Al Betts, executive director for the Insurance Council of Texas and Commissioner of Workers’ Comp from 2005-2008, summed it up at the recent DWC Educational Conference:
“In the 1990s and early 2000s, Texas was nearly on par with California with high costs that threatened to bankrupt the system. Regulators turned Texas around with the ODG treatment guidelines, the closed drug formulary and an ombudsman program created to help injured workers without attorneys to navigate the system.”
Rates have dropped 50% in a “remarkable story.” Betts noted that other states are looking to Texas as the model system for the nation.
Better outcomes, at lower costs.
Quality care quickly, and timely RTW, without the waste, fraud and abuse.
New Texas DWC Biennial Report to the Legislature
"A closed formulary is a list of drugs with an associated reimbursement status. For example, the Official Disability Guidelines (ODG)—adopted by Texas in 2011, Oklahoma in 2014, and Arizona and Tennessee in 2016—has statuses “Y” for preauthorized for use and “N” for not allowed or needs authorization. On average, 24% of drug costs and 17% of prescriptions in a service year are for N drugs. The intent of formularies is to use evidence‐based guidelines to reduce over‐prescribing (of opioids, in particular), to maximize healing, to improve return‐to‐work outcomes, and to contain drug costs. Exhibit 4 shows NCCI’s estimates for potential drug cost savings from the ODG formulary for a number of states. In many states, the introduction of the ODG formulary has the potential to reduce WC prescription drug costs by 10% or more. As evidence‐based guidelines tend to be more restrictive when dealing with opioids, states with higher opioid use tend to produce the largest estimated savings."
Q: What is the story behind California's proposed drug formulary?
A: California Assembly Bill 1124 requires adoption of a workers’ comp drug formulary by the Division of Workers’ Comp (DWC) by July 1, 2017, a tight timeline. DWC hired Rand to perform a study, which recommends updating the state’s Medical Treatment Utilization Schedule (MTUS), which is a mix of ODG and ACOEM guidelines. DWC agrees that it’s time for an update, and has so far updated the ODG portion last month, and is now considering similar updates to the ACOEM chapters.
Most importantly, DWC has also created their own MTUS Drug List (“MTUS Formulary").
Q: Is the proposed MTUS Formulary the same as the ACOEM Formulary, the ODG Formulary, or something else entirely?
A: It is neither ODG's nor ACOEM's new Formulary. It is a state-specific formulary, created by DWC. Their intentions are good, but stakeholders should understand what is happening, why it is happening, and the potential missed opportunity.
While the MTUS Formulary is being positioned as based on the ACOEM Guidelines, it is significantly different from the ACOEM Formulary marketed by Reed Group since November 2015. The differences are many (the Formularies have little in common), and I encourage stakeholders to compare them. There are many approved drugs on the ACOEM Formulary that are Non-Preferred on the MTUS Formulary.
Second, the “claim to fame” for proponents of the ACOEM Formulary is that it is diagnosis-specific, while ODG has indicated this approach is impractical from a regulatory standpoint. ODG’s position has been that while treatment guidelines must be diagnosis-specific (patient selection is applied in the clinician’s office and through UR), a Formulary must be a binary indicator. A pharmacist should not be expected to apply evidence-based treatment guidelines and patient selection criteria at the counter at Walgreens, when they simply have to determine quickly (yay or nay) if they need preauthorization before releasing a medication to a customer. DWC veered away from the ACOEM Formulary to use a binary indicator (Preferred and Non-Preferred), validating the ODG approach. This is consistent with the Rand recommendation that “condition-specific requirements be imposed sparingly” (Rand page xiii).
Q: Who created the MTUS Formulary?
A: The California Division of Workers’ Comp.
Q: Is the MTUS Formulary evidence-based?
A: It is not, and that is not a knock on DWC staff. They are highly educated, experienced, and qualified, but they do not have the resources to conduct an evidence-based process.
