Tag Archives: Evidence-Based Medicine

Content Out of Context

The adoption of evidence-based medicine (EBM) by state jurisdictions tends to polarize workers’ compensation stakeholders – sometimes for good reason. Many justify that it is the political machine driving the opposite perspectives. This may very well be part of it, but lack of understanding combined with the improper use of the scientifically based standards by certain system verticals is almost certainly a recipe for varying points of view and disagreement.

Evidence-based Medicine is Not Always Unequivocal

Proponents for the adoption of EBM in workers’ compensation generally agree that the content is a path leading to improved medical care for injured or ill workers. Various metaphors (e.g., speed bump, guard rails, etc.) have been appropriately used to describe the content’s ability to steady the tempo of decision-making around care considerations ensuring that safety and efficacy remain priorities in the care and claim continuum. These metaphors, however, miss an important attribute that is evident in a well-developed medically responsible EBM standard – it may not always be unequivocal.

Today, non-clinical professionals often view EBM as absolute standards for the appropriateness of care rather than scientifically based guidance to inform medical decision-making. The use of the content in worker’s compensation as a rigid basis for approving or denying reimbursement for treatment is in large part responsible for maintaining this perception. While this application of EBM, when informed by clinical consensus, may be an acceptable use of the content, it is not its sole purpose and the original intent for the guidance.

Certain recommendations for, or against, specific protocols can be very straightforward and have clear guidance that is actionable for clinical professionals, and non-clinical personnel alike. However, ensuring appropriate clinical interpretation of the recommendations by considering each individual patient’s unique medical needs prevents the use of the content from being out of context and avoids perpetuating a cook-cutter approach in medicine.

The original intended application of EBM was to strengthen weak standards in clinical practice and to increase confidence in clinical decision-making. If the application of the content was more prominent in clinical settings used by medical professionals in workers’ compensation, would the industry view EBM as unequivocal standards, versus trustworthy guidance useful to aid in the care of the individual patient as it was initially intended to be?

The Over-simplification of Complex Concepts

Publishers of EBM continuously walk a fine line between creating tools and widgets, that deliver the content in concise actionable formats and potentially over-simplifying complex medical concepts that become diluted and dangerous when made to fit into an overly simplistic delivery. This, along with prospectively rigid applications previously mentioned, leads to distrust of the content and breeds opposition among the stakeholders for whom EBM is intended to support.

Opposition among providers outside of the Occupational Medicine specialty for EBM always surprises me. I have had the privilege of interviewing numerous providers who oppose the use of EBM over the last ten years. Their perspective has a common thread that echoes the issues identified above. And while medical providers are often accused of rejecting the use of EBM standards due to avoidance of oversight and accountability, a more sensible source of their opposition may be due to the oversimplification of the complex medical concepts delivered via poorly engineered EBM tools and inadequately credentialed users of the content.

A recently posted blog by a long-term, well respected, proponent of EBM documents a young Air Force physician’s disillusionment of medicine due to EBM, among other things. The young physician states that EBM sucks the intellectual challenge and creativity, or as he puts it “the fun” out of the art of medicine. He further shares that following the guidelines is the “easy path” and that there is neither “encouragement nor reward for taking the extra mental step” to determine if the guidance fits the patient’s needs, or if a variance is medically appropriate.

I have several thoughts about why the young physician’s disillusionment of medicine may be misplaced. However, the acknowledgement of the lack of reward for varying from EBM guidance, when warranted, in pursuit of the best medical care and health outcome for his patient is telling of a system’s over-simplification of the complex medical scenarios he must work to resolve.

A rigid, over simplistic application of guidelines will only shorten the cycle for reimbursement, but can risk stifling a good doctor’s willingness to invest the time to identify the best treatment plan that will produce the best health outcomes for their patient. This rigid approach to medicine will breed and reward poor practice habits in the clinic and potentially result in a higher medical spend long term. Conversely, a doctor unwilling to investigate the best course to recovery for their patient irrespective of the hurdles encountered may be subject to criticism for prioritizing other interests ahead of their patient’s needs.

The data is clear. The impact that EBM has on improved health outcomes in workers’ compensation is overwhelmingly positive. Adverse patient and provider experiences are more accurately contributed to the inappropriate rigid use of the content in a system that is engineered to focus more on reimbursement versus quality medical care and improved health outcomes.

