Tuesday, January 10, 2012

Redefining “stable”

One of the ways dictionary.com defines stable is “firmly established”.

A Workers’ Compensation definition of “stable” is Maximum Medical Improvement (MMI), a rather self-defining term that means the patient’s condition cannot be improved any further.  Keep in mind this doesn’t necessarily mean they have reached a point where the patient is satisfied with their health, or that the injury is fully healed with no pain, just that there is no further improvement expected in the patient’s health.  This implies that a variety of treatments have been tried (conservative, surgical, pharmacological, psycho-social), and with varying degrees of success they have delivered the patient to a certain plateau of wellbeing.  In California, the term Permanent and Stationary (P&S) is the legal term for “the point when the employee has reached maximum medical improvement, meaning his or her condition is well stabilized, and unlikely to change substantially in the next year with or without medical treatment.”

So why, when a Payer (or a Peer Reviewer) asks a treating physician for their clinical rationale of a treatment plan that has remained the same for many months/years but the patient still has low Activities of Daily Living (ADL) and high levels of pain (7+ out of 10), is their response that they have “stabilized” their care?  In its purest definition that is probably true because nothing substantial has changed from month to month except the date of the office visit.  However, if there is no objective proof that functionality has increased over time and that pain is becoming better controlled, repeating the same treatment from month to month is having no effect in moving the patient towards MMI.  Using Albert Einstein’s definition of insanity, doing the same thing over and over again and expecting different results, it is fair to say that continuing the same treatment (including the drug regimen) but yet having low function and high pain is insane.
CMS prefers the WCMSA proposal not be sent until the “individual’s condition has stabilized so that it can be determined, based on past experience, what the future medical expenses may be.”  That is a completely reasonable expectation, and we should expect no less during the management of claims.
So let common sense prevail and do not allow a clinically inappropriate regimen with no track record of success be classified as “stable”.  Per the great sage Hank Haney (Tiger Woods’ golf swing coach), if you’re not getting better you’re getting worse.
In this together – Mark Pew

On Twitter @PRIUM1

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