Tag Archives: Patient Safety

Patient Engagement in Workers’ Compensation

This article was published on WorkCompCentral’s Work Comp World. Click here to link to the article.

The call to increase patient engagement to inform the development of standards and policies is gaining traction. The development of these standards ultimately helps improve health outcomes in workers’ compensation, and other health care influenced industries. Efforts to consistently collect and incorporate patient perspectives into the scientific process is becoming a priority for many. This is welcome news to all patients and patient advocates!

How important is patient input to ensuring the best possible health outcomes for ill or injured workers?

Understanding the importance of patient involvement in the composition of evidence-based Guideline Development Groups (GDG), The National Academies of Sciences, Engineering, Medicine (formerly the Institute of Medicine (IOM), included the requirement of patient input as one of its eight Standards for Developing Trustworthy Clinical Practice Guidelines in 2011. The standard directs guideline developers to incorporate patient involvement, at least, when formulating clinical questions and reviewing Clinical Practice Guideline (CPG) drafts. Former patients, patient advocates, or patient / consumer organization representatives qualify to participate in the GDGs under this requirement.

Accordingly, the requirement of patient involvement is included in AHRQ’s National Guideline Clearinghouse’s (NGC) assessment of submitted guidelines’ adherence to the academy’s standards of trustworthiness. Patient and public perspectives, along with multidisciplinary group participation and methodologist involvement, is measured by the NGC when grading the content developer’s GDG composition.

The newly energized push for patient engagement is prompting content developers aiming to align with National Academy standards to improve methods for soliciting, receiving, and incorporating patient and public input into the content development process. The American College of Occupational and Environment Medicine (ACOEM) accepts patient, and other stakeholder, input through an online portal to assist the development of its evidence-based medicine practice guidelines.

Patient Engagement beyond Content Development

Notable recent activity from the Food and Drug Administration (FDA) includes assembly of a Patient Engagement Advisory Committee (PEAC). A statement issued by the FDA explains the committee exists to support its efforts to broaden engagement with patients and deepen patient involvement in the administration’s regulatory activities.

More specifically, the initiative will seek patient perspectives for use across medical device design, clinical trial process, and post market evaluation. Additional guidance on patient preferences, such as tolerance of risk and patient point of view on benefits, will be used by the FDA to assess device benefit-risk profiles.

The administration can consider the systematically gathered patient preference information, in conjunction with its assessment of scientific evidence that demonstrates a device’s probable benefit outweighing its likely risks, to form its complete grouping of clinical and non-clinical testing.

Workers’ Compensation Continues its Efforts for Patient Engagement

Very few venues exist in workers’ compensation that facilitate direct engagement between industry vendors and patients. Perhaps the most visible platform today is WorkComp Central’s Comp Laude® Awards & Gala. Event participants advertise that Comp Laude’s most memorable moments typically occur when patients are involved in panel discussions. Event organizers have voiced their excitement about the overall positive impact patients have on the industry get-together.

Stemming from the mission and vision of the event’s late founder David DePaolo, Comp Laude® created a scholarship intended to create a path for direct engagement between the industry and its patients. The scholarship provides travel funds and covers lodging expenses along with conference registration for the patient and a guest. Several vendors, among them ReedGroup, are honored to have the opportunity to be sponsors of the scholarship fund.

Many have criticized the workers’ compensation industry for its numerous shortcomings, myself included. While it is important to acknowledge the industry has more work to do in the pursuit to increase patient engagement to improve health outcomes, it is equally important to acknowledge the progress gained by organizations whose corporate point of view regularly advocates for patients and their well-being. For this, the industry should be complimented.

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 Details Matter for Louisiana in the Formulary Debate

An edited version of this article was published on Louisiana Comp Blog. Click here to link to view.

The Proverbial Broad Brush

Generalities plague the Workers’ Compensation industry. From indirectly typecasting opioid-using patients as drug addicts to characterizing physicians as narrow-minded profit-driven narcissists, and former State officials suggesting a single binary drug list can have similar cost-saving effects in multiple jurisdictions. The proverbial broad brush is a potent distraction from the specific issues needing attention in order to improve the quality of care to injured workers.

Louisiana’s Need of a Drug Formulary

Former Texas Workers’ Compensation Commissioner, Rod Bordelon, has represented Work Loss Data Institute and their ODG Treatment Guidelines and Drug Formulary in a number of jurisdictions. In November of 2016, he made a stop at the Louisiana Association of Self Insured Employers (LASIE) annual conference.

Armed with the usual workers’ compensation cost savings statistics from the State of Texas, Mr. Bordelon and LASIE made a case suggesting that Louisiana can experience similar savings if they adopted the same formulary as Texas – the ODG binary drug list. The presentation overlooked two critical differences between Louisiana and Texas that will have a significant impact on the formulary’s performance:

  • Louisiana recognizes the Colorado Treatment Guidelines as the presumptively correct standard of care and not the ODG Treatment Guidelines like Texas.
  • Louisiana does not have a legislative mandate to use Return-To-Work Guidelines to support the return to work process of its injured workers.

The Colorado Treatment Guidelines and ODG Treatment Guidelines have very different levels of rigor in their development methodology. As an indication of the differences in their scientific basis, the Colorado Guidelines are listed in AHRQ’s National Guideline Clearinghouse for being trustworthy clinical guidelines aligning with the Institute of Medicine’s Standards for Developing Trustworthy Clinical Practice Guidelines. After it was determined that they did not meet critical standards of evidence-based medicine such as transparency, study inclusion/exclusion criteria, the ODG Treatment Guidelines were removed from the National Guideline Clearinghouse in June of 2016.  As a result, Louisiana stakeholders should expect to experience friction and disconnect resulting from using the ODG drug list, purportedly based on the ODG Treatment Guidelines, and the Colorado Guidelines in concert.

