Tag Archives: evidence-based medicine

Opportunities for Treatment Guidelines

Medical treatment guidelines can be a great benefit to any workers’ compensation system. They can prevent unnecessary medical procedures and the prescribing of potentially harmful medications. However, they are not all the same, nor are they without challenges. Understanding a jurisdiction’s strengths and shortcomings, taking a strategic approach to developing treatment guidelines and following some common-sense tips can lead to better outcomes for injured workers — and, ultimately, lower costs for payers.

That’s the view of workers’ compensation experts who spoke during our Out Front Ideas webinar on the subject. The panel included representatives from the regulatory, medical, pharmacy benefit management and third-party administrator communities. They were:

  • Amy Lee – special advisor, Texas Department of Insurance, Division of Workers Compensation
  • Dr. Douglas Benner, MD – chief medical officer from EK Health and national medical director of Macy’s Inc, Claims Services
  • Mark Pew – senior vice president, PRIUM
  • Darrell Brown – executive vice president, chief claims officer – Sedgwick.

Dr. Benner brought a unique and important viewpoint to the panel. As a practicing physician for over 30 years, he has firsthand experience practicing medicine under guidelines. He has also been involved in the development of treatment guidelines for both the Official Disability Guidelines (ODG) and the American College of Occupational and Environmental Medicine (ACOEM).

A majority of states now have some type of medical treatment or return-to-work guidelines in their workers’ compensation systems, and nearly half either have or are considering drug formularies. But there is some confusion about how they work within various jurisdictions and how effective they are. The speakers gave us great insights to better understand how to develop and implement successful treatment guidelines and how to get the most out of them.

Texas’ Example

Many in our industry look to Texas as a state with highly effective treatment guidelines. Texas had some of the highest workers’ compensation costs in the nation, along with some of the poorest return-to-work and patient satisfaction outcomes. After implementing treatment guidelines and a drug formulary, the state now boasts some of the best workers’ compensation outcomes in the nation, as well as lower costs.

But the Texas story is not quite as simple or transferrable as you may think. As our panel explained, it took a multi-year, painstaking effort by representatives in all facets of the system to develop and implement the model now in place. The change also required a deep understanding of the workers’ compensation system as it existed in Texas for the treatment guidelines to get to the point they did.

The changes in Texas began with legislative reforms in 2005. It would be two more years before the treatment guidelines were implemented and three years after that for the drug formulary to begin being phased in — first with new claims, then with legacy claims. One of the keys to Texas’ success was a change to include evidence-based medicine in the guidelines.

See also: Texas Work Comp: Rising Above Critics  

EBM

Evidence-based medicine (EBM) is a term we hear often these days, but there’s disagreement about what it truly means. Texas sought to clarify the issue by including a statutory definition in the treatment guidelines, so it defined EBM as follows:

“Evidence-based medicine means the use of current best quality scientific and medical evidence formulated from credible scientific studies, including peer-reviewed medical literature and other current scientifically based texts, and treatment and practice guidelines in making decisions about the care of individual patients.”

Texas switched to basing the guidelines on EBM to reform the previous consensus-based model, which was perceived as allowing for too much unnecessary medical care. EBM was chosen as the standard for selecting treatment guidelines, return-to-work guidelines and adjudicating claim level disputes on medical care. It is also the standard expected from healthcare providers, payers and others.

The idea of EBM is to provide a systematic approach to treating injured workers based on the best available science. Ideally, medical providers should base their treatment regimens on EBM, although it is also important to consider the specific needs of each individual patient.

Unfortunately, some of the most pervasive medical conditions among injured workers have not been as heavily researched as other ailments, such as heart disease or hypertension. This means EBM is not the basis for every single medical condition. The developers of EBM for workers’ compensation consider all available research, ‘weigh it’ in terms of quality then fill in the ‘gaps’ with a consensus of expert panels. That does not mean those particular guidelines are not scientific. For example, there is little research indicating someone with chest pains should undergo an electrocardiogram (EKG), but medical common sense dictates that is the appropriate action to take.

