Standardization In Workers’ Comp

| | Physician Peer Review, Technology & Integration, Utilization Review

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Kats May 2017 Article on Standardization
Over the past year or two, there have been more conversations about making broad changes to workers’ comp. These conversations have run the gamut from abolishing worker’s comp, to having state health care plans like ColoradoCare that include coverage for on the job injuries. If you read the Department of Labor’s 2016 report titled Does The Workers’ Compensation System Fulfill Its Obligations to Injured Workers? you’ll probably get the impression that many areas of workers’ comp don’t work and need to be reformed.

The 2016 DOL report shocked many workers’ comp industry stakeholders. Certain system participants were even worried about a “federal takeover” of workers’ comp. But all that changed in November 2016 when Donald Trump was elected president. Since the election, the DOL does not seem nearly as interested in reforming workers’ comp. But in the aftermath of the report, a key question remains. Should certain areas of workers’ comp be more uniform from state to state so insurance carriers and other system participants can standardize their operations and pass along their cost savings to businesses large and small? I’m not talking about a federal takeover but about system participants from various states getting together and asking “How can workers’ comp become more standardized?”

At UniMed Direct, we have a trademark phrase: Fast to Yes, Easy to Know®. This is more than just a phrase for our company.  As part of our philosophy, we believe that if we can provide a quality utilization review decision quickly, all participants win. In other words, Fast to Yes, means you get your decision quickly. Easy to Know means it’s easy to understand why the decision was reached.

In thinking about standardization in light of our company philosophy, we would like to consider what changes could be made that could make the entire process more uniform, efficient, and affordable.

Here are my five areas where a national approach would lead to greater standardization.

  • A Nationwide Drug Database: As we know, while the opioid crisis in the U.S. is slowly improving, many rightfully believe it’s still out of control, both in workers’ comp and in group health. If a national prescription drug monitoring program (PDMP) were created, it would allow any prescriber to verify any/all drugs being taken by a patient. We could avoid contraindicated drugs, identify drug seeking patients, and more easily look at historical drug use to determine appropriateness and efficacy.
  • Universal Guidelines: Many system participants are familiar with ODG, ACOEM, Presley Reed, McMillan, etc. And while these guidelines all have their strengths and weaknesses, the one thing that stands out is that they are all different. So an insurance carrier writing business in California, Arizona, New Mexico and Texas, will essentially apply four different sets of guidelines depending on where the claim arose. How much easier would it be if there was just one set of guidelines? When I think of quality universal guidelines, these concepts stand out as superior:
    • Up to Date Guidelines: As we know, advances in medicine are happening every day, so if the guidelines are “old,” they may not contain the most current medical information. So I would love to see national guidelines updated at least annually. Also, it should be very easy to tell which version of the guidelines you are using.
    • Quality of Evidence: Is the evidence based on blind studies? Is the qualifying factor that the treatment is better than a placebo? What type of medical literature review was used? Where there clinical trials involved? These are all important questions that need to be addressed.
  • A Drug Formulary Integrated with the Universal Guidelines: Many states are currently creating or considering a drug formulary. While this is a step in the right direction, we must be careful in how a drug formulary is constructed when we’re looking for efficiencies, and focus on quality patient care. Complicated formularies will not allow us to get Fast to Yes, Easy to Know answers for the patient or prescriber. Complexity would add confusion and delays by increasing workloads, which will not result in the best outcome. A simple formulary fully integrated with the guidelines is key.
  • A Uniform Approach to Mental Health: This is generally a taboo topic in workers’ comp. However, it is my belief that while the carriers do not accept long term psychological claims related to an injury, there is a component of being injured that does impact the psyche. Many businesses offer an Employee Assistance Program (EAP) to assist employees for brief periods of time when. It seems that the same offering could be made available for workers’ comp claimants. If so, the injured employee would have the opportunity to discuss their concerns (or fears) related to the injury and learn coping mechanisms that would allow them to more easily return to work.
  • The Elimination of Same-State Physician Reviewer License Requirements: In theory, requiring utilization review physician reviewers to be licensed in the injured workers’ state may sound good, but as a practical matter, when a state requires this, it greatly reduces the pool of qualified reviewers available, and this drives up costs. Also, I have not noticed that doctors licensed in California or Texas are, for example, better than doctors licensed in New York or Florida. A good doctor is a good doctor regardless of the state in which she obtained her medical license. Also, it doesn’t seem to make sense that an injury in one state would be treated differently in another state. If I were to sprain my ankle in Texas should it be treated differently than if I sprained my ankle in Colorado? How can that be the case? The human ankle is the same no matter where you sprain it.
  • Granted, none of these changes would necessarily be easy, and many would be controversial. But if some of these programs were adopted, and policies and procedures were more uniform from state to state, we believe it would result in less confusion, possibly quicker and better care for injured workers, and significant savings for everyone in the system.

    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.