The pursuit to simplify and streamline solutions has become part of our cultural fabric. Just as technology has made it possible for our society to make advancements in medicine, it will eventually become a vehicle to better deliver these advancements. For now, however, we rely on the appropriate application of EBM standards by qualified professionals in the clinic and beyond allowing for flexibility when warranted.

A Case for National Standards for State Workers’ Compensation

Would you be surprised to know that the definition of “Employee” and “Contractor” varies from one state to another? Would you be shocked if I told you that more state Workers’ Compensation agencies operate without a full-time, or part-time, Medical Director on staff than those that do?

Speaking with a prominent regulator, and Workers’ Compensation expert, at the #IAIABC103 conference in Portland, OR last week, rekindled my interest in determining what establishing national standards could do for a system where variances from one jurisdiction to the next seem endless.

The sources of variability in definitions and standards are numerous. Among the most prevalent, RESOURCES (expertise, budget, time etc.). Is it reasonable to suggest that the varying availability of resources from state-to-state present limitations for regulators in their pursuit to appropriately research prospective public policy that will improve system outcomes?

Take evidence-based medicine (EBM) for example…

Admittedly, EBM is a very complex concept that few people truly understand and appreciate (Note: This is particularly true, and ironic, in the Workers’ Compensation industry where misaligned incentives makes it nearly impossible for stakeholders to share a common goal). EBM goes beyond the review of literature and authoring of content. The path taken to form conclusions, interpreting scientific literature and answering defined clinical questions ultimately constitutes the content as evidence-based. Without an informed guide to point out technical deficiencies and/or important considerations, the outcome for the agency looking to adopt may result in the selection of a consensus-based resource, or worse, a resource with an undetermined basis.

Serving a Thanksgiving Meal on a Fast-food Budget

In Workers’ Compensation, state officials routinely struggle to serve a Thanksgiving meal given little more than a fast-food budget. This type of limitation in resources hinders small markets from properly researching and vetting EBM tools when considering a source for adoption.

In a best-case scenario, the adopted solution goes through uncontested for quality and trustworthiness, due to a lack of understanding, and provides a standard of care where there previously was none, albeit lesser in quality. Worst-case scenario, the inadequately vetted solution becomes a liability to patient health and is a source of significant system friction and cost due to errant research findings by the agency adopting it. With proper informed due diligence, which requires RESOURCES, both scenarios are entirely avoidable.

Stakeholders in the Workers’ Compensation system throughout the country are actively expanding the conversation on the necessary attributes in EBM treatment guidelines and drug formularies for state adoption. Increased scrutiny is placed on determining if guidelines and formularies are built atop a basis that aligns with public standards defined by the National Academies of Sciences, Engineering, Medicine (formerly the Institute of Medicine). Interestingly, these standards, and the non-profit entity that measures alignment among content sources (i.e., AHRQ’s National Guideline Clearinghouse), are deemphasized and lessened in value by small market states who do not have properly experienced personnel evaluating the standards’ merits. This should prompt action by every person with an interest in Workers’ Compensation – employees, employee attorneys, employers, physicians, carriers, et al.

Good Public Policy is Never Easy and Rarely Inexpensive

Select state agencies have expressed concerns with limited options for adopting EBM content and tools due to absent resources such as a Medical Director, Pharmacy and Therapeutics Committee, and staff with expertise in the area of scientific research. A state’s “limitations” supersedes its “needs” under these restrictive circumstances. The more limited the resources, the less available options for these agencies to consider for adoption.

It is my sincere belief that small market agencies, much like their large market counterparts, work extremely hard to educate themselves on evidence-based medicine treatment guidelines and drug formularies, as well any other area they seek to reform, and aim to make the right decisions. In the end, they are left to act using the resources they have at their disposal, whether plentiful or scarce.

Perhaps a national standard for the evaluation and adoption, better yet a definition of EBM for Workers’ Compensation, as an example, would help afford better options for small markets managing with modest resources.

Removing Friction from California’s Workers’ Compensation System

The California workers’ compensation system has been buzzing with activity since the passage of AB 1124 in 2015 requiring the Administrative Director of the Division of Workers’ Compensation to establish a drug formulary as part of the state’s Medical Treatment Utilization Schedule (MTUS). The addition of the formulary, in concert with the impending updates to various treatment guidelines (following the new expedited process set forth in SB 1160), in MTUS will improve the system by:

  • increasing the use of evidence based care administered to patients therefore reducing the inappropriate prescription of dangerous drugs and inappropriate medical treatment;
  • reducing system friction by providing a common standard to base medical decisions for injured workers at every step in the care and claim continuum.