Evidence-based medicine requires a systematic review of the medical literature, ranking and weighting studies on their design and quality, and then sourcing the Formulary to that literature. That was not done by DWC in creating the Formulary, although they did list the chapter in the MTUS guidelines where they found discussion of each medication, but without any linkage or references. The elephant in the room is that the MTUS Formulary is in disagreement with the ACOEM Formulary, and both are suggested to be sourced from the same guidelines. Which is right? That is a mystery.
Q: Does the MTUS Formulary fulfill the requirements of AB 1124?
A: It most certainly does not. The main requirements of AB 1124 are that the formulary be evidence-based, nationally recognized, updated quarterly. We covered the evidence-based piece – it was not based on a systematic review of the medical literature. As for national recognition, this is a brand new formulary. It has never been put into practice, and up until last month, had never seen the light of day, so it’s most certainly not nationally recognized. As for updates, it is purportedly based on the ACOEM Guidelines, and per Rand, the ACOEM Guidelines are updated every 3-5 years (Rand page 34: “ACOEM Guideline revisions occur every 3–5 years”). That misses all three marks.
Q: Why didn’t they just use the ACOEM Formulary?
A: Rand confirmed the ODG format is preferable for a formulary. While the ACOEM Formulary is interesting in theory, it is unworkable from a regulatory standpoint (Rand page 31: “While the Reed Group markets its final product as a drug formulary, it is not a formulary in the traditional sense. A traditional formulary is a list of covered drugs with rules on how the drugs may be accessed and under which conditions”).
Q: Why didn’t they just use the ODG Formulary?
A: This is where things went awry. Rand’s primary recommendation is that the California Formulary be consistent with MTUS. While all formularies performed well, and ODG was acknowledged by Rand as the most proven in other jurisdictions and easiest to implement (Rand page 77: “For several reasons, the ODG formulary would be easier to implement. It is already in use by several WC programs and has been operationalized through NDC codes. The ‘Y/N’ structure of the formulary preauthorization rules makes it easier to operationalize because it does not require diagnostic information when processing most pharmacy bills”), Rand also noted that most of MTUS is currently ACOEM. Thus, the logic was they have to try to stick to MTUS.
Q: Do you anticipate problems with the MTUS Formulary?
A: It is new, unknown, and unproven, so at best, it is a gamble, and I would not advise playing dice with the world’s sixth largest economy. There are also many obvious reasons why it is suboptimal. Here are the top two-
1) The recent CWCI study reports that 78% of prescription drug payments in California will require preauthorization under the MTUS Formulary. That acts as a tax, delaying access to care on three of every four medications prescribed, which goes too far. ODG has twice as many preferred drugs, which have proven safe and effective when coupled with ODG guidelines, and thus do not need pre-authorization. This will further frustrate doctors from taking patients in the workers’ comp system, and increase the IMR backlog that has plagued the MTUS era with frictional costs.
2) The MTUS Formulary is merely a PDF file, and cannot be operationalized in its current state using NDC or GPI codes. Applying it will be like a trip back to the 1970s. We live in the age of automation, which is the only way for California businesses to compete on a global scale. Any formulary or treatment guideline must not only be easily searchable and sortable (this one is not), with links to the supporting treatment guidelines (not available), but also accessible and automatable by API, or Application Programming Interface (not even close). We receive over one million API calls PER DAY to the ODG servers from healthcare providers, PBMs, insurance carriers, and TPAs, using medical codes to determine medical necessity and RTW data in real-time. Manufacturers release hundreds of new NDCs each month, which get rolled into the ODG database. None of these things can happen for the MTUS Formulary, which is simply a static PDF file.
Further, keeping a product like this up-to-date is an impossibility for a state agency. Editorial control for the MTUS Formulary also remains mystery, given copyright questions and multiple parties claiming credit.
Q: Is there a better solution?
This is a huge opportunity to fix what has been wrong with MTUS for 13 years, namely that it is an amalgamation of outdated guidelines that are not easily integrated or operationalized. The success with ODG at the state level (better RTW outcomes, by 13-35%, and lower costs, by 30-50%, in TX, OH, ND, KS, OK, NM, AZ and TN) is not simply because we have the most comprehensive, evidence-based, multidisciplinary, and up-to-date treatment guidelines available, but also use state-of-the-art application tools to apply them efficiently, ensuring quality care quickly, while using managed care judiciously. That cannot happen with old PDF files from different sources slapped up on the Internet.
