Evidence Based Medicine Guidelines for Work Comp

The active use of Evidence Based Medicine (EBM) within Workers’ Compensation is less than a decade old.  While there have long been research and studies and scientific evidence available for when treatments should / should not be used, in my opinion there were two triggering events to bring this into the forefront:

• California SB 899 in 2004 that changed the “presumption of correctness” from the treating physician to American College of Occupational and Environmental Medicine (ACOEM) as the standard of care (and since then the custom-written MTUS guidelines were added)
• Texas HB 7 in 2005 that set the stage for establishing Official Disability Guidelines (ODG) in 2007 as the standard of care

In both cases, the statutes and subsequent rules were required because Work Comp costs were dramatically increasing each year (and driving employers away) and Payers had very little leverage in contesting the medical appropriateness of care since the treating physician’s opinion was irrefutable.  The advent of EBM and scientifically-based standards of care at least made for a level playing field and slowed the growth of Work Comp costs (although there are so many variables that continued cost escalation was inevitable).  Giving carte blanche to anyone, including physicians, without some form of reconciliation to objective best practices do not make sense.

Currently there are:

• 14 states that use ODG, ACOEM, or a combination of both (9 use ODG exclusively)
• 21 states currently have no guidelines (although 10 are considering them)
• 16 states who crafted guidelines locally (6 use excerpts from ODG while Louisiana still seems to be fighting over the Supreme Court decision on the final composition)

An interesting case study about the process of “creating” guidelines is Arizona.  Michael blogged about their approach on Feb 1, but an interesting thing happened yesterday on the way to the victory party.  HB 2365 proposed a change of “presumption in correctness” be changed to nationally recognized guidelines by 07/01/14 and if none explicitly selected then ODG or ACOEM would be the default.  There are two very good summaries of this published today, an article by Greg Jones of workcompcentral (requires a subscription) and a blogpost by David DePaolo, so I won’t go into the details here.  Suffice to say that when you have so many constituents and stakeholders who have a myriad of competing incentives (and most are not aligned with the Work Comp goal of returning a claimant to work and health ASAP), it is almost impossible to reach consensus.  In Arizona’s case, competing forces won and HB 2365 was deferred.

When special interests (with revenue at stake) and politicians (with votes at stake) allow decisions to be made about healthcare without the clinical objectivity of scientific evidence, patients lose.  And especially in the vacuum where no objective standard of care exists, all bets are off.

In this together – Mark

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