LexisNexis has selected some recently issued noteworthy IMR decisions that illustrate the criteria that must be met to obtain authorization for a variety of different medical treatment modalities. LexisNexis...
CALIFORNIA COMPENSATION CASES
Vol. 89, No. 2 February 2024
A Report of En Banc and Significant Panel Decisions of the WCAB and Selected Court Opinions of Related Interest, With a Digest of WCAB Decisions...
By Hon. Susan V. Hamilton, Former Assistant Secretary and Deputy Commissioner, California Workers’ Compensation Appeals Board
In the 1785 poem, To a Mouse , Robert Burns observed that the best...
By Hon. Colleen Casey, Former Commissioner, California Workers’ Compensation Appeals Board
The struggle is real. How and when should Workers’ Compensation Judges (WCJs) apply the statute...
Oakland, CA - The number of inpatient hospitalizations in the California workers’ compensation system declined 51.1% between 2012 and 2022, spurred by declining claim volume, technological advances...
First Comprehensive Study Evaluating EBM Guidelines in Comp Setting
In recent years within the workers’ compensation (WC) arena, proponents of evidence-based medicine (EBM) have contended that managing an injured worker’s care according to established practice and treatment guidelines results not only in a savings in overall medical care costs, but also in better outcomes for the injured worker. A recent study published in the Journal of Occupational and Environmental Medicine [See Hunt, Dan L., DO, et al., “A New Method of Assessing the Impact of Evidence-Based Medicine on Claim Outcomes,” JOEM, Vol. 58, No. 5, pp. 519–24, January 2016], now provides at least some empirical support for that claim. The researcher’s findings—that adherence to peer-reviewed evidence and guidelines results in as much as a 13 percent reduction in claim duration and a 38 percent decrease in overall medical costs for injured workers—is certain to provide additional cover to groups seeking to expand the use of EBM at the expense of clinically-based medical care.
Study Objectives and Methodology
The researchers sought to fill what they contend is a void in workers’ compensation research. According to the authors, their work is the first comprehensive study “to evaluate the impact of adherence to EBM guidelines on medical costs and the duration of patient treatment.”
Two Moving Targets
The researchers sought to aim at two separate targets. First, they desired to develop a quantitative score that could be used to determine the level of treatment compliance with EBM guidelines. The specific guidelines chosen were the Official Disability Guidelines (ODGs) maintained by the Work Loss Data Institute (WLDI). Second, they wanted to examine the relationship, if any, between the use of the guidelines and the outcome experienced both by the injured worker and the entity responsible for paying for the medical treatment. That is to say they wanted not only to determine if adherence to EBM guidelines resulted in better medical treatment, but also to determine if such adherence translated into shorter durations of treatment and lower claims costs.
Large WC Dataset
The study researchers utilized a large dataset, comprising more than 45,000 WC indemnity claims with at least two years of development filed with four large, related insurance carriers between 2008 and 2013. Because they were aiming at not one, but two targets, the researchers developed two separate analytical techniques. One gauged each claim for medical complexity. The second gauged adherence to the ODG.
Using the “flag” system of the ODG, the researchers then gauged the adherence of every procedure given a specific diagnosis for each claim based on the following four ODG flags:
> Green flags, if the procedure was recommended based on prevalence, medical consensus, and historical claim outcomes.
> Yellow flags, if the procedure was a common treatment for a particular diagnosis and should be allowed on a limited basis with a restriction on the number of times it should be performed.
> Red flags, if the procedure had low prevalence in workers’ compensation settings and if the treatment was not necessarily indicated based on current scientific research. For treatment tagged with these flags, the procedure should be carefully reviewed for necessity.
> Black flags, if the treatment was inappropriate. In these cases, the treatment request should probably be denied.
The researchers provided an example of how this flag feature works. If, for example, the patient’s diagnosis were uncomplicated Type II diabetes, rotator cuff surgery would receive a black flag; the treatment generally would not be associated with the underlying condition. On the other hand, if the patient had a rotator cuff sprain or injury, it would receive a green flag for rotator cuff repair.
Using this methodology, the researchers separated the claims into group core groups. First, those claims that had mostly green and yellow flags were judged to be relatively compliant with the ODG. Alternatively, those that had mostly black or red flags were judged to be non-compliant. Once the claims had been separated into the two groups, the researchers indicated that they were able to judge the difference between the groups in both medical treatment duration and medical cost.
