Monday, April 15, 2013

Medical Treatment Guidelines: Evidence vs. Consensus

Senate Bill 200 is all but signed into law in Tennessee.  The bill brings broad reform measures to the state, some of which were desperately needed (e.g., the creation of an administrative dispute resolution system that will largely relieve the civil courts of the burden of work comp fights) and some of which will be deeply contentious (e.g., the revised definition of AOE/COE that will surely shift a material number of injuries that might have been covered by work comp historically into the commercial/group health insurance market). 

One seemingly minor point caught my eye.  The law gives the newly created position of Administrator of Division of Workers' Compensation, appointed by the governor, the charge to adopt medical treatment guidelines for the diagnosis and treatment of workplace injuries.  These guidelines need to be in place by January 1, 2016.  Assisting the Administrator in this task will be a medical advisory committee which will be assembled as soon as the law goes into effect and will expire on July 1, 2015.  Assuming the committee is formed over the next several months, it appears they'll have approximately two years to adopt medical treatment guidelines.

Two years? 

If Tennessee isn't careful, they'll end up with a Louisiana-like approach to the development and adoption of medical treatment guidelines - a process so fraught with lobbying, special interests, law suits, and covering of tracks that sections of the resulting guidelines more closely resemble instructions for Medtronic spinal implants than actual medical treatment guides. 

The choice for Tennessee's medical advisory committee is simple: they can choose evidence-based guidelines or consensus-based guidelines.  While it sounds reasonable that a group of Tennessee-based medical experts should assemble themselves and consider all stakeholder views to develop a set of guidelines for which there exists broad acceptance... the reality is that good politics often leads to bad medicine.  Before the citizens of Tennessee realize what's happening, lobbyists from pharma, medical device, and physician constituencies will take pen to paper to write sections of the guidelines - as a service, of course, to the very busy committee members. 

Instead, the role of the medical advisory committee should be to debate which set of existing, off-the-shelf, evidence-based, nationally recognized, constantly updated guidelines should be adopted by the state in their entirety with no edits, additions, or subtractions driven by special interests.  This will be tougher to accomplish politically, but will lead to the best, most consistent, most credible, and most reliable clinical and financial outcomes for the work comp system. 

(Note: See Texas.  This works.) 

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