We are 13 years into the MTUS era, and California is still the highest cost state, with poor health outcomes, and frustrated doctors. Is it not time for wholesale change?
The better solution, frankly, is to adopt ODG (guidelines and formulary) system-wide, to unleash stakeholders to use the one solution proven to work best in multiple jurisdictions, and already integrated with claims, medical management, and UR systems. ODG is the most widely used workers’ comp guideline in the world, for good reason. The academic evidence and reports from successful adoptions in other states is overwhelming.
Q: Why does this matter outside of California?
A: This is the age old debate of state-specific guidelines/formulary, versus a nationally recognized solution. We need to spread the word not just in California, but across the country. Evidence-based medicine does not vary from state to state, no more than the acceleration of a falling object due to gravity, or the atomic number of helium. For a well-functioning system, with good health and RTW outcomes, quality medical care, and low premiums, stakeholders should demand a proven solution. With guideline adoptions in more than 15 states over the last 15 years, it is clear what works and what does not in the ODG, ACOEM and Frankenstein (state-specific) debate.
Remember, you cannot reinvent the wheel, without changing the design. Don't reinvent the wheel.
Q: What should stakeholders do?
A: Make your voice known. Submit comments to the Open Forum posted at the DWC site, and hurry. The due date is Friday, 09/16/16.
Call to action:
Alert DWC on what solution is proven to work best in your experience. This is not simply an opportunity to fix the proposed Formulary, but all of MTUS. Think big, about the best system-wide solution in your mind, be that ODG, ACOEM or Frankenstein.
Don’t miss this opportunity, for one week only. Historically, Forum comments have resulted in revamped regulations by DWC to better the system, but they do REQUIRE PUBLIC SUPPORT to make the changes rather than passive acceptance. This is an opportunity to get on the record, and talk about real solutions.
DWC is full of intelligent, qualified, pragmatic people, who asked for feedback and will not cling to a bad idea in the face of evidence to the contrary. They are expert regulators, but they need to hear from you, the expert guideline users.
When this window closes, it closes for a long time.
Q: Are you not self-interested, and can stakeholders trust you, Phil?
A: Thank you for taking the time to get this far, and yes, like everyone, of course I am self-interested. What I like most about working and growing with ODG over the last 16 years is that we have aligned our interests with improving the workers’ comp system in California and elsewhere. We cannot be successful without doing that, and thankfully, we have earned ample opportunities to prove our merit along the way.
This is a story that I and others like the late Dave Depaolo have been telling for a long time. I am the one who revealed that device lobbyists were writing content for the Louisiana Medical Treatment Guidelines, and the same guy who has been writing your “ODG Update” emails for 15 years, who has always tried to be available to take your calls and reply personally. Maybe I was even the young Account Exec on your ODG installation many years ago, or the one who trained your staff.
Whatever our connection, my job is to tell you what I would want to know, if our roles were reversed. To me, that means gaining your trust, only by being right.
Expertise is hard won, and always comes with a track record. Look long and hard at it, because it predicts the future.
And if you have a story about guidelines that improve outcomes in workers’ comp in California, let your voice be heard, and be specific. Then join our Webinar below.
Thanks again, and be well!
More evidence on the ODG solution to the opioid epidemic...
By Ken Eichler, Vice President, Work Loss Data Institute
FORMULARIES CAN HELP ADDRESS LIFE THREATENING ISSUES
There is a consensus among Stakeholders that action needs to be taken to protect the well-being of Louisianans against the life threatening prescription drug crisis confirmed by the Workers Compensation Research Institute (WCRI), the Centers for Disease Control (CDC) and other respected sources. Louisiana has experienced record overprescribing in workers’ compensation, along with prescription related overdoses and deaths. It is therefore frustrating that a second or third year may pass with more lives being destroyed as stakeholders consider the options. It appeared that Stakeholders were on the road to agreeable legislative/regulatory language in 2015, and with appropriate modifications and provisions for development of regulations reflecting negotiated stakeholder positions, HB725 could be a vehicle to help address the crisis.