California Code of Regulations and Presumptive Weight

Perhaps my day-to-day exposure to regulations and legislative text is what drives my “geeking out” on the code. I have actually heard highly influential people say, “no one pays attention to the labor code”, or “no one cares about what the regs state”. Comments such as these just don’t make any sense.

Admittedly, regulation text can miss the mark if stakeholder input is not considered. Real-world experience and wisdom must inform the process that is expected to turn the gears of the workers’ compensation industry. Absent sound and constructive input from the marketplace, regulations run the risk of being detached from the day-to-day needs of the system and all of its stakeholders.

In California, the Division of Workers Compensation’s Administrative Rules emphasize the state’s commitment to injured workers and their employers by defining what may well be the most critical of expectations – that the best available evidence be used to guide clinical decision-making. The state’s commitment to injured workers and their employers is again emphasized by the thorough analysis that was conducted to inform their selection of the content source that powers the MTUS’ treatment guidelines and drug formulary.

The outcome of the state’s thorough analysis of multiple treatment guidelines and drug formularies lends great weight to the state’s assignment of the MTUS (and the platform that provides the foundation for the MTUS, the ACOEM Practice Guidelines and Drug Formulary) as being the “go-to” source when treating ill or injured workers in the California market:

§ 9792.21 Medical Treatment Utilization Schedule.

(c) The recommended guidelines set forth in the MTUS are presumptively correct on the issue of extent and scope of medical treatment. The MTUS constitutes the standard for the provision of medical care in accordance with Labor Code section 4600 for all injured workers diagnosed with industrial conditions because it provides a framework for the most effective treatment of work-related illness or injury to achieve functional improvement, return-to-work, and disability prevention. The MTUS shall be the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers.

Assigning this weight to the MTUS prioritizes the use of its treatment guidelines and drug formulary above all other sources. In doing so, MTUS becomes California’s primary language of communication for all workers’ compensation system stakeholders. Understanding that on occasion secondary sources may be needed to form a comprehensive foundation for evidence base care, California’s Division of Workers’ Compensation defines a very clear path (through its Medical Evidence Search Sequence) for introducing standards not found in the MTUS. This path should only be taken after the MTUS is considered (see charts below).

More Than Claims and UR Tools

California’s endeavor to establish the tools contained in MTUS as the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers is based in the realization that in order to meaningfully improve the friction in the workers’ compensation system, MTUS must be the guiding source for treatment from day-one.

The treating physician’s initial interaction with the injured worker is paramount to accomplishing favorable health outcomes. The dialog between doctor and patient not only sets appropriate (or inappropriate) medical expectations, it ultimately shapes the trajectory of the claim – smooth going, or friction-filled. This is the point where evidence based care is most effective and necessary.

Retrospective efforts to get a run-a-way claim train back on track are perceived as detrimental to employee benefits by employee advocacy groups. Deviating from or challenging a doctor’s orders, even when informed by the highest-grade of evidence-based medicine, can be an invitation for friction. Disparate standards of care introduced outside of the established path (Medical Evidence Search Sequence) further widens the gap among stakeholders and adds friction to the process.

Opponents of Sound Patient-Centric Medicine

Sound patient-centric medicine will always have opponents – opponents by commission and opponents by omission.

Misaligned interests are present in numerous verticals of the industry. Opponents by commission are identifiable by their persistent off-center messaging in the marketplace. Their message intends to deemphasize what the State has created as a standard; they work to obfuscate what is otherwise a clear path to scientifically based standards for optimal care. Their interest is driven by personal gain, forgetting that a conflict-free, good working system that produces optimal health outcomes benefits everyone.

In some cases, opponents do not see themselves on the opposing side of sound medicine. Opponents by omission are parties that remain neutral when confusion is intentionally sown into the marketplace by the aforementioned. I often question, are opponents of sound patient-centric medicine unware, or are they indifferent to the friction they invite by their lack of action?

California’s success in removing friction from its workers’ compensation system hinges on all of the state’s stakeholders committing to work from the same standards and speaking the same language. Anything short of this type of cooperation is both counter-productive and an affront toward the collective effort to produce improved health outcomes for California’s injured workers.

