By Ruth Estrich, Chief Strategy Officer of MedRisk, Inc.
Medical treatment guidelines have been around for thousands of years, throughout the entire history of medicine – both modern and otherwise. With the objective of guiding clinicians in making the best decisions regarding diagnosis and treatment of various conditions, they were until recent times, based on tradition, anecdote and expert opinion. They were also optional. While it was reasonable to expect that your physician was familiar with the general guidelines of his or her area of practice, no one was mandating that these guidelines be followed.
That was then. Guidelines today, while continuing to incorporate expert opinion and general consensus, are increasingly incorporating evidence-based information. Clinical studies and outcomes data are now informing more than just cancer treatment protocols. Evidence-based medicine is only a reality where there are evidence-based guidelines. And in the area of workers’ compensation, the optional use of these guidelines is becoming a thing of the past.
By definition, medical treatment within the workers’ compensation paradigm is trickier than in all other arenas of medical care. This is the direct result of the dual objectives of medical management and return to functionality/work. In workers’ compensation, you are managing two things – the delivery of appropriate healthcare and the management of the employee’s disability. And part of the art of this area of healthcare is to keep these dual objectives from becoming dueling objectives, with the injured worker squarely in the middle. Often it is the very delivery of very specific treatments that will restore employees to functionality and their pre-injury lives.
The advent of modern guidelines within workers’ compensation can be traced to two seminal publications: The Official Disability Guidelines (ODG) – now in its 17th edition – and the Occupational Medicine Practice Guidelines – originally published in 1997. The former, developed by the Work Loss Data Institute, provides “evidence-based disability duration guidelines and benchmarking data covering every reportable condition.” The latter, developed by the American College of Occupational and Environmental Medicine (ACOEM), supports the “evaluation and management of common health problems and functional recovery in workers.”
The use of these guidelines and other variations on these themes was optional almost everywhere except a handful of trailblazing jurisdictions (Washington State, Rhode Island, etc.) until the last decade when the rate of state adoption greatly accelerated. New Mexico recently became the 30th state to adopt1 the use of evidence-based treatment guidelines for workers’ compensation, specifically eliminating the need for prior authorization if the recommended medical services are aligned with either the most recent edition of ODG or ACOEM’s Practice Guidelines.
In general, the state mandates have taken one of two paths: like New Mexico, they have endorsed national guidelines, or in the case of 14 states including Colorado, Massachusetts, Minnesota, and Montana, they have developed and adopted their own state-specific guidelines. Arizona looks to be the next state to implement its own guidelines.
What does all of this mean in the area of physical medicine, specifically physical therapy, occupational therapy and chiropractic care? As the 1990 Institute of Medicine (IOM) report on Clinical Practice Guidelines stated, this “significant cultural shift” moving away from “unexamined reliance on professional judgment toward more structured support and accountability for such judgment” can only result in better treatment and better outcomes for injured workers.
The inappropriate use of physical medicine – either in situations where it is not warranted or continued use beyond efficacy – neither supports the injured worker nor his or her employer’s bottom-line. Anecdotal stories of over-utilization of physical medicine abound, and with reason. The mandatory use of treatment guidelines to direct when the use of physical medicine is appropriate and to create treatment duration expectations can only support improved outcomes for all.
But the additional challenge in the area of physical medicine is that the range of interventions or services available at each visit is great. The extent of service options within the AMA’s Current Procedural Terminology Guide for physical therapy alone numbers in the hundreds. And the reality is that the choice and sequencing of the delivered services can significantly impact the outcome. Inappropriate treatment choices can be at best ineffective and at worst can exacerbate the patient’s condition.
Like all areas of medical treatment, there is growing evidence available as to which services are most effective for which situations. But the timing and sequencing of these multitudes of choices is complex and beyond the general ability of an individual clinician or clinic to either codify or maintain current as new data become available.
So while general treatment guidelines can substantiate the need for the trip, the destination and the expected arrival time, they do not on their own ensure success. Like a map, they can tell you where to go and how long it should take to get there (Chicago to Indy – 190 miles, three hours; PT – eight visits over four weeks). But they lack the specificity to support an on-time arrival.
Physical medicine specific guidelines can supplement these general guidelines. Like a GPS, they can provide turn-by-turn recommendations and choices based on current conditions, increasing the likelihood of arrival at Indy in the estimated three hours or patient discharge in eight visits. By visit, they can provide a detailed and contemporary view into the best practice for the given moment in time.
Taken together, the growing popularity of mandated treatment guidelines coupled with supplemental physical medicine visit-specific evidence-based recommendations can be exactly what the doctor ordered.
1 New Mexico’s guidelines are scheduled to be implemented on July 1, 2013.
About Ruth Estrich
Ruth Estrich is the Chief Strategy Officer for MedRisk, Inc. and a dynamic industry expert in the areas of Property & Casualty and Group Health Managed Care. As part of MedRisk’s executive management team, she is responsible for new product development.
Under Ms. Estrich’s expert leadership, MedRisk has identified and implemented new business models for a number of Workers’ Compensation processes including guideline driven utilization management services and strategic managed care integration.
Ms. Estrich has held senior management positions at national insurance companies where she managed many key operations including planning and budgeting, claims, product development, and managed care.
Ms. Estrich holds a Bachelors degree from Simmons College and has chaired a number of key industry committees including the Health Insurance Association of America’s (HIAA) Prevailing Healthcare Charges System Committee. She also represented the insurance industry on the Patient Record Committee at the Institute of Medicine, National Academy of Sciences, and she is the Chair of the Board of Directors of the Insurance Accounting and Systems Association (IASA). She can be reached at firstname.lastname@example.org.
Founded in 1994 and based in King of Prussia, Pa., MedRisk, Inc. is ranked as one of the fastest-growing companies in the Greater Philadelphia area on the Inc. 500|5,000 and the Deloitte “Technology Fast 50” lists. The company provides specialty managed care services for the physical rehabilitation of injured workers. MedRisk is fully accredited under URAC and has successfully completed a SSAE 16 Type II examination. MedRisk’s programs deliver savings and operational efficiencies that are significantly greater than traditional programs. Customers include insurance carriers, self-insured employers, third-party administrators, state funds, general managed care companies, case management companies, claims adjusters and physical medicine providers. To make a referral or obtain more information, visit www.medrisknet.com or call 800-225-9675.