters is one of his responsibilities. Baker asked for any further discussion. Baker called for a vote on the motion to accept the report. All members were in favor and the motion passed. Lohman noted the department will get started writing rules and will come back to the board with them. 5. New business and discussion/approval of 2006 schedule Lohman proposed the department produce the reports about muscle relaxants and narcotics rather than a task force of the board. The same evidence-based process would be used there as for NSAIDs, and all the results would be available on the Web site. The board would be kept informed of the process by e-mail and members could look at the information posted to the Web site whenever they wanted to. The final report would be sent to the members well in advance of a meeting. With the report in hand, the members could go to the Web site to verify the findings and evaluate the recommendations. The board would then decide whether to accept the report and its recommendations.

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Michael Goertz asked about the reviews and whether someone had read all of them. Goertz believes the person who reads them needs to rank them by quality and then highlight the articles that are of particular interest. Lohman said this was done for the report about NSAIDs and is the process proposed for future reports. Lohman noted he would do the work and keep the members informed. Goertz noted he is uncomfortable with this process and that it should be a whole committee working on an issue. He believed this could possibly change the outcome of the recommendations. Baker agreed with Goertz’s concern that the board does need to weigh-in on the process. Lohman noted that any report would come for their approval. He assumes that by keeping the members aware, they can go to the Web site to look at all the information to determine if they agree with the recommendations being made. Baum clarified that this would be a department report to the board and then the board would read it and make a recommendation to approve or not approve the recommendations. Lohman said the board would get the report detailing how the work was done and then they would have access to the Web site and could confirm or disconfirm the recommendations and make their own independent determination of whether they think it is supported or not by the actual data. Baker asked if the report could be put out a month or two before the meeting, so members can have time to look at the spreadsheets and other information. Lohman said yes. Baker noted there are sometimes problems with the Web site. Assistant Commissioner Todd said anytime there is a problem with the Web site, members can e-mail Lohman or her to get the problem fixed. Lohman noted they are password-protected files and he will send a copy to anyone who needs the workbook and separately send a password that would allow them to unlock it. Bonsell asked Lohman if he could send an e-mail message notifying members if there has been some changes. Lohman said he will do that and let members know what he has accomplished, so members will know what is available and what they need to review. Bonsell said he would be comfortable with that. There was further discussion amongst members about the ability to access the Web site and Lohman said we could get the problem resolved. Someone noted he would feel more comfortable if the process could be more streamlined. Lohman said that validation has to be done every time, since an essential part of the process is showing that you picked the right articles. Pollack asked if Lohman could provide the members with an outline and target dates for what he thinks he might be accomplishing and when, and then the members would be able to use it as a table of contents to know what information to be looking for. Lohman said he could try to do this, but it is hard for him to predict, because it all depends on what he finds when he looks at the articles. Bonsell commented that what Lohman is proposing is excellent and he likes the process for what is being investigated and that it has a lot of merit, but he thinks the board is going to run into some problems if the board tries to do everything evidence-based in the future. Lohman noted that is part of the process, that you try to start with systematic reviews. If they are not available, you go to randomized controlled trials. If you don't have those, you go to observational trials and then case series and expert opinion. Bonsell noted as long people outside of the scientific community understand why the board is doing what they are doing now, but why it hasn't been done in the past and why in the future it may not apply. Lohman would argue that it does apply and it actually strengthens your hand because then you can write the report saying that there are no systematic reviews, etc., so the board had to rely on case series and expert testimony. Lohman

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noted that following this format is exactly the way to go every time. Bonsell said he's not saying that the format isn't the way to go, but the board may run into some issues as the board has in the past where they can't apply enough evidence. Baker said she likes this process better than having a small task-force, because if a board member is available that week and is very interested in the topic, you can weigh in; if you are out of town or doing something else, this way the whole group is involved. Baker noted the larger issue is attendance at the meetings. Baker likes the idea of calling in by phone and the possibility of a conference call or possibly changing the starting time to accommodate members. Baker said that she thinks a later meeting time would be better. Lohman noted the board used to start at 4:30 p.m. Members discussed leaving the time at 4 p.m., but thought a permanent phone-in option is a good idea. The department will look at setting up a permanent option to phone in. Members discussed the following dates for the 2006 meetings: Thurs., Jan. 12, 2006 Thurs., July 20, 2006 Thurs., April 20, 2006 Thurs., Oct. 12, 2006

A motion was made to approve these dates and the motion was seconded. All members were in favor and the motion passed. 6. Adjourn Bonsell made a motion to adjourn. Baum seconded the motion. The meeting was adjourned at 5:55 p.m. Respectfully submitted, Rosaland Hoffman