Formularies

Ensuring injured workers are given the most appropriate medications for their conditions is, or should be, the goal of drug formularies in workers’ compensation, according to the panelists. Not all drug formularies are the same, and it is helpful to understand their differences.

As we learned in the webinar, drug formularies started in the group health area and were primarily a way to reduce costs, because out-of-pocket expenses are involved. There are different tiers to guide the best drug for the patients with the aim of finding the one that is the least expensive.

Because workers’ compensation does not typically include co-pays, the goal for many jurisdictions is clinical efficacy — finding the medication that will result in the best outcome for the injured worker and get him or her back to function and, ultimately, work.

See also: States of Confusion: Workers Comp Extraterritorial Issues

States such as Texas have a “closed” drug formulary, although compared to closed formularies in group health, it is not the same. Whereas in the group health context, some medications will be disallowed in terms of reimbursement, formularies in workers’ compensation instead require pre-authorization for certain medications. The term “preferred drug list” is more appropriate for workers’ compensation.

Texas uses the Official Disability Guidelines for its list of “Y” and “N” drugs. All FDA-approved drugs are included, but those on the “N” list are not automatically paid for through the workers’ compensation system.

Almost immediately after Texas implemented its drug formulary, prescribing patterns changed. Physicians began prescribing more medications on the “Y” list, rather than justifying the use of those on the “N” list. That was among the main goals of the drug formulary — to get prescribers to avoid prescribing opioids and other potentially dangerous drugs right from the start.

The formularies in workers’ compensation systems in other states differ. However, the goal is the same: to encourage providers and others to prescribe medications that are the best for the injured worker, considering his or her injury and any comorbid conditions. Patient safety, rather than lower costs, should be the goal.

Many in the industry are closely watching California as it faces a summer deadline to finalize its drug formulary. There are estimates that the state could see about 25% of its currently-prescribed medications put on the fast track for approval and thus avoid delays from utilization review once the formulary is implemented.

Challenges

Having heard about the many potential benefits of treatment guidelines, we then turned to the panelists to discuss some of the obstacles and how to overcome them. Educating all stakeholders was among the most important strategies they mentioned.

For example, a claims examiner may not see a recommended treatment in the guidelines for a particular jurisdiction and issue a denial for a requested procedure. But, upon further investigation, the treatment requested by the provider may be the best for all considered.

In a California case, a claim was halted for several years — with indemnity expenses continuing to be paid — as the parties awaited the outcome of a dispute over an MRI scan. The case points to the need for those involved in a claim to be flexible. While following the guidelines should be the general rule of thumb, it’s also important that those overseeing a claim take a holistic approach and see what really makes sense for the injured worker.

It is also vital to educate physicians on what to do to gain approval for treatments that stray from treatment guidelines. Often, little or no explanation is provided as to why a particular patient needs a certain procedure or medication. Without complete information, the rate of denials increases. Texas took the unique step of implementing Appendix B to provide guidance to physicians on how to document exceptions to its guidelines.

The consistency (or lack thereof) of guidelines can be frustrating, especially for organizations that operate in multiple jurisdictions. Again, those involved in the claim need to be informed about the guidelines used in each.

It is important that everyone involved in reviewing treatment recommendations — including claims examiners, nurses, physicians and even administrative judges — understand the treatment guidelines and their limits for the jurisdictions in which they operate. The decisions each person makes must be consistent for the guidelines to be most effective.

Keeping the guidelines current is another challenge for some jurisdictions. With medical science changing rapidly, it’s best if jurisdictions find a way to get updated information published as soon as possible and make it easily accessible.

The Future

While a majority of states have medical treatment guidelines in their workers’ compensation systems, 21 did not at the time of the webinar. About 20 states either have or are considering drug formularies.

There are additional efforts underway on the state level to address medical care for injured workers. Several Northeastern states, for example, have placed limits on the number of days for which opioids can be prescribed. Some have limited it to seven days, while New Jersey is imposing a five-day limit. That trend is expected to continue.

See also: 25 Axioms Of Medical Care In The Workers Compensation System  

Other states are looking at helping wean injured workers off opioids. New York recently rolled out a new hearing process to address claims that involve problematic drug taking.

