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Treatment Guidelines: Recommendations and Implications for Providers Dr. Robert Snyder, Medical Director Suzy Douglas, Moderator. Treatment Guidelines: Recommendations and Implications for Providers. Division of Workers’ Compensation Robert B. Snyder, M.D. Text 754730 and your

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Treatment guidelines recommendations and implications for providers

Treatment Guidelines:Recommendations and Implications for ProvidersDr. Robert Snyder, Medical DirectorSuzy Douglas, Moderator


Treatment guidelines recommendations and implications for providers

Treatment Guidelines:Recommendations and Implications for Providers

Division of Workers’ Compensation

Robert B. Snyder, M.D.

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Tennessee workers compensation law

Tennessee Workers’ Compensation Law

  • 2013 Edition

    • 50-6-124(g), (effective on July 1, 2014)

      • “the administrator shall, by rules to become effective on January 1, 2016, adopt guidelines for the diagnosis and treatment of commonly occurring workers’ compensation injuries.”

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Tennessee workers compensation law1

Tennessee Workers’ Compensation Law

  • 2013 Edition

    • 50-6-124(h), effective on July 1, 2014.

      • “Any treatment that explicitly follows thetreatment guidelines… or is reasonably derived therefrom,

        …shall have a presumption of medical necessity for utilization review purposes.”{if it follows a ‘published’ guideline, then…}

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Tennessee workers compensation law2

Tennessee Workers’ Compensation Law

  • “…Guidelines for the Diagnosis and

    Treatment… ”

    • Clinical Practice Guidelines

      Clinical Guidance

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Clinical guidance

Clinical Guidance

  • Different Forms:

    • Consensus Statements

    • Expert Advice

    • Appropriate Use Criteria (AUC)

    • Clinical Effectiveness Research (CER)

    • Evidence Based Medicine (EBM)

    • Practice Guidelines

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Clinical guidance1

Clinical Guidance

  • Practice Guidelines

    • Institute of Medicine(2011)

  • “…statements that include recommendations intended to optimize patient care that are informed by a systematic review of the evidence and an assessment of the benefit and harms of alternative care options.”

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Clinical guidance2

Clinical Guidance

  • Evidenced Based Medicine (EBM)

    • “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”

  • Expert Advice

    • “the opinions of our teachers…”

  • Consensus Statements

    • A group of peer “experts” discuss and arrive at a conclusion as to a particular question.

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Clinical guidance3

Clinical Guidance

  • Appropriate Use Criteria (AUC)

    • “… to use a procedure…when the expected benefits exceed the expected risks by a wide margin…facilitate these decisions by combining the best available scientific evidence with the collective judgment of physicians.”

  • Clinical Effectiveness Research (CER)

    • “the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care.”


Trustworthy guidelines

Trustworthy Guidelines

  • Institute of Medicine (1)

    1. Based upon systematic review of the existing evidence.

    2. Developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups.

    3. Considerate of important patient subgroups and preferences.

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Trustworthy guidelines1

Trustworthy Guidelines

  • Institute of Medicine (2)

    4. Based on an explicit and transparent process that minimizes distortions, biases, and conflicts of interest.

    5. Clear in their explanation of the logical relationships between alternative care options and the health outcomes

    6. Provide ratings of both the quality of the evidence and the strength of recommendations.

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Trustworthy guidelines2

Trustworthy Guidelines

  • Institute of Medicine (3)

    7. Reconsidered and revised as appropriate when important new evidence warrants modifications of recommendations.

    • Extra caveats:

      a. Be easily accessible and user friendly (clear) for those who need to use them.

      b. Have a reasonable acquisition and use cost.

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Potential focus

Potential Focus

“…the most commonly occurring…”

1) Most numbers of procedures

2) High cost-length of disability

(indemnity and medical)

3) Payment under “open medical”

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Factors that will influence the decision

Factors that will Influence the Decision

  • Implementation Barriers

    • Access

    • “User friendly”

  • Resources Available

    • Cost

    • Manpower

    • Time

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Factors that will influence the decision1

Factors that will influence the Decision

Input from Stakeholders

  • Division and other state agencies

  • Providers

  • Carriers, Utilization Review Agencies

  • Employers

  • Injured workers and their representatives

    • Attorneys

    • Families

    • Ombudsman program

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The decision

The Decision

The Medical Advisory Committee

The Final decision rests with the Administrator

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First guideline

First Guideline

The Management of Chronic Pain

Tennessee Department of Health

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Potential sources

Potential Sources

  • Physician Specialty Societies

  • Other States

  • Proprietary Companies

  • Other Interested Stakeholders

  • Internal Tennessee Development

    • Department of Health

    • Workers’ Compensation Committees

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Preliminary review

Preliminary Review

  • Washington

  • Colorado

  • Other states

  • WLDI-ODG™

  • ACOEM

  • Specialty Societies

  • Department of Health

  • Medical Care Cost Containment Committee

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Use of the guidelines

Use of the Guidelines

  • If the Guidelines are used:

    • After January 1, 2016: “presumed to be medically necessary” and not subject to utilization review.

      “Carrot” versus “Stick”

    • Not like Medical Fee Schedule: “mandatory”.

    • Until January 1, 2016: all should get familiar with the recommended guidelines and start using them.

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References

References

ODG: http://www.odg-twc.com/

ASIPP: http://www.asipp.org/Guidelines.htm

ACOEM: http://www.acoem.org/Guidelines

Washington State: http://www.lni.wa.gov/

TN DOH: http://health.tn.gov/Downloads/ChronicPainGuidelines.pdf

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