Tag Archives: WC State Regulation

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.

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.

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.

AHRQ’s National Guideline Clearinghouse and its Relevance

This article was published on Louisiana Comp Blog. Click here to link to the article.

Still Relevant?

Medical practitioners face considerable uncertainty practicing the art of medicine. They rely on their knowledge, skills, experience, and patient preferences. They also rely on the scientific literature to inform their decisions on treatment planning and measuring patient restoration of function. Marketing-savvy device and drug manufacturers often cloud the picture and make identifying effective treatment protocols more difficult. The quality of life for many injured workers weighs in the balance, which is why it is necessary to have organizations such as the National Guidelines Clearinghouse separate trustworthy content from marketing speak.

Institute of Medicine Standards for Trustworthy Guidelines

As of 2011, there were over 3,700 published clinical practice guidelines from 39 countries available for use. Hundreds of these guidelines meet the definition of nationally recognized guidelines; a definition used in most legislative bills introduced and enacted by state legislatures to govern the standard of care for injured workers throughout the country. Being nationally recognized does not mean a guideline is safe and trustworthy to use as a standard of care for injured workers.

Because the term “evidence-based” has been thrown around quite readily, the U.S. Congress tasked the Institute of Medicine (IOM), now known as the National Academy of Medicine, through the Medicare Improvements for Patients and Providers Act of 2008 to initiate a study defining best practices used in developing rigorous, trustworthy clinical practice guidelines. The outcome of the request became the formation of an expert committee. The committee developed eight standards focused on developing guidelines using approaches that are objective, scientifically valid, consistent, transparent, and free of bias.

Evaluation of Guidelines’ Trustworthiness

The Agency for Healthcare Research and Quality (AHRQ) directs a portion of its research funding, through its National Guideline Clearinghouse (NGC), to evaluate guideline provider submissions against the Institute of Medicine’s eight standards. Assessments are made to determine the reliability, validity, and effects of these guidelines on health care quality and patient outcomes. As a result, the NGC is required to discontinue the inclusion of guidelines whose development does not meet the eight standards and whose development is insufficiently documented.

The standards used by National Guideline Clearinghouse to assess rigor and trustworthiness include:

Establishing transparency, management of conflict of interest, guideline development group composition, clinical practice guideline–systematic review intersection, establishing evidence foundations for and rating strength of recommendations, articulation of recommendations, external review, and updating.

NGC’s Applicability to Commercially Available Guidelines

NGC made national headlines in June of 2016 after announcing the removal of the Official Disability Guidelines (ODG), published by Work Loss Data Institute from its database of trustworthy clinical practice guidelines. According to NGC, the removal of ODG took place due to the following deficiencies:

  • Failure to explain how they selected studies for their evidence-based review;
  • Document did not include the number of studies identified or the number of studies evaluated;
  • No summary of inclusion and exclusion criteria; and
  • ODG did not provide synthesized detailed descriptions or evidence tables.

Phil Denniston, ODG’s former-President, went on the record commenting that the Clearinghouse “has moved in the direction of hosting academic guidelines, primarily guidelines produced by medical specialty societies who give the guidelines away to support the interests of their members.”

Mr. Denniston continued: “All of the leading commercial medical treatment guidelines, including Hearst, Milliman, MCG, Zynx, McKesson, Interqual, Dynamed, UpToDate, and others, now also decline to participate in NGC.”

Could it be that the pursuit of healthier margins are the reason commercial treatment guidelines publishers have declined to participate?

Meeting strict standards is not easy and it is not cheap, but the health of injured workers is too important and because of this importance, ReedGroup, owners of the ACOEM Practice Guidelines, have made the requisite commitment to meet the eight essential standards described earlier. As a result, NGC notified ReedGroup on March 2nd, 2017, that guidelines it submitted for evaluation were accepted for inclusion in the NGC. For the record, Reed Group’s ACOEM Practice Guidelines is the only other nationally recognized commercially available guideline for workers’ compensation.

