Tuesday, October 30, 2012

Treatment Guidelines, Prospective Review, and Patient Safety

New Mexico is currently working through the process of adopting medical treatment guidelines.  Thankfully, they appear to be leaning toward nationally recognized, evidence-based guidelines like ODG and ACOEM (vs. the Medtronic-influenced, politically-driven brew of guidelines that states inevitably end up with when they try to develop their own guidelines).  Also encouraging is the presumption of correctness that the New Mexico rule contemplates.  Holding treating physicians accountable to the guidelines (even if that means ensuring clear, documented rationale for treating outside of said guidelines) is the only way to improve patient care and reduce state-to-state, practice-to-practice, and physician-to-physician variability in care.

Less encouraging is the proposed elimination of the requirement for providers to obtain prior authorization for medical services that are recommended by the guidelines.  While that sounds logical and efficient, there may be unintended consequences.

Prior authoriziation (or pre-authorization or pre-certification) comes in several shapes and sizes.  In many states, it's optional - something the provider will utilize only in circumstances where high cost care is being rendered and the provider wishes to ensure future payment (i.e., for a surgery).  In some states, pre-authorization is mandated - something the provider must do prior to delivering care.  There are pros and cons to both approaches.  Optional pre-authorization is administratively simpler and less onerous on providers.  Mandated pre-authorization is the opposite - more demanding administratively and on doctors.

But the clearest and most compelling argument for mandated pre-authorization is patient safety. New Mexico may allow for retrospective review if a physician performs a surgery or procedure outside of ODG or ACOEM.  But by then, the care has been rendered, potentially to the detriment of the patient. 

Texas serves as a bright spot in this regard.  Texas has adopted nationally recognized medical treatment guidelines and still maintains mandated pre-authorization, which now includes pre-authorization for certain pharmaceutical treatment as well.  Does anyone doubt that measures such as these have made Texas one of the most cost-effective work comp systems in the nation? 

High marks for New Mexico regarding treatment guidelines.  Low marks for trying to remove mandated prior authorization.  This strikes me as a quid pro quo with the physician community ("we're going to adopt these guidelines... but you don't have to ask permission anymore..."), but I don't think this bargain is in the best interest of patient safety.

On Twitter @PRIUM1


  1. What states mandate txt guidelines and make UR optional ?

  2. CO, CT, LA, ME, MN, and WV all have guidelines with optional UR. Some of this is up to interpretation and other states that have guidelines might have UR that is required for certain treatments but not for all.

  3. Michael LA UR is mandated by statute last year. Rules defining have been recently sent to the state register for final implementation

  4. Great update about patients safety. Hope those guidelines will be carefully followed to avoid medical negligence.