Perhaps the most underestimated component of the Texas Workers’ Compensation system that has supported their reduction in prescription drugs is their legislated mandate to use Return-To-Work guidelines to help injured workers return to productivity as soon and safely as possible. Texas’ efforts to keep workers employed while recovering from work-related injuries and illnesses has resulted in a drop in lost-time claims from 165,000 in 2000 to fewer than 90,000 in 2014. The success of the Return-To-Work program is preventing the pathogenic effects of job loss such as, decreased physical and mental health and higher treatment utilization, and thus driving down medication consumption.

The Basis of a Trustworthy Drug Formulary

On Monday, May 1st, the California Division of Workers Compensation (DWC) held a public hearing required by statute in order to collect feedback on its proposed regulation package for the enactment of the MTUS Drug Formulary/Preferred Drug List derived from the ACOEM-based Formulary. Their journey to adopting a trustworthy drug formulary has been long, detailed oriented, and started with a comprehensive independent report from the RAND Corporation, Implementing a Drug Formulary for California’s Workers’ Compensation Program.

Several assumptions regarding how California’s DWC would design and implement the drug formulary underpinned RAND’s methodological approach and policy analyses. Their first, and possibly most important, assumption was that the DWC intended to adopt a formulary designed to maximize quality-of-care, health, and work-related outcomes; this has also been a guiding principal behind Louisiana’s HB 592 according the bill’s sponsor, Representative Kirk Talbot and the Louisiana Association of Self Insured Employers. To accomplish these objectives in California, RAND recommended the formulary drug list and drug classification scheme to be evidence-based and as consistent with the California’s Medical Treatment Utilization Schedule (i.e., California’s Treatment Guidelines) as possible.

RAND reviewed five existing drug formulary models: Washington State Department of Labor and Industries, Reed Group’s ACOEM-based Formulary, Work Loss Data Institute’s ODG Formulary, Ohio Bureau of Workers’ Compensation, and California Department of Health Care Service (Medi-Cal, California’s Medicaid Program). The five models were compared across six criteria including, but not limited to: Reliance on evidence-based criteria, Transparency in process used to establish and maintain the formulary drug list and recommendation, Established process for regular updates to the formulary drugs and recommendations.

The RAND report identified that while the ODG formulary would be easier to implement, methods used to develop the guidelines used as the formulary’s basis have been less rigorous than its counterparts in the workers’ compensation arena (Nuckols et al., 2014), and the methodology used to derive California’s Prospective Review requirements when there are condition-specific variations in the guideline recommendations is not transparent. Based on these findings, the ODG Formulary may be easy to implement, but was not determined to be a trustworthy source to maximize quality-of-care, health, and work-related outcomes.

Due to fact that very little of California’s MTUS guidelines were based on ODG, the adoption of the ODG Formulary would represent a major departure from the current California Treatment Guidelines. Similar to California, a departure from Louisiana’s presumptively correct standards, the Colorado Treatment Guidelines, will create an environment governed by friction and disagreement.

Trends in State Adoptions of Commercial EBM Guidelines and Drug Formularies

A trend seems to be evolving throughout the country regarding proposals to adopt evidence-based treatment guidelines and drug formularies. In 2016, numerous stakeholders in more than a dozen States proposed the adoption of nationally recognized evidence-based medical treatment guidelines and drug formularies. A number of bills introduced during the 2016 legislative session specifically named the ODG treatment guidelines, drug formulary.

As education aimed at providing State lawmakers and stakeholders in workers’ compensation with important information to measure the quality and trustworthiness of EBM content sources becomes more popular, the interest in the ODG brand is waning. Of the two commercially available workers’ compensation guidelines and formularies, only Reed Group’s ACOEM Treatment Guidelines and Drug Formulary have been selected for adoption in the last 24 months (California and Nevada).

It is clear that AHRQ’s National Guideline Clearinghouse’s announcement of ODG’s removal from its database in June of 2016 was a major disruptor in the national workers’ compensation industry’s pursuit of the content source. According to Mary Nix (AHRQ’s Health Scientist Administrator), the removal was prompted after AHRQ’s clearinghouse was not able to assure that the systematic evidence review was conducted for the topics covered in ODG.

In addition to Louisiana, Montana, Nebraska, New York and Pennsylvania have ongoing legislative conversations pertaining to the adoption of a drug formulary. As with Louisiana, the Colorado Treatment Guidelines are adopted in part, or in whole, in Montana and New York providing the content source presumptive weight. The question of what formulary will work best in concert with the Colorado Treatment Guidelines will also need to be answered in these jurisdictions.

Time Will Tell

While most stakeholders in Louisiana feel an evidence-based drug formulary can be a useful tool to support other State measures to curb opioid prescriptions, not many believe the ODG binary drug list is the right fit for injured workers in the State. Louisiana Representative Chris Broadwater, author of this year’s HB 529 calling for the Louisiana Office of Workers’ Compensation Administration to create a drug formulary, pulled a similar bill introduced in 2016 requiring the use of the ODG binary drug list. What does Representative Broadwater know that Representative Kirk Talbot, Bordelon, and LASIE do not?

Comparing the Texas workers’ compensation system to Louisiana’s system is like comparing apples to oranges. The expectations for similar outcomes is a stretch, to say the least, at the expense of injured workers.

In an industry where complexity is normal and expected, it seems a broad-brush approach to anything would be unfamiliar and uncomfortable. Time will tell if the desire to save money will prevail over common sense, medical sensibility, and preserving the injured workers’ right to the appropriate medical care.

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