Aides from Dr. Raymond Meister, CA DWC Medical Director

*Complete presentation deck is available at http://ccwcworkcomp.org/ccwc/assets/File/2017%20Conference/PPT%20Presentations/4_1%20Implementation%20of%20SB1160.pdf.

MTUS Online Education

http://www.dir.ca.gov/dwc/CaliforniaDWCCME.htm

Why Standards Matter

I had the privilege of attending the AASCIF conference for the first time, hosted in Oklahoma City this year. I was honored to have so many in the state compensation insurance fund community express support of our organization’s efforts to elevate evidence-based medicine (EBM) and advocate for the improvement of the quality of medical care to injured workers.

One conversation left a lasting impression. A well-known workers’ compensation veteran verbalized discomfort with some of my topical write-ups on EBM, trustworthy clinical guidelines, and my willingness to name certain commercial guidelines publishers in hopes of encouraging accountability. They echoed the conflict-free mantra, “There is enough room for all EBM treatment guidelines in workers’ compensation.”

A thought immediately consumed me:  My point of view is based on standards that are not defined by me, or my employer (also a commercial guidelines publisher), but standards that were developed independently by a non-interested not for profit entity at the request of the U.S. Congress looking to establish best methods used in developing clinical practice guidelines. The goal was to ensure such guidelines have information on approaches that are objective, transparent, scientifically valid, and consistent – the ideal basis of accountability for the clinical guidelines industry.

What is at Stake?

The statistics are sobering. Treating providers experience challenges in the clinic. A 10-year study conducted by a medical consultation firm found that nearly a fifth (~21%) of medical diagnoses in workers’ compensation claims involve errors costing the injured worker prolonged disability and household financial distress.

Workers’ compensation only covers a portion of the earned income and there is usually a ceiling, typically 66% of pre-tax earnings up to the state’s average weekly wage. Lost time from work for the injured worker due to injury or illness means loss of income. According to a study by the Washington State Department of Labor and Industries (2015), injured workers with less than 3 months of lost time lose an average of 3.5% of earning capacity over a 10-year period. Conversely, lost time of 3 to 12 months produces losses of income of approximately 11.6%; 28% loss in earnings is experienced after a 3-year absence due to workplace injury or illness.

Another study published in January 2017 looked at ~1.9 million short-term disability and workers’ compensation claims investigating for absences where prescribed opioids were contrary to a leading EBM drug formulary’s recommendations. The study estimated 57,000 (~3%) claims were found to have had an opioid prescribed that was either moderately or strongly not recommended in the formulary. The study also discovered approximately 133,000 (~7%) claims where prescribed opioids were contrary to the formulary recommendations for disorders of the peripheral nervous system including ulnar nerve lesions and carpal tunnel syndrome.

The challenges experienced in the care and claim continuum are plentiful and very difficult to navigate. Employees, employers, insurers, and medical providers deserve content measured and deemed trustworthy according to non-bias standards to guide injured workers through these challenges and on to recovery.

Thought-Leaders Stand Up

With the deep knowledge base and hands on experience of how quickly a workers’ compensation claim can go into free fall toward catastrophic health and recovery outcomes for the injured worker, why aren’t more “thought-leaders” taking a closer look at the status quo to identify inadvertent, or unintended, consequences and voice opportunities for improvement in their respective areas of expertise? Why is accountability viewed as a negative for industry report and the cost to the individual worker is almost intentionally ignored?

There may be enough room for all EBM treatment guidelines in workers’ compensation. However, there should never be room for vendors to profit from poorly constructed products that are dangerous to the well-being of injured workers and subsequently cost employers a lot more time and money.

Leading “comp-sters” have a duty to encourage accountability in the spirit of preserving the heart of the Grand Bargain, where the employee and the employer are center of the discussion. In cases where benefits and quality of medical care suffer from intendedshortcuts, or vendors falsely representing the basis of their products, accountability should not be viewed as bad for the industry rather it should be viewed through the eyes of an injured worker trusting they will get better.

California Demonstrates Great Leadership

Major Overhaul Planned for MTUS

The California Department of Industrial Relations Division of Workers’ Compensation (DIR DWC) continues to demonstrate its commitment to improving the quality of medical care available to ill or injured workers in the state by announcing that all MTUS Guidelines will be updated to Reed Group’s ACOEM Practice Guidelines.