Progress is being made to improve injured workers’ outcomes and treatment guidelines, and drug formularies are a big part of these efforts. The goals of better safety and clinical outcomes, quicker return-to-work, shorter treatment periods and better overall outcomes should drive the conversations going forward.

To listen to the complete Out Front Ideas with Kimberly and Mark webinar on this subject, please visit Out Front.

Better Outcomes for Chronic Pain

The workers’ comp industry is burdened with perhaps 200,000 or more injured workers on long-term opioid treatment for chronic pain. Many more workers enter these ranks yearly. For 10 years, I have observed this awful misery slowly accumulate. But claims payers can do more to prevent new case and resolve “legacy” cases. It will require from them more commitment to best practice care and a lot more frank, open collaboration among themselves and with medical providers.

Conservative care is hugely under-exploited as an approach to prevent and resolve chronic pain among injured workers. Workers’ compensation claims payers would not have paid so much for opioid treatment, failed surgeries and claims settlements had they adopted conservative care decades ago, when research support for this approach was already pretty strong. The failure to promote this approach cost the policyholders perhaps $100 billion in higher premiums and cost injured workers years of disability and, in some cases, funerals.

By conservative care, I refer to functional restoration programs, which came into existence in the 1970s or earlier. Cognitive behavioral therapy became established in the 1980s. Coaching, as a non-medical method of helping persons in pain, has been around forever but recently gained visibility as a scalable form of intervention. There’s a lot of innovation going on, such as the PGAP program imported from Canada and a number of nerve-stimulation services such as Scrambler in New England.

Payers need to learn how to create conditions within which conservative care can prosper rather than repeatedly blossom only to die.

A friend prods me to use the term “evidence-based medicine.” But “conservative care” is my choice for an umbrella term because it is easy to remember, though inexact.

A few years ago, I talked by phone with a senior medical case manager at a claims payer in Kentucky, an epicenter of opioid prescribing excesses, who had never heard of functional restoration programs. This reminded me of the Harvard professor who spent a year in Munich without ever hearing about Oktoberfest.

The long history of insurers includes many instances where they brought risk management solutions like conservative care to the market. The first modern evidence of that goes all the way back to London fire insurers in the late 17th century. Mutual insurance companies played an essential role in introducing automatic fire-suppressing sprinkler systems to American factories in the late 19th century.

In my special report published by WorkCompCentral, “We’re Beating Back Opioids – Now What?”, I propose that claims payers and selected medical providers collaborate for the purpose of better success in treatment. This is particularly valuable for conservative care. The collaborations would allow each party to act on its own but to pool information. Periodically, analysts will dig into the database to report on the group’s experience on outcomes and costs.

The healthcare community, sometimes with the explicit support of health insurers, engages in collaborations to improve health outcomes. A Health Affairs article in 2011 is titled, “How a Regional Collaborative of Hospitals and Physicians in Michigan Cut Costs and Improved the Quality of Care.” The article addresses surgical collaborations, for instance:

  • Michigan BCBS has been supporting since 2006 a bariatric surgery data-sharing project involving 27 hospitals and some 7,000 patients a year.
  • Its major general and vascular surgery collaboration recorded 50,000 patients a year.

The article concludes that “results from the Michigan initiative suggest that hospitals participating in regional collaborative improvement programs improve far more quickly than they can on their own. Practice variation across hospitals and surgeons creates innumerable “natural experiments” for identifying what works and what doesn’t.

Elsewhere, collaborations among independent medical providers have been noted in asthma, diabetes, surgery and congestive heart failure.

Another analysis of collaborations commented that “real improvements [in treatment] are likely to occur if the range of professionals responsible for providing a particular service are brought together to share their different knowledge and experiences, agree what improvements they would like to see, test these in practice and jointly learn from their results.

Claims payers need to help this cross-fertilization happen. Hard as it may seem, they need to “own” the need to build conservative care resources in their markets. Physicians don’t understand conservative care; referral patterns are not set; and the providers of conservative care are often under-resourced. Claims payers need to step up.

