The California Workers’ Compensation Institute (CWCI) released a preliminary look at the state’s Utilization Review (UR) and Independent Medical Review (IMR) outcomes involving pharmaceutical requests since the state implemented a workers’ compensation formulary in January.

The evidence-based formulary was incorporated into California’s Medical Treatment Utilization Schedule (MTUS) to try and reduce delays and costs and to ensure that medications for injured workers were meeting evidence-based standards. The analysis used data from 141,643 pharmaceutical requests and UR decisions from the first five months of 2017 and 2018, as well as 58,604 IMR decisions from the first four months of those years to compare pre and post-formulary outcomes.

They measured the percentage of UR and IMRs involving pharmaceutical requests, the mix of UR decisions involving requests for drugs categorized as exempt, non-exempt or not listed and the amount of UR approvals, modifications and denial rates for every category. They also measured the mix of approval rates for IMR decisions involving exempt, non-exempt and not listed drugs and the proportion of exempt drugs that were co-prescribed with non-exempt or not listed drugs that were reviewed by UR and IMR, as well as the proportion of UR and IMR decisions that involved opioid requests and the UR approval and IMR uphold rates for those requests.

What they found was that the proportion of UR decisions involving prescription requests was down to 40.7 percent from 44.5 percent during the pre-formulary study period. The percentage of UR decisions where a prescription request was denied remained unchanged (14.6 percent) and UR decisions involving opioid requests saw little change, decreasing from 30.6 percent to 30 percent in the post-formulary period. UR approval rate for opioids declined a little bit more, decreasing to 68.8 percent from 72.3 percent. The percentage of IMR decisions that involved UR modifications or denials of opioids increased from 29.2 percent to 33.6 percent under the formulary, and the IMR uphold rate for those modifications or denials increased from 90.1 percent to 91.4 percent.

Read the press release and purchase a copy of the study from CWCI.