On February 23rd and 24th, then again on March 2nd and 3rd, the DIR DWC hosted several breakouts during the State’s Workers’ Compensation Education Conferences in Los Angeles and Oakland respectively. As expected, the team spent a considerable amount of time discussing updates to the enactment of California’s drug formulary. Dr. Raymond Meister (Medical Director, DIR DWC), Jackie Schauer (DIR DWC Legal Unit), and John Cortes (DIR Legal Counsel) also spent time discussing updates to MTUS via Senate Bill 1160’s expedited process.

Initial MTUS Guidelines Updates (As Discussed in Great Detail at Each Conference)

– ACOEM 2004 Neck and Upper Back Complaints (Updated to ACOEM 2016 Cervical and Thoracic Spine Disorder Guideline)

– ACOEM 2004 Shoulder Complaints Chapter (Updated to ACOEM 2016 Shoulder Disorders Guideline)

– ACOEM 2007 Elbow Disorder (Updated to ACOEM 2013 Elbow Disorders Chapter)

– ACOEM 2004 Forearm, Wrist, and Hand Complaints (Updated to ACOEM 2016 Hand, Wrist, and Forearm Disorders Guideline)

– ACOEM 2004 Low Back Complaints (Updated to ACOEM 2016 Low Back Disorders Guideline)

– ACOEM 2004 Knee Complaints (Updated to ACOEM 2015 Knee Disorders Guideline)

– ACOEM 2004 Ankle and Foot Complaints (Updated to ACOEM 2015 Ankle and Foot Disorder Guideline)

– ACOEM 2004 Eye (Updated to ACOEM 2017 Eye Disorders Chapter)

New Guidelines To Be Added

– ACOEM 2017 Hip and Groin Guideline

– ACOEM 2016 Occupational/Work Related Asthma Guideline

– ACOEM 2016 Occupational Interstitial Lung Disease Guideline

MTUS Updates Beginning Spring of 2017 via Expedited Process

– ODG 2015 Chronic Pain Medical Treatment Guidelines (Updated to ACOEM 2017 Chronic Pain Medical Treatment Guideline)

– CA MEEAC Opioids Treatment Guidelines (Updated to ACOEM 2014 Opioids Treatment Guideline)

– ACOEM 2004 General Approaches Guidelines (Updated to ACOEM 2016 General Approaches)

MTUS Updates To Be Made via Expedited Process Upon Completion of Guidelines by Reed Group/ACOEM

– ACOEM 2004 Stress Related Conditions (Updated to ACOEM 2017 Behavioral Health Guideline)

– ACOEM 2017 Traumatic Brain Injury Guideline

RAND Corporation and The National Academy of Medicine Measures of Quality EBM

The major updates to the MTUS coincide with the RAND Corporation’s report “Implementing a Drug Formulary for California’s Workers’ Compensation Program” and recommendations for the treatment guidelines and the formulary to incorporate the evidence-based standards of care that best meet the needs of California’s injured workers. The RAND report also recommended that there be consistency between the MTUS guidelines and the adopted ACOEM-based drug formulary. Perhaps the most important reason for California’s wholesale adoption of Reed Group’s ACOEM Practice guidelines is RAND’s determination that the ACOEM guidelines have a more rigorous, transparent development process. (Click HERE to view the complete PowerPoint presentation, Slide 4 provided below.)

The ACOEM Practice Guidelines are the only commercial nationally recognized content source that meticulously complies with all eight (8) Standards for Developing Trustworthy Clinical Practice Guidelines established by the National Academy of Medicine (NAM, formerly the Institute Of Medicine, IOM). The defined standards are:

  1. Establishing Transparency
    • The processes by which the clinical practice guideline is developed and funded should be detailed and explicitly and publicly accessible.
  2. Management of Conflict of Interest
    • Prior to selection of the guideline development group, individuals being considered for membership should declare all interests and activities potentially resulting in conflicts of interest with development group activity, by written disclosure to those convening the group activity.
  3. Guideline Development Group Composition
    • The guideline development group should be multidisciplinary and balanced, comprising a variety of methodological experts and clinicians, and populations expected to be affected by the clinical practice guideline.
  4. Clinical Practice Guideline-Systematic Review Intersection
    • Clinical practice guideline developers should use systematic reviews that meet standards set by the Institute of Medicine’s Committee on Standards for Systematic Reviews of Comparative Effectiveness Research.
  5. Establishing Evidence Foundations for and Rating Strength of Recommendations
    • For each recommendation, the following should be provided: An explanation of the reasoning underlying the recommendation, including:
      • A clear description of potential benefits and harms.
      • A summary of relevant available evidence (and evidentiary gaps), description of the quality (including applicability), – quantity (including completeness), and consistency of the aggregate available evidence.
      • An explanation of the part played by values, opinion, theory, and clinical experience in deriving the recommendation.
      • A rating of the level of confidence in (certainty regarding) the evidence underpinning the recommendation.
      • A rating of the strength of the recommendation in light of the preceding bullets.
      • A description and explanation of any differences of opinion regarding the recommendation.
  6. Articulation of Recommendations
    • Recommendations should be articulated in a standardized form detailing precisely what the recommended action is and under what circumstances it should be performed.
  7. External Review
    • External reviewers should comprise a full spectrum of relevant stakeholders, including scientific and clinical experts, organizations (e.g., health care, specialty societies), agencies (e.g., federal government), patients, and representatives of the public.
  8. Updating
    • The clinical practice guideline publication date, date of pertinent systematic evidence review and proposed date for future guideline review should be documented within the guideline.
    • Literature should be monitored regularly following the clinical practice guideline publication to identify the emergence of new, potentially relevant evidence and to evaluate the continued validity of the guideline.

ACOEM Practice Guidelines Meet The National Guideline Clearinghouse Inclusion Standards

The National Guideline Clearinghouse (a public agency for the AHRQ and public resource for summaries of evidence-based clinical practice guidelines) measures compliance to the above-mentioned standards. A prominent workers’ compensation news media outlet announced on Tuesday, March 7th, that the ACOEM Practice Guidelines were accepted by the clearinghouse, confirming they meet all of the newly updated inclusion criteria.

The National Guidelines Clearinghouse also made national workers’ compensation news in June of 2016 after announcing that the other commercial nationally recognized guidelines provider, ODG published by Work Loss Data Institute, had been removed from its database after it was determined that the ODG content and development process did not meet evidence-based medicine standards. Some examples provided of the unmet standards include:

– Explaining how ODG selected studies for their evidence-based review

– Including the number of studies identified

– Including the number of studies evaluated

– Providing a summary of inclusion and exclusion criteria

According to the NGC and AHRQ, evidence from the selected studies must also be synthesized in a detailed description or evidence table, which ODG did not provide for all of its treatment recommendations.

California’s patient-centric decision to replace all of its existing guidelines with the most current versions of the ACOEM Practice Guidelines is the first step in the much-needed direction towards patient advocacy. In addition to taking a position that places the doctor-patient relationship as paramount, the State also decided to take a leadership position with adopting a drug formulary model that differed from the news-mainstay and savings-focused Texas model. By moving away from the draconian yes/no drug list approach of yesteryear to a modern formulary model that eradicates assertions of a cookie-cutter, one-size fits all approach, the California ACOEM-based formulary elevates the importance of each individual patient’s medical condition and where they are in their respective treatment path, is not only the right thing to do, its smart medicine.

Will California’s innovative approach to improving medical care for injured workers pay off?

The sense is that while learnings will present themselves along the way, we are now much closer to making significant progress in workers’ compensation. The future will tell if other States follow California’s lead to put patients’ health and well-being at the center of their adopted standards for drug formularies and medical treatment guidelines.

Fending Off the Feds

The Department of Labor’s report on Workers’ Compensation – Does the Workers’ Compensation System Fulfill Its Obligations to Injured Workers– is the subject of much discussion among stakeholders in the workers’ compensation industry. Does the key to much of what ails today’s workers’ compensation industry lie in the adoption of the value-based healthcare model?

Many media outlets have reported on the Department of Labor’s findings. Forum speakers touched on issues ranging from benefit and wage inadequacy to cost shifting.

For the most part, the panel ignored the real problem – the cause and treatment of disability.

The issue plaguing injured workers, and all workers’ compensation system stakeholders was almost entirely overlooked by the discussion’s organizers. The issue? Iatrogenesis– treatment by health professionals that does not support the recovery goals of the affected patient. This is a topic that demands great scrutiny if the workers’ compensation industry hopes to change the perception that its practices are negatively impacting social programs.