If Texas experienced improved patient outcomes with an over 60% decrease in prescribing of opioids and a decrease in over 80% in spending since the adoption of the ODG Formulary, Louisiana should be capable of significantly improved patient outcomes as well. The ODG Formulary will most significantly impact post adoption claims with associated changes in prescribing patterns, resulting in less drug dependency and less over prescribing. Formularies and their supporting guidelines further insure proper access to drug tapering and weaning programs as necessary, along with any other medically indicated restorative or maintenance care for the accepted condition.
In a group health scenario, formularies are a list of covered drugs and the associated pricing tiers. In workers’ compensation, injured workers are entitled to any drug that can be medically substantiated and causally related to the accepted condition(s) regardless of cost. The formulary is simply a means of bucketing prescriptions into levels of review for authorization (fast track versus needing detailed medical substantiation) to safeguard injured workers against higher risk or unnecessary medications. This affords all injured workers equal access to medications regardless of employer, insurer or pharmacy benefit managers (PBM). Delivery of lower risk medications is expedited while decreasing costly layers of processing and review.
A formulary affords safeguards in both employee or employer “choice of pharmacy” scenarios, with consistent formulary standards for all injured workers, improved outcomes, decreased prescribing of higher risk drugs and lower overall pharmacy spends.
EVIDENCE & CONDITION BASED FORMULARIES
Formularies and the supporting evidence-based guidelines afford decision makers access to the evidence-based medicine (EBM) to support fair and equal decision making for all injured workers while allowing for case specific scenarios.
Most PBM, Payer and UR systems have already successfully integrated the ODG Formulary (database over 33,000 lines with access to condition-specific guidelines) into their systems and processes with improved clinical outcomes. Physician, Pharmacy, PBM, Payer and UR systems offer varying degrees of automation and non-automated clinical decision making and support. These processes are largely dictated by state and policy specific laws, regulations, company policy and procedure, as well as employer and insurer specific prescription handling protocols.
It is imperative to recognize that an effective independent objective publisher of evidence-based medical treatment guidelines:
The ODG Formulary Table is based on the EBM and references cited in the condition-specific ODG Treatment guidelines. The extended list of treatment options are so displayed to stimulate consideration of the options, such as restorative or alleviating treatment versus prolonged care with addictive debilitating opioids and narcotics. This speaks against references to the Texas and ODG Formulary as a binary or flat system. The ODG Formulary tables, lookup tools and associated links are merely “search tools” to afford easy access to the evidence-based citations, studies and recommendations in the condition-specific evidence based guidelines text.
REALITIES VERSUS PERCEPTIONS
Unfortunately, many who object to workers’ compensation formularies have never physically viewed one and/or the associated supporting guideline. Further, most objectors have not reviewed the current, versus the possible, medication-related processes under an adopted formulary (meeting the Louisiana Guidelines criteria by statute) from the point of a patient-physician encounter, while also taking into consideration the treatment options through the prescribing, initial fill, refill, authorization/denial process, clinical review, UR, appeal, dispute resolution and payment processes for PBM and non-PBM dispensing. Experiencing the reality of a successful evidenced-based formulary program may afford insights into the benefits for all, and would likely dispel subjective perceptions and concerns. It is highly recommended that reviewers apply the formularies to real world, case-specific scenarios, simple and complex, as an insightful “test drive.”
Incorrect assertions have been made that ODG is “binary,” offering only Yes and No options to prescribing, which are not condition specific. On the contrary, the ODG Formulary Table is a look-up tool, linked directly to the supporting evidence, and it encourages consideration of optimal treatment options for the individual patient and causally related conditions.
