The delisting of a popular commercial guideline provider has initiated dialog within the Workers’ Compensation community about raising the bar on the standard of care for the American worker. According to the National Guidelines Clearinghouse (NGC), the delisting occurred due to key fundamental elements of evidence-based medicine missing from the content’s development. The missing elements are standards for trustworthy guidelines that were established by the Institute of Medicine (IOM) in 2011 at the request of U.S. Congress, through the Medicare Improvements for Patients and Providers Act of 2008. NGC, administered by the Agency for Healthcare Research and Quality (AHRQ) – a division of the U.S. Department of Health and Human Services, took on the request for the study to provide guideline users with a mechanism to immediately identify high quality, trustworthy clinical practice guidelines.(1)
The removal of the content aggregator, which labels itself “The Evidence-Based Guideline Company”, solicits one of two responses: Alarm/caution and indifference. Advocates for employee health and patient-centric solutions agree that the delisting of the content aggregator should, at the very least, serve as a flag for interested parties/authorities to dig deeper into the shortcoming. While alarm and caution seem perfectly rational responses to the issue, a sense of indifference seems out of place in an industry that’s origins are rooted in employee/employer advocacy.
The delisted content is widely used by workcomp insurers in compliance with jurisdictions’ adoptions of the content across the country to serve as a standard of care for injured workers. On its corporate website, the content’s aggregator equates efficacy to medical cost-savings (25%-60% by state, payer, TPA, and health plan), shortened disability durations (34%-66%, median duration down 20%), and other measurements calculated internally by the organization.
An article, citing preliminary findings from the National Council on Compensation Insurance, Inc. (NCCI), published in late December 2015 expanded on the likelihood of private workcomp insurers experiencing a second straight year of underwriting profitability in 2015.(2) Confirmation of NCCI’s preliminary findings for 2015 was published in May 2016 stating that the combined ratio for private carriers was 94%, a six-point improvement from 2014’s combined ratio of 100%. The write up announced, “the workers’ compensation market is healthy and profitable.”(3)
With the touted cost savings, why should workcomp insurers, or anyone else for that matter, care about the guidelines’ trustworthiness as it pertains to IOM’s standards for evidence-based medicine?
The answer is simple: Absent of trustworthy evidence-based medicine, the denial of care is NOT EQUAL to quality care.
The California Workers’ Compensation Institute (CWCI) published a report dated March 3rd, 2016 analyzing outcomes for Workers Compensation inpatient hospitalizations and implant eligible spinal surgeries from 2008 to 2014. The report commemorated a decrease in inpatient hospitalizations by 22.8% and assessed that the number of Workers Compensation implant-eligible spinal surgeries declined 8.4% in 2013 and 13.6% in 2014. The report also explained that payers of Workers’ Compensation claims saw fewer hospital stays than Medicare, Medi-Cal and private coverage between 2013 and 2014. The CWCI report cites that the decline “coincided with continued development of evidence-based medicine…” – employing trustworthy evidence-based medicine guidelines that comply with IOM’s standards will produce improvements in costs, reducing unnecessary utilization of treatment, and ultimately returning injured workers to health and productive endeavor.
The State of California’s pursuit of what DIR Director Christine Baker called “the
best formulary in the nation” has been focused on reducing system friction and utilization review costs. Supporting prescribers with trustworthy, transparent, reproducible evidence-based medicine for script recommendations allows all stakeholders down the work-comp production line to confirm appropriateness using the scientific evidence underpinning the drug recommendation. The result is reduced friction, less disputes, and streamlined care to the injured worker.
When I asked a very well-respected colleague, whose clients primarily consist of insurance companies, principles, and agents, why Insurers should care about quality content supporting healthcare decisions for injured workers the answer was two-fold:
- Quality, trustworthy content is easier to defend. In the event that a disagreement arises about the course of treatment for the injured worker, having the ability to justify the appropriate course of treatment with quality, trustworthy content is paramount.
- Insurers are not just there to insure and fund claims. As part of their brand, insurers have a big responsibility to its clients to help with claims management and medical management. Using the best quality scientific evidence available protects the insurer/employer and the injured worker from undue complexity in the claim due to content whose development is not transparent and reproducible.
Perhaps the most compelling answer to the question on why WorkComp insurers should care about trustworthy EBM is actually another question – Why not?
If trustworthy, IOM-compliant EBM is available today, why wouldn’t ALL WorkComp stakeholders, including insurers prefer it over content proven to lack EBM’s most important attributes. Why would anyone expose injured workers, employers, insurers, and all others involved to undue risk and liability?
I can only assume that stakeholders choosing anything other than guidelines that meet the IOM criteria have never been aware that criteria for a quality, trustworthy guideline exists.
Thanks to the AHRQ and the National Guidelines Clearinghouse for bringing this matter to the forefront. If you’d like to learn more about IOM’s criteria for a trustworthy, quality guideline, click here.
- National Academy of Sciences. “Clinical Practice Guidelines We Can Trust.” The National Academies of Sciences, Engineering, Medicine Health and Medicine Division. 23 March 2011. 25 July 2016.<http://nationalacademies.org/hmd/~/media/Files/Report%20Files/2011/Clinical-Practice-Guidelines-We-Can-Trust/Clinical%20Practice%20Guidelines%202011%20Report%20Brief.pdf>
- Goldberg, Stephanie. “Workers comp insurers stay profitable amid industry changes.” Business Insurance, 20 December 2015. Web. 12 July 2016. <http://www.businessinsurance.com/article/20151220/NEWS08/312209984>
- NCCI. “Workers’ Compensation Market Improved, Grew Premium in 2015: NCCI.” Insurance Journal, 06 May 2016. Web. 12 July 2016. <http://www.insurancejournal.com/news/national/2016/05/06/407778.htm>