September 1, 2006

Texas Picks ODG Over ACOEM
The Texas DWC proposed rules that would make Official Disability Guidelines, not ACOEM, the standard for non-network care

Republished with permission from WorkCompCentral.com

The Texas Division of Workers' Compensation on Thursday proposed rules that would mandate the use of the Work Loss Data Institute's Official Disability Guidelines (ODG) for non-network medical care and the Reed Group's Medical Disability Guidelines (MDA) for disability management.

  The decision dealt a blow to the American College of Occupational and Environmental Medicine (ACOEM), which had been lobbying Texas officials to follow California 's lead in adopting its treatment guidelines. DWC spokesman John Greeley would not say why his agency had chosen ODG over ACOEM.

  "We have no comment at this time other than to say we are letting the rulemaking process work to produce the best treatment guidelines for the workers' compensation system and for the citizens of Texas ," Greeley said in an e-mail. "As you know, we are accepting comments until Oct. 2, when a public hearing is scheduled here at DWC."

  The proposed Texas rules would require physicians to treat injured workers according to ODG when not covered by a health care network. Networks in Texas are allowed to adopt their own guidelines.

  The MDA disability treatment guidelines would be used to guide insurers and employers on expected recovery times for various industrial injuries.

  Treatment and disability management guidelines were mandated by House Bill 7, a reform measure signed into law by Texas Gov. Rick Perry in 2005.

  "These proposed rules provide carriers with guidance to manage claims through the use of consistent benchmarks established by the guidelines and through the treatment planning process when treatments and services or diagnoses are not addressed in the guidelines," the DWC said in an explanation of its proposal. "Application of disability management tools should reduce indemnity benefit costs through the efficient utilization of medical services with resulting reduction in medical costs, and improved return-to-work outcomes."

  Phil Denniston, president of the Work Loss Data Institute, said the proposed rules should make life easier for Texas physicians compared with their counterparts in California . The Texas rules guarantee that physicians will be paid for their work if they treat according to ODG, he said. In California , there is no guarantee of payment even if ACOEM is followed, he said.

  "In California , they can go 14 days" without payment, Denniston said. "That's terrible, no matter what the guidelines are. That's not the fault of the guidelines. Study after study has shown that workers should get early access to treatment."

  As to why Texas is going with ODG treatment guidelines rather than ACOEM, Denniston said he believes officials saw that the Work Loss Data Institute -- a private company -- has the only set of guidelines that are adopted by the federal government's medical guideline clearinghouse. ODG also regularly updates its guidelines and has easy-to-find references to the latest research on the effectiveness of various treatment options.

  But Denniston said ACOEM also publishes good guidelines and he wouldn't be surprised if carriers used ODG, ACOEM and even other guidelines available to them.

  ACOEM Executive Director Barry Eisenberg said many of the health care networks already approved in Texas , including Concentra and Liberty Mutual, have already adopted ACOEM. He said Texas ' proposal to establish a separate set of guidelines for non-network care could cause unnecessary confusion. It's possible, Eisenberg said, that physicians will be forced to use one set of guidelines when they treat patients who are not covered by a network and a different set of guidelines when they treat patients whose employers are enrolled in a network.

  In a written statement issued after Texas posted its proposed rule, ACOEM took a shot at the state's decision to go with a private company rather than a recognized medical society whose guidelines are widely used across the nation.

  "We would hope that Texas would at a minimum allow physicians to use a set of treatment guidelines developed by the medical profession rather than mandating the exclusive use of guidelines developed for commercial purposes," ACOEM said.

  But in California , proposed rules that would make ACOEM the exclusive source of treatment guidelines were widely criticized by medical specialists during an Aug. 23 public hearing. They said ACOEM does not address chronic conditions and has many other gaps that cause unnecessary disputes between physicians and insurance carriers.

  The California DWC proposed to adopt ACOEM along with future updates promised by the medical society. It would also appoint an evaluation committee that could also broaden the guidelines later.

Steve Cattolica, government affairs director for the California Society of Industrial Medicine and Surgery, said he does not have detailed knowledge of ODG, but he knows that they are widely used by physicians and "it appears the marketplace is speaking." Cattolica said he hopes Texas ' decision will alert California DWC officials that they should look beyond ACOEM.

  "That's what we advocated at the public hearing -- not specifically about ODG -- but that the division do what it can to broaden the available guidelines now and not wait for their committee," Catollica said. "We would like them to look outside of California and see what's going on."

  The Texas rules have also caused some controversy.

  The proposal released Thursday is similar to a draft version released in February, despite complaints by business and insurer groups that using two separate guidelines -- ODG and MDA -- would increase costs.

  The division said in an explanation of the rules proposal that any extra expense would be minor -- only $360 for users who subscribe to the Internet versions of both guidelines. Large companies that need to provide access to many employees could save any more through group-user arrangements, the division said.

  The Texas DWC will hold a public hearing to take testimony on the proposed rules on Oct. 2 in the Tippy Foster Room, Division of Workers' Compensation, 7551 Metro Center Drive , Austin .

  To view a copy of the proposed regulations, go to:
http://www.tdi.state.tx.us/wc/rules/planning/documents/pr137dismgmt.pdf.

  By Jim Sams, WorkCompCentral Senior Editor
jim@workcompcentral.com