Joe Paduda (a highly respected industry thought leader, principal of Health Strategy Associates and the founder and president of CompPharma – “a consortium of PBMs that identifies and prioritizes industry-wide problems and then develops and delivers solutions”) and other supporters of medically evidence-based, condition-driven formularies have presented on the topic in Louisiana and elsewhere. Many have been incorrectly led to believe that ODG does not meet these criteria or embrace this approach, but that the Reed/ACOEM Formulary, which has not been adopted in any jurisdiction, does.
Requiring a diagnosis at the time of prescription fill would clearly be a departure from the standard operating procedures in place throughout this country and would significantly negatively impact an injured workers access to prescription medications. It is important to recognize that:
STATUS & RECOMMENDATION CODES
Where ODG uses “Y” and “N” in the Formulary tables, Reed/ACOEM uses “Recommended,” “Not Recommended” and “No Recommendation.” Although these may both appear on the surface to be “binary” or “pick an option,” in the real world handling of claims they are not intended for flat decisions without clinical review. The fact remains that time sensitive and ideally immediate decisions need to be made to authorize, request substantiation or deny. These “Y,” “N,” “Recommended,” “Not Recommended” and “No Recommendation” terms are intended to be used in the pharmacy review process to route the approval of the prescription for case-specific deeper decisions as needed to factor in the injured workers’ scenario. Clinical review (real time, retrospective and/or prospective) of case-specific factors generally includes review of accepted conditions and diagnoses, poly-pharmacy interactions, confounding factors and unrelated medical factors.
Regardless of a ranking of “Y,” “N,” “Recommended,” “Not Recommended” or “No Recommendation,” and regardless of the use of a mandated formulary adoption, a medication must be medically necessary and causally related to be covered by workers’ compensation in most jurisdictions. In ODG, the “Y” designation indicates the drug is indicated as a first line treatment option without submission of detailed substantiation of medical necessity prior to authorization. The “N” designation in ODG indicates that there is a further, “Need for Medical Substantiation,” as a safeguard for the injured worker due to the associated risks of a drug on a stand-alone basis and/or in comparison to other evidence based alternatives. This flags “N” drugs for review of risks and/or medical substantiation prior to authorization of first or subsequent medication fills, thereby significantly decreasing overprescribing, abuse, overdoses and deaths from medications which are not medically substantiated. Review can be achieved in real time or within a short period of time stipulated by regulation and subject to rules for emergent, urgent, in-patient and ambulatory surgical center care. How a Reed/ACOEM “No Recommendation” would be handled when a decision must be made to cover, authorize, request additional substation or deny requests for authorization or payment is unknown to us at this time.
CITATION AND RANKING OF EVIDENCE
Both ODG and ACOEM cite and include high ranking evidence in condition-based guidelines sections/chapters.
ODG cites and transparently ranks the relevant available evidence, including low ranking quality of evidence. All ODG chapters are updated annually, with more frequent updates as needed to reflect growing bodies of evidence. Noting that an EBM guideline publisher amalgamates, rather than authors, the objective evidence, providing access to available evidence which may be low ranking is better than not citing any evidence.
It is our understanding that Reed/ACOEM Guidelines indicate “No Recommendation” or “Insufficient Evidence” when high ranking evidence is not available.
STATE ADOPTIONS & INTEGRATIONS
If a key factor under consideration is ODG versus Reed/ACOEM, it must be pointed out that ODG is the only commercially produced evidence-based formulary that has been formally and specifically adopted by statute and/or regulation in any jurisdiction for workers’ compensation in the United States as of April 2016. There are independent statistical and real world documented outcomes and projections of outcomes with ODG adoptions.
Most PBM, Payer and UR systems have already successfully integrated the ODG Formulary with access to the supporting evidence-based ODG guidelines into their systems and procedures.
The ODG Formulary has been formally adopted in Texas, Oklahoma, Tennessee and Arizona. ODG Formulary tables and updates are provided to adopting jurisdictions at no cost or charge for posting on the state agency websites and for unlimited use by regulators and stakeholders.
