Published 12/1/2014
Tom Farrell

Making the Case for Guidelines in Workers’ Compensation

The push for evidence-based guidelines in workers’ compensation is understandable. Workers’ compensation is one of the few areas of medicine in which healthcare protocols are not well scripted in advance of patient encounters. In addition, patients have no responsibility for payments such as deductibles and copayments. That leaves employers liable for 100 percent of all reasonable and required medical care.

But who decides what treatment is reasonable and required? One would naturally think that it is the treating provider. But the current fee-for-service model offers a financial incentive for doctors to perform and bill for treatments and procedures, preferably those with high margin codes.

As a result, overtreatment—and sometimes the wrong treatment—occurs. This drives up employer costs and makes businesses less competitive. That brings fewer available jobs, lower salaries, a higher general price level for goods and services, and higher premiums and healthcare costs for everyone. Sometimes the result is ruined lives due to unnecessary surgeries, failed back syndrome, permanent disability, opioid abuse, addiction, overdose, and death.

Some of the doctors most likely to overtreat are also the ones most willing to put up with the onerous paperwork necessitated by the regulatory stronghold that is workers’ comp. This environment can make for a bad combination.

Some states try to write their own guidelines, but guidelines and evidence-based medicine are not strictly synonymous terms. Evidence-based medicine requires a comprehensive review of the literature, with a transparent and reproducible evidence-weighting process. Asking a group of physicians to write treatment guidelines results in consensus-based—not evidence-based—guidelines.

For treatment guidelines to work, they must use evidence-based medicine to serve a dual mandate—safeguarding and expediting access to quality care while also limiting unnecessary or excessive utilization. It’s a fine line. All guidelines are not created equal, nor are they interchangeable.

States like Texas, Ohio, and North Dakota use the ODG (Official Disability Guidelines, published by the Work Loss Data Institute) as their guideline of choice. These states report lower workers’ compensation premiums and costs.

But states such as Louisiana and New York that write their own or use other state-authored guidelines continue to falter, hemorrhaging cash, pushing employers and jobs to other states, condoning dangerous utilization patterns, and causing undue hardship on injured workers and their families.

I do not deny that I have a bias. I work for ODG; it is in my self-interest to support its adoption. But we at ODG have tried to align our interests with those of the health and timely recovery of injured workers. By extension, in representing the interest of injured workers, we necessarily try to make the treating provider’s job smoother. Guidelines first and foremost must expedite access to quality care. We need to make it easier for physicians to do the right thing and get paid for it.

When that happens, there are fewer cases of inappropriate care. The ODG is successful because it improves health and return-to-work outcomes for workers’ compensation patients, with cost-savings as a byproduct.

I admit that we need to do a better job positioning ODG as a tool for providers, one that ensures timely approval and payment for services, gets utilization review off of a good doctor’s back, streamlines access to care, puts everybody on the same page, and avoids the unnecessary delays, disputes, denials, and friction that are so common in workers’ compensation.

The workers’ compensation arena is a flawed world, in which 30 percent of spinal fusion and artificial disk replacements are performed—even though workers compensation represents only 1.5 percent of total medical spending. Guidelines can provide coverage to good doctors who support their decision with evidence-based medicine. Physicians report authorization rates jumping to well over 90 percent when they cite ODG in communication with insurance companies.

Insurance adjusters looking for a reason to deny care shouldn’t be the only ones using the ODG. Providers should open up the ODG and see for themselves how it can be used to their advantage.

Appendix D, Documenting Exceptions to the Guidelines, and the subsection called Process for Suggesting Updates to ODG are for providers to use. We aim to make the workers’ compensation experience as smooth as we can for healthcare providers. If we’re not doing that, we want to hear about it, as long as those claims are evidence-based.

I am more than happy to provide a complimentary trial and access to the ODG to any AAOS members interested in exploring it for themselves.

Tom Farrell is a senior account executive and GSA project manager with the Work Loss Data Institute, which publishes the ODG. He can be reached at tom@worklossdata.com