25 Axioms Of Medical Care In The Workers Compensation System

  1. The right medical care at the right time is always in the best interest of the injured worker and almost always will result in the lowest claims costs.
  2. The right medical care at the right time will (almost always) result in an earlier return to work with less permanent residual disability.
  3. Evidence-based medicine is the right care for the legitimately injured workers. (There is a hierarchy on how to apply evidence-based medicine).
  4. To control worker's compensation medical costs requires both a fee schedule and an ability to control the frequency and the appropriateness of treatment. One without the others usually results in massive increase in medical costs for the system.
  5. The medical treatment fee schedule should be clear, easy to use, accurate and reflect the latest technology.
  6. A fee-for-service system may result in incentives for physicians to over-treat, inappropriately.
  7. In many jurisdictions Worker's Compensation is generally the last fee-for-service system.
  1. As long as workers compensation uses a fee-for-service system, medical utilization review is needed to make sure that the physicians will treat adhering to evidence-based medicine.
  2. Pharmacy utilization is problematic because of the “Medicalization” of the general population. (Medicalization is the direct advertising of symptoms and diagnoses to the general population by drug manufacturers, resulting in an overuse and/or misuse of some types of drugs and therapies).
  3. There is a significant problem with “off label use” of drugs in the worker's compensation system. (Off Label is the use of a drug for treatment that was not the reason for its approval from the FDA).
  4. Medical decisions should be made by medical professionals. Most Workers' Compensation judges, attorneys, and claims adjusters have little to no formal medical training and are not medical professionals.
  5. Poorly (inappropriate) placed incentives will result in poor medical outcomes. (There are several studies that demonstrate that allowing physicians to do self-referrals or to dispense pharmacy goods from their offices will usually result in a utilization of unnecessary services or inappropriate usage of drugs).
  6. Even if the doctor is not dispensing the drugs, opiates require regular visits to the doctor for renewal of the prescription and also may involve expensive drug testing; so there is a financial interest on the part of some doctors to prescribe opiates.
  7. Some physicians who prescribe opiates do not fully appreciate the addictive power of the drugs that they are using or the difficulty in detoxing the patients.
  8. There are currently enough treating physicians and specialty physicians in most urban areas; however there are not enough physicians (treating, orthopedic or neurosurgeons, etc.) in the rural areas to meet the demand. This problem will only get worse as the population ages and more doctors retire. It will also get worse if physicians leave workers' compensation due to the demand for their services due to the implementation of the federal universal health care programs.
  9. Many surgeons and other physicians want to perform their craft (do surgery, provide injections, etc.). They truly believe that their surgery or injections will work even if the prior treatments have not been successful or if current evidence-based medicine says surgery is not appropriate.
  10. Every patient looks like a good candidate for an MRI when there is an MRI machine in the doctor's office.
  11. Not every person with a surgical or potentially surgical condition is a good surgical candidate. Though pre-surgical psychiatric evaluations are required for spinal cord stimulators (post spine surgery), the same is not true for many other surgeries.
  12. It is difficult for a patient who is in intractable pain to believe that strong medications (including opiates) are not appropriate or are not good.
  13. It is difficult for a patient who is in intractable pain to believe that not having back surgery will have the same ultimate result as having surgery when the surgeon is saying (with confidence) that the surgery will cure all. Even though current evidence-based medicine says differently.
  14. Because “doing something is better than doing nothing” when the patient is in intractable pain, if the surgeon says surgery will not be successful, the injured worker will attempt to find someone who will say that the surgery “will be more successful than not having surgery,” and will then attempt to have the surgery.
  15. Patient advocacy is the application of appropriate treatment and patient encouragement that allows the patient to remain as functional and productive as possible.
  16. Patient advocacy does not always mean the pursuit of treatment a patient desires.
  17. Patient advocacy may require the physician to decline to do the treatment sought by the patient when that treatment is inappropriate.
  18. In Workers'Compensation, there are many (known and unknown) underlying non-industrial, psyche/social issues that may hinder or completely stop optimum medical recovery.