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.