As one panelist stated, Gary Franklin, MD, PhD, long-time Medical Director of the Washington State Department of Labor and Industries, “workers’ comp medical care is about the worst in the country”. (1)

Enough said.

Concurrent with the over-prescription of narcotics, injured workers have been subject to the over-utilization of treatment (such as with lumbar fusion as referenced by Dr. Franklin on the call) and prolonged physician-approved absences from work. This has gone on for decades. These examples can be pointed to by many outside the workers’ compensation industry as the result of a lack of accountability and high quality healthcare in today’s system. As a result, injured workers become disabled workers,which adds additional stress to both SSDI and the healthcare industry.

Could moving to a value-based healthcare model in workers’ compensation establish shared accountability for all members in the care and claim continuum? Could the use of an evidence-based alternate payment model create a unified focus on returning injured workers to productivity at the soonest medically-appropriate time?

One key element of a value-based healthcare model is to eliminate unnecessary and expensive medical treatment. For example, rewards based on outcomes and productivity would curtail the rampant over-prescription of narcotics on new claims. As a result, disability duration, indemnity costs, and iatrogenic disease would materially decrease and be replaced by improved healthcare outcomes – a result the workers’ compensation industry could, and should, embrace.

A move to value-based healthcare may, or may not, dissuade the federal appetite to intervene in state workers’ compensation systems, but it will reduce the burden to social programs caused by prolonged disability and prescription drug addiction.

  1. Paduda, J. (2016, October). Takeaways from DOL’s State Workers’ Compensation Report [Web log post]. Retrieved fromhttp://www.joepaduda.com/2016/10/takeaways-dols-state-workers-compensation-report/

There Are No Easy Answers

Regulators and legislators have the very difficult job of developing and implementing public policy that preserves and protects the best interest of their constituents. For them,there are no easy answers.

Respective to medical care in workers’ compensation, evidence-based medicine (EBM) has been the center of discussion for the past decade. However, significant confusion about the term “evidence-based guidelines” remains. The same questions asked in 2008 are being asked today:

Can you help me understand the term “evidence-based guidelines?” Various organizations are all saying they have them – and in fact seem to be competing over whose is the best. If they’re all evidence-based, why shouldn’t we just use the most user-friendly or cheapest one?

                                                                                                                                             Evelyn in Evanston”(1)

I had the opportunity to participate in a discussion on drug formularies hosted by The Business Council of New York State last week. Similar to stakeholder sentiment in the state of California, New York regulators are aiming to adopt a drug formulary for workers’ compensation that works in harmony with the state’s Medical Treatment Guidelines (MTGs).

The purpose of having a drug formulary coincide with recommendations on pharmaceutical therapy in an existing MTG source, is the enforceability of formulary recommendations based on EBM – presuming the MTG source was developed according to EBM standards.

If there is now consensus that practice guidelines are the foundation for both treatment recommendations and drug formularies, then concerns about rigor, methodology and quality are of the utmost importance. Medical treatment decisions are being informed by this information. If the quality of the guidelines is in question, then every treatment or drug recommendation stemming from the guidelines must also be in question.

Most, if not all, states that have adopted and enacted EBM treatment guidelines and drug formularies have acted on the counsel of subcommittees comprised of medical providers, vendor representatives, and state representatives. All are well respected in their fields and are good-intentioned individuals. Although, a very visible gap in expertise exists in almost all cases – methodology (i.e., an expert who knows how to grade the quality of methodology).

The reliability of the technical aspects of the scientific method used to develop the guidelines is the most important issue to solve for. The underpinnings of the recommendations, both treatment protocols and drug recommendations, must stand up under scrutiny. If the recommendations themselves are a byproduct of the research process, they should be secondary in consideration to the quality of the methodology employed to develop them.

The question every regulator, legislator, and subcommittee should ask is not:  What is the easiest and cheapest resource available? Rather, what is the most rigorous, transparent, reproducible, method used among the guidelines/drug formulary options?

If we can answer the question of quality correctly, all subsequent questions on appropriateness of care are also answered.

 

1.     Christian, J. (2008, June). The Challenge of Evidence-based Guidelines [Web log post]. Retrieved from http://www.webility.md/pdfs/DrJ-column-2008-06.pdf