Jurisdictional adoptions (by statute or regulation) of the ODG Treatment guidelines and/or ODG Drug Formulary in the United States as of April 2016 include Arizona, California, Kansas, New Mexico, North Dakota, Ohio, Oklahoma, Tennessee and Texas. ODG is referenced and/or permitted by statute or regulation in multiple additional jurisdictions including Louisiana, Florida, New York and many others. ODG is commonly utilized by Louisiana Stakeholders to supplement the current Louisiana Workers’ Compensation Treatment Guidelines, as permitted by statute/regulations.
Additional jurisdictional adoptions (by statute or regulation) of the ODG Treatment guidelines and/or ODG Drug Formulary in the United States as of March 2016 are proposed, under review and/or consideration in jurisdictions including but not limited to Alaska, Georgia, Louisiana, Maine, Michigan, Montana, Nebraska, North Carolina, New York, Oregon, Pennsylvania, South Carolina and others.
The ACOEM Practice Guidelines sections were adopted in California (outdated sections dating back six to over ten years) as part of the Medical Treatment Utilization Schedule (MTUS), as were older and more recently updated ODG sections. Both ODG and ACOEM are deemed applicable by the California DWC under the 2015 Strength of Evidence Rules along with MTUS. The only other current state adoption of the ACOEM Guidelines is in Nevada, which adopted guidelines in the late 1990s. Application of the guidelines is not required in Nevada for authorization of care or permitted to be used for denial of care.
ACOEM Practice Guidelines content previously included in the New York Workers’ Compensation Treatment Guidelines has been removed, modified or significantly edited by the NY Workers’ Compensation Board and is not is sync with or supported by the current Reed/ACOEM Guidelines.
Approximately six years ago, ACOEM licensed a now outdated version of the ACOEM Practice Guidelines content to Montana Department of Labor & Industry to be blended with a now outdated version of the Colorado Guidelines to create a new treatment guideline now known as the Montana Utilization & Treatment Guidelines. This new Montana Utilization & Treatment Guidelines is periodically updated and edited by the Montana Department of Labor & Industry.
The ODG guidelines and associated ODG Formulary are published by Work Loss Data Institute (WLDI), an independent privately held company with over 20 years in the guidelines publishing business. WLDI and ODG ownership is independent of any insurance companies, case management or service providers, device or pharmaceutical manufacturers, special interests and/or medical specialty societies.
Multi-disciplinary, independent ODG editorial review boards are convened representing all specialties treating or evaluating specific conditions and body parts under review. Reviewers and are shielded from producers of evidence, citations, studies and reports, as well as special interests and outside influences. WLDI/ODG accepts and encourages open submissions of qualifying evidence for review and consideration.
The Reed/ACOEM Treatment Guidelines and Drug Formulary are the solely owned intellectual property of Reed Group, whose parent company is Guardian Life, an Insurance Carrier. The Reed/ACOEM Drug Formulary has yet to be mandated or specifically adopted in any jurisdiction in the United States. The earlier Beta Version of the Reed/ACOEM Drug Formulary was briefly introduced and withdrawn from the market in 2015.
STAKEHOLDERS & CompPharma
It is noteworthy that regional and national stakeholders doing business in Louisiana, as well as members of CompPharma, including Helios (the largest Workers Compensation PBM) and Coventry/First Script, are ODG users and have publically voiced positive experiences and improved outcomes with the ODG Formulary and Guidelines. Additional CompPharma PBM members are Express Scripts, Mitchell Pharmacy Solutions, My Matrix, and Optium (owners of Helios, CatamaranRX & HealthCare Solutions). These and other industry stakeholders specifically involved with drug formularies can provide testimony on the successes of ODG in other jurisdictions and will further support an ODG Formulary in Louisiana.
By Phil LeFevre, Senior Vice President, Business Development, Work Loss Data Institute (WLDI)
Workers’ comp is the only area of medicine where health encounters aren’t fairly well scripted in advance. Health insurance plans set and publish health policy statements, which are a combination of evidence-based analysis and demand-driven health “benefits”. If Dr. Smith accepts the insurance from HealthPlanA, Dr. Smith provides only that care authorized in the policy of HeathPlanA. This policy limits the amount and conditions under which care is provided, and it is further limited by cost-sharing (deductibles, copays and coinsurance) of the patient. Do I really want another doctor visit for $35 out-of-pocket? What about a procedure that requires $500 or $1,000 deductible? I’ll certainly think twice.
