Arizona House Bill 2365, currently awaiting a hearing in the Banking and Insurance Committee of the Arizona State House, would establish the American College of Occupational and Environmental Medicine Treatment Guidelines (ACOEM, for short) as presumptively correct on issues concerning the extent and scope of medical treatment. The bill also allows for other evidence-based guidelines to be used if a particular procedure or therapy isn’t covered in ACOEM.
In several recent posts on new prescription drug rules in monopolistic states like Washington and Ohio, I made mention that payors in other states need to get to work on a market-driven solution. I’d like to clarify what such a solution might look like. Arizona presents a potentially solid test case.
There is a difference between simply recognizing treatment guidelines (like ACOEM, MTUS, or ODG) and establishing those guidelines as presumptively correct via statute. Arizona is (potentially) following the lead of other states like Texas and California in making it clear to the medical community that the burden of proof for the necessity of treatment that is inconsistent with the guidelines rests with the claimant and his physician. This is a simple, but powerful approach to appropriately controlling the utilization of health care services, including medications. When evidence-based medicine prevails, both the payor and the claimant win.
Additionally, this approach allows for market-based mechanisms like utilization review agents, independent medical examiners, pharmacy benefit managers, case managers, and others to take credible, evidence-based, statutorily supported positions on specific treatments for individual claims. Ultimately, this gives the payers the medical-legal high ground on treatment and payment disputes and, when used properly, prevents egregious, out of control drug regimens.
AZ House Bill 2365 is a smart first step to eliminating the inappropriate use of prescription narcotics in the Arizona work comp system. Other states that have not already done so would be wise to follow suit.
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