Guideline Adoption, Pros and Cons

| | Evidence Based Medicine, Physician Peer Review, Utilization Review

Kats June Article on ACOEM v ODG 2

For the past few months, Pennsylvania has grappled with HB 1800. This bill would require the Department of Labor & Industry to adopt a “nationally recognized guideline.” As Pennsylvania regulators and stakeholders work to determine which guidelines to implement, they are asking some of the same utilization review questions that other states have pondered. The age old question arises: Which guideline(s) should we choose, or should we build our own?

Historically, guidelines are used in all lines of medical treatment. They are not limited to workers’ compensation. Guidelines can be specific to a ventilator, osteoarthritis, muscular-skeletal and any number of other medical protocols.

There are numerous evidence-based guidelines that provide insight as to the appropriate treatment for any type of workers’ comp injury. These include state guidelines (such as CO, NY, MA, ACOEM, ODG, Green’s Hand, etc.).

The definition of the guideline acronyms listed above are:

ACOEM:   American College of Occupational and Environmental Medicine (published by the Reed Group)

ODG:     Official Disabilities Guidelines (published by Work Loss Data Institute)

In workers’ comp, we predominantly see the use of commercial guidelines such as ACOEM, ODG or a state created guideline such as NY or CO. In state created guidelines, the state compiles a separate, independent medical guideline under the direction of a medical team that allows the state to specify the treatments addressed. There are challenges in creating and maintaining state specific guidelines:

  • keeping them current with changes/advances in medicine,
  • ensuring proposed treatments are FDA approved
  • evidence with case studies supporting the treatment
  • accessibility and knowledge of the guidelines by treating providers and clinical reviewers

ODG and ACOEM are considered “commercial” guidelines. They offer files for vendors to use in creating guideline rules. Both guidelines offer web-based access to treatment parameters for physician reviewers to access based on body part, condition, and treatment options with the determination (approval or additional review) based on a CPT Code and a diagnosis code (ICD9 or ICD10) combination along with the treatment units.

As an example, a request may be related to a back strain or sprain (724.0) with CPT Code 97110, requesting 12 physical therapy (PT) visits. The guideline then looks at coding and visit information and runs the rules based on the age of the claim (Date of Injury or DOI). In the example of the PT x 12 request, the treatment would be appropriate for a new claim but would not be appropriate (without further review) with an advanced date of injury. This would result in an approval for the new claim and denial for an older claim based on the evidence available.

So you might be asking the question, “Is there a preferred guideline?” Is there a single guideline that is considered better than the others? Does the role that you perform create a preference one way or the other?

When a state like Pennsylvania is considering mandating a utilization review guideline, what items should be considered?

  • Are there clearly defined regulations governing utilization review in the state?
  • Does the state believe that there should be clear, concise evidence to support the treatment, or should there be flexibility that gives the physician reviewing various options?
  • If a state guideline is mandated (vs. a commercial guideline), is there a process to ensure that the evidence is maintained and updated on a regular basis in order to take medical advancements into consideration? This may also require additional medical staff.
  • In the case of a state guideline, how will access be granted to the providers and reviewers to access, review and cite the guidelines?
  • Do the guidelines support the regulatory initiative? In other words, do they help reduce claims costs, expedite return to work, and ensure appropriate medical treatment is provided timely?
  • Is there a cost savings to elect commercial guidelines vs. creating an independent guideline?
  • Is there a timeframe mandated in which guidelines are to be introduced?
From a commercial rule standpoint, the states using commercial guidelines:
  • Have easy access and familiarity amongst the physician reviewer population
  • Update the medical evidence on a regular basis, keeping current with medical trends and procedures
  • Are easily implemented with minimal cost
  • Lead to cost savings
  • Ensure appropriate medical treatment is permitted in a timely manner

We will continue to watch the development of state mandated utilization review regulations and implementation of guidelines across the states. Stay tuned and check out our regulatory map for more details regarding guidelines and other utilization review rules.

Karen Atkins

Karen Atkins, Chief Operating Officer with UniMed Direct, is leading the conversation, and the industry, on how to make the utilization review process more efficient for all stakeholders: physicians, insurance companies and, most importantly, patients.