Study Findings: Non-Compliant Treatment More Costly
Using the study’s methodology, the researchers determined that across the average of all levels of medical complexity, claims in the non-compliance group had a 13.2 percent increase in claim duration and a 37.9 percent increase in medical costs compared to the high compliance group. The researchers also found that the more medically complex the claim, the greater the difference in result between the high compliance claims and those with low compliance.
Particularly troublesome, according to the study, was that across all levels of medical complexity, the mean number of appropriate procedures for the high compliance and low compliance groups was strikingly similar, yet the mean number of inappropriate procedures performed per claim in the low compliance group was significantly higher than that in the high compliance group. According to the researchers, this suggests that “the primary driver of increasing duration and medical spend in the low compliance group (or the bottom 50% of the population) is the addition of inappropriate care to the injured worker.”
Study May Draw Criticism
Those who don’t like EBM generally may point to the fact that the study was funded, at least in part, by the AF Group (formerly Accident Fund Holdings Inc.), a group of WC companies that originated in Michigan. Employers and insurers generally favor most forms of EBM.
Study Implications: Gasoline on the Fiery Debate
The study results, published in JOEM, surely will add gasoline to the already fiery debate over EBM within the workers’ compensation setting. That debate, while growing increasingly more contentious in recent years, is almost as old as the WC system itself. Since employers (and their carriers) are ordinarily responsible for 100 percent of the “reasonable and necessary” medical expenses associated with the injury, employers have long voiced concerns as to whether the prescribed treatment in a particular case was appropriate.
Traditionally, doctors were left to determine medical necessity, but since their own compensation has ordinarily been based upon a fee-for-service model, the doctors and other medical care providers were financially incentivized to provide more and longer, not less and shorter, methods of treatment. While most medical care providers were honest, some were not, and the result—at least according to some employer groups—was a significant increase over the years in the cost of care.
To be sure, the huge increase in the cost of medical care in recent years has not been limited to the WC world. The increases have been caused by a myriad of factors, not just a failure on the part of some health care providers to follow EBM guidelines. Nevertheless, some employers have increasingly begun to feel that they have virtually no say in the care and treatment of injured workers. Some have determined that they are mere wallets and not partners in providing the care. They argue that they have a significant stake in getting the injured employee back to work as quickly as possible. They also argue that leaving the decisions up to the physicians has generally helped physicians, but not always the injured workers.
Some Form of EBM Utilized in 42 States
Responding to these pressures, a number of WC experts began to argue for more objective standards of treatment. According to WLDI, by 2016, 42 states have adopted EBM standards in one form or another. While most states have adopted either the ODG or an alternative set of guidelines espoused by the American College of Occupational and Environmental Medicine (ACOEM), some states have crafted their own.
Has the Pendulum Swung Too Far Toward Managed Care?
Some workers’ compensation experts say the pendulum has swung too far toward standardized medicine. One such critic, Robert G. Rassp, California attorney and author of The Lawyers Guide to the AMA Guides and California Workers’ Compensation (LexisNexis) has joined others in referring to EBM as “cookbook medicine.” Others counter, however, that if practicing without a cookbook had worked, the WC community wouldn’t find itself in the medical/pharmaceutical predicament it now faces.
A growing number of WC experts argue that EBM shouldn’t be considered an all or nothing issue. For example, after reviewing the JOEM study, Stuart Colburn, an attorney who represents employers and carriers in the Austin, TX office of Downs Stanford, P.C., said,
EBM has its place in workers compensation systems as a tool to make sure workers receive appropriate medical care. EBM is only a tool and should not be used as a hard ceiling (what some refer to as cookbook medicine). But, EBM is useful to limit the practice of some providers from prescribing for profit instead of objective standards and the needs of their patients. As they say, doctors should first “do no harm.” Over-utilizing care harms employees and employers. States should feel more comfortable adopting objective standards as a tool in their workers compensation schemes.
Further Study Needed
As indicated above, the researchers posit that theirs is the first comprehensive study to evaluate the positive impact of adherence to EBM guidelines. Additional studies are needed to confirm the findings noted here. Jennifer Christian, MD, MPH, FACOEM, a thoughtful spokesperson with the WC community, suggests that researchers should supplement this study with one (or more) scored according to ACOEM’s Occupational Medicine Practice Guidelines.
It would also be interesting to blend these EBM sorts of studies with separate research that tracks true medical outcomes in WC cases that pass through the Utilization Review process. While it is certainly the case, as Coburn points out, that over-utilizing care harms employees and employers, likewise the overutilization of UR is currently choking the system in some states. Delayed care is often denied care. It seems clear that much more work in weighing these important factors lies ahead.
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