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.
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
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.
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.
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.
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.