The Importance of University-based Research

Reed Group’s approach to development using a university-based research team anchors the effort to produce trustworthy clinical practice guidelines. The team consults various databases for primary sources of original research. Also searched, are other databases likely to contain references to high quality literature:

  • National Library of Medicine’s National Institute of Health (PubMed)
  • CINAHL (nursing, biomedicine, health sciences librarianship, alternative/complementary medicine, consumer health and 17 allied health disciplines)
  • Cochrane Central Register of Controlled Trials
  • Scopus
  • Google Scholar

ODG’s methodology document, posted on its website, lists literature sources that include textbooks, conference proceedings/presentation slides, and case reports and descriptions. None of these sources meet the selection criteria for creating quality guidelines and rating literature set forth by the Institute of Medicine.

What does this mean to Louisiana and the rest of the country?

If the evidence underpinning the guidelines is in question, then every recommendation (conservative or invasive care, pharmacological, etc.) stemming from the guidelines must also be in question.

Discussions to adopt evidence-based drug formularies continue across the country. Will legislatures continue to perpetuate actions focused on fiscal benefits? Or, will a leader emerge in the south to recognize the relevance of the National Guideline Clearinghouse’s rigorous assessment of quality and trustworthiness among a sea of guidelines promoting physical benefits?

Meeting NGC criteria is not only relevant, it’s vital.

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.

WorkComp’s Unsung Hero

Today’s workers’ compensation regulatory landscape is populated by requests to standardize the use of prescription drug monitoring technology, evidence-based medicine treatment guidelines, drug formularies, and other modern approaches to Occupational Medicine. All is geared toward minimizing the over-utilization of treatment and the eradication of inappropriate prescriptions of highly addictive pain medications. The key to addressing these grave healthcare concerns is not flashy, sophisticated, or modern…it is expressed in one word – WORK.

Return-to-work is mostly referenced as a retrospective outcomes metric that indicates a program’s success and often viewed as the end-game, or the goal.  In workers’ compensation, the effectiveness of evidence-based medicine treatment guidelines and drug formularies is measured by their impact on drug spend and return-to-work rates, when quality data is available.

The State of Texas has been widely used as an example for their success in reducing the amount of non-preferred, non-formulary drugs prescribed to injured workers and overall drug spend by pundits in workers’ compensation. Receiving less headlines, however, is the fact that the success of the Texas formulary is strongly driven by Title 28 of Texas’ Administrative Code §137.10:

(a) Insurance carriers, health care providers, and employers shall use the disability duration values in the current edition of The Medical Disability Advisor [now known as MDGuidelines®], Workplace Guidelines for Disability Duration, excluding all sections and tables relating to rehabilitation, (MDA), published by the Reed Group, Ltd. (Division return to work guidelines), as guidelines for the evaluation of expected or average return to work time frames.

DC Campbell, research director of the Workers’ Compensation Research and Evaluation Group at the Texas Department of Insurance has stated that lost-time claims have dropped from 165,000 in 2000 to less than 90,000 in 2014.(1)  The state’s diligent effort to keep workers employed while recovering from a work-related injury or illness is preventing the pathogenic effects of lob loss such as, decreased physical and mental health and higher treatment utilization, and thus driving down medication consumption.

Gordon Waddell (pronounced WAD-uhl) and A Kim Burton explored the positive influence of work on a sick, or disabled person’s overall health and well-being in their book Is Work Good for Your Health and Well-being. Their findings state that when a person’s health condition permits, remaining in or re-entering work as soon as possible will be therapeutic, help promote recovery and rehabilitation, lead to better health outcomes, reduce risk of long-term incapacity, and improve quality of life and well-being.(2)

Conversely, Waddell and Burton document a strong association between job loss and poorer general health, poorer mental health, higher medical consultation, higher medication consumption, higher hospital admission rates, and higher mortality.(2)

If these findings are valid, why are return-to-work guidelines not as frequently considered for standardization by state workers’ compensation agencies compared to their content counterparts, treatment guidelines and drug formularies?

Is it due to the perception that return-to-work will sort itself out with strong compliance to treatment and pharmaceutical standards?

