By John Stahl, Esq.
Phil LeFevre, who is a Senior Account Executive, with the Work Loss Data Institute (WLDI) spent much of a recent webinar entitled “Emerging Trends in Workers’ Comp Treatment Guidelines by State: Has the Fox Been Left to Guard the Hen House” comparing the Official Disability Guidelines (ODG) with other workers’ compensation treatment guidelines. WLDI publishes the ODG.
The overall theme was that the ODG provides more objective guidance than individual state systems that often reflect the self-interests of medical providers in that jurisdiction. Identified problems associated with the fox guarding the hen house were that this hindered the universal workers’ compensation objectives of reducing that system’s costs and getting a workers’ compensation claimant (claimant) back to work as quickly as possible.
LeFevre stated that the ODG was based on evidence-based medicine (EDM). The EDM model provided for “transparency, literature review, and evidence ranking.” This system’s stated goals included objectively ensuring that medical care providers who treated claimants used the right tool for the job after considering every available treatment.
Other cited benefits of EDM were:
Prior, as opposed to pre, authorization of medical services was identified as an underlying element that achieved the positive results described above. Prior authorization differs from pre-authorization in that diagnosing a condition triggers a right to ODG-approved treatment for compensable harm. Conversely, pre-authorization requires utilization review of treatment that is recommended after diagnosing an injury or disease.
Prior authorization avoids reinventing the wheel by eliminating the need to determine the “reasonable and necessary” treatment each time that a claimant sustains the same type of harm that other claimants had sustained. This reduces review-related delays and costs.
The reduced review costs help lower workers’ compensation expenses; the reduced delay help claimants return to work earlier because they do not sit around awaiting pre-approval of recommended treatment.
One caveat that LeFevre shared was that treatment decisions must be based on the most current version of the ODG. Stated reasons for doing so included ensuring that the utilized guidelines reflected the most recent medical evidence.
ODG v. Physician-based Guidelines
LeFevre comparing doctors selecting workers’ compensation guidelines to NASCAR drivers setting speed limits set the tone for discussing a local medical community establishing approved treatments. Examples of potential abuse included indications that lobbyists would have undue influence regarding guidelines and that some physicians were shown to blatantly act in a self-serving manner.
The webinar additionally asserted that the ODG’s advantages over guidelines that a legislature or physician’s group established extended well beyond the “hen house” argument. One example was that practitioners in one medical field establishing the ODG for compensable treatment for relevant harm helped ensure that claimants received appropriate treatment. LeFevre noted that the ODG did not allow a surgeon to establish guidelines for acupuncture treatments.
This portion of the webinar also contrasted the ODG with the Colorado Guidelines. The data demonstrated that the Colorado Guidelines resulted in higher costs than the ODG for reasons that included Colorado having “the guideline of yes,” rather than the ODG offering “more balanced guidelines.”
Other identified flaws with the Colorado Guidelines were that they reflected community input and the consensus that Colorado medical providers reached, rather than the EBM. LeFevre observed that that consensus may not have always reflected the “greater weight” of medical evidence.
On a related note, the webinar rejected the notion that states needed individual guidelines. The clear message was that the medical needs of claimants did not differ in a manner that precluded applying different guidelines to a claimant in, for example, Massachusetts than one in Kansas despite the different types of industries that were prevalent in those states.
Any workers’ compensation guidelines must be as objective as possible and support a claimant’s right to timely and “reasonable and necessary” treatment for compensable harm. Those who decide the guidelines should not have a horse in the race.
© Copyright 2012 LexisNexis. All rights reserved.