Workers’ comp has neither of these limiting factors. Payers cannot set their own health policy and patients shoulder no portion of the cost because of the “grand bargain”. Employers must pay for 100% of all reasonable and necessary medical care. But who decides what is reasonable and necessary? Traditionally, it was supposed to be the doctor. But, with the fee for service model, doctors are incentivized only to perform and bill for CPT codes, preferably higher margin codes. More more more. Do some over treat? Absolutely. Is that bad? Indeed it is. At the very least, it drives up costs to employers 100% of the time which translates into businesses being less competitive, offering fewer jobs, lower salaries, and higher prices. In many cases, it’s even worse, and results in ruined lives (unnecessary spinal fusion, failed back syndrome, permanent disability, opioid abuse, addiction, overdose and death). Further, those doctors most likely to over-treat are the ones most willing to put up with the onerous paperwork necessitated by comp. That is a bad combination.
So, what MUST states do about this? They need to set health policy for payers by adopting evidence-based treatment guidelines for medical necessity determinations. How should they do this? Well, they should write their own, of course, because the human race is subdivided into 50 unique species owing it’s individuality to invisible lines on a map. Group health carriers and the Mayo Clinic do it, right? (They don’t, and they would laugh at the argument if they were even paying attention to what happens in comp). Second, there is no one better suited to writing medical guidelines than bureaucrats or policymakers at the state level. Maybe the folks at the DMV could do it? I’m kidding, of course. The DMV can’t write treatment guidelines. They don’t have medical backgrounds. So, maybe the state policymakers should round up in-state treating doctors active in workers’ comp, and ask them to write or designate the guidelines. Ask them to set their own health policy? Do the group health carriers do that? Are you kidding? Doing that will simply codify excessive treatment into the regulatory framework and render UR mechanisms impotent. You may as well ask the docs to set their own fee schedule while you’re at it.
The truth is that policymakers must do the same thing they would when they need a new computer system or heavy machinery. Call the experts. HP, IBM. Caterpillar. Or in the case of treatment guidelines, ODG. They are no less complex or technical in nature, and like anything in life, expertise is only obtained through time and investment, and always comes with a track record. Evidence-based medicine is not simply a parlor term. It requires a comprehensive review of the literature, with a transparent and reproducible evidence-weighting process. If you put a group of treating doctors together in your state and ask them to write treatment guidelines, congratulations, you just defined the term consensus-based. But, please don’t use the phrase “evidence-based” any longer, because it simply doesn’t apply in your case. For treatment guidelines to work they must use evidence-based medicine to serve a dual mandate: (1) safeguard and expedite access to quality care while (2) limiting unnecessary/excessive utilization. It’s a fine line, and it’s not traversed well by accident. But, 10 years into the guideline story, there should be no more surprises. States can see where guidelines have gone well, and where they have not. The single biggest factor in that determination is which guidelines were implemented. All guidelines are not created equal, nor are they interchangeable.
States that use ODG continue to lead the nation, as evidenced by Texas, Kansas, North Dakota, and Ohio. States that write their own or use other state-authored guidelines (i.e. Louisiana, New York, etc) will continue to falter, hemorrhaging cash, shunning employers and jobs to other states, condoning dangerous utilization patterns and causing undue hardship on injured workers and their families. If you don’t think that is an accurate statement, just wait five years. The device lobby is hard at work to obfuscate the issue, but outcomes are clear about wherein lies the truth.
Last but not least, full disclosure. I am Strategic Director for WLDI, publisher of ODG. Like everyone you meet, you should assume I am self-interested. But, unlike many participants in work comp, at ODG we have aligned our interests with those of the injured worker, employer, and policymaker. We are only successful by improving workers’ comp health and return-to-work outcomes, with cost-savings as a byproduct, and our track record at that is a good one.