According to Dr. Jennifer Christian’s Work Disability Prevention Manifesto, health care providers, employers, and benefits administrators typically involved in return-to-work situations do not feel responsible for avoiding job loss, or absences.(3)

Similar to the education process that should occur in the clinic between the treating provider and the patient when considering the use of narcotics, the benefits of return-to-work and the risks of worklessness should be discussed in comprehensive detail. Creating appropriate expectations about return-to-work, or stay-at-work, at the point of care should be the highest priority understanding the impact it will have on the overall recovery and treatment and medication consumption by the patient.

The AMA Guides to Evaluation of Work Ability and Return to Work 2nd Editionprovides the following guidance:

Physicians are familiar with prescribing medications for patients. If a physician looked up a drug in the Physician’s Desk Reference and found a “black box” warning required by the Food and Drug Administration (FDA) like this one:

would physicians prescribe that medication?

Physicians should have the same mind-set when filling out return-to-work forms as when about to prescribe a medication with the above black box warning.(4)

Addressing possible solutions to the problem of job loss, Dr. Christian writes, “Health-related work disruption should be viewed as a life emergency. Productive activity should be a part of treatment regimens.” (3)

Perhaps the best model to follow when considering an injured worker’s readiness for return-to-work involves the consideration of Risk, Capacity, and Tolerance.(5)

Risk is a basis for physician-imposed activity restrictions. Most return-to-work forms sent to physicians have a line on which the physician can state restrictions that may pose a risk to the individual or to others (e.g. co-workers, the general motoring public, etc.).  Risk, in this context, means the person should not do something, even though they may actually be capable of doing the activity.  For example, individuals with uncontrolled seizure disorders are not permitted to work as commercial airline pilots or bus drivers based on risk.

Capacity is the basis for physician described activity limitations, and means the individual is not yet physically capable of an activity. Many of the aforementioned forms have a line on which the physician can state limitations based on capacity evaluation. For example, after a wound into the biceps muscle mass of the arm, an individual may not yet have the strength to permit lifting a certain amount of weight; or after a fracture of the shoulder, an individual may not yet have enough shoulder motion for his/her hand to reach the overhead control on a factory press.

Tolerance is the issue with which doctors, employers, employees, and insurers struggle. It is the ability to put up with the symptoms, such as pain or fatigue, that accompany doing work tasks, that the individual can clearly do, in order to gain the rewards of work (e.g., income, self-esteem, health benefits of work, etc.).  Tolerance is not a scientific concept, and is not scientifically measurable.  Patients consider factors like income and finances, job satisfaction, need for employer provided health insurance benefits, availability of disability or workers’ compensation insurance to maintain income, ability to switch to physically easier careers, etc. when deciding whether the rewards of working are to them worth the “cost” of working.

This model, which effectively brings into consideration the main factors that involve job loss, works well in conjunction with the MDA disability duration tables’ Minimum, Optimum, and Maximum timeframes for physiological recovery, adopted by the State of Texas.

Return-to-work is a potent ally in preventing medical scenarios from becoming unnecessarily complex and causing long-term disability while fostering over-utilization and over-consumption of treatment and medications. It can, and should, be used proactively as part of treatment regimens to ensure injured workers profit from the therapeutic benefits of the workplace.

Dr. Richard Pimentel, a passionate disability rights activist, once stated, “You do not get injured workers well to get them back to work. You get them back to work to get them well.”

1.     Foster, JTodd. “State Touts Workers’ Compensation System as ‘Model’ for the Nation.” WorkComp Central, September 2016. Web. 01 November. 2016. https://www.workcompcentral.com/news/story/id/a8f3b13bdbbc471ce6b81a036649c0e836863559

2.     Waddell GA, Burton AK. Is Work Good for Your Health and Well Being? The Stationery Office, London, 2006

3.     Christian, J. (2016, August). Work Disability Prevention Manifesto [Web log post]. Retrieved from http://www.jenniferchristian.com/tag/work-disability/

4.     Talmage JB, Melhorn JM. Hyman, M. AMA Guides to the Evaluation of Work Ability and Return to Work 2nd Edition. AMA Press, Chicago, 2011. P.3-4

5.     Talmage JB, Melhorn JM. A Physician’s Guide to Return to Work. AMA Press, Chicago, 2005