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Luna: A Case for National Standards in State Workers' Compensation

By Carlos Luna

Friday, October 13, 2017 | 1066 | 0 | 0 min read

Would you be surprised to know that the definition of “employee” and “contractor” varies from one state to another? Would you be shocked if I told you that more state workers’ compensation agencies operate without a full-time or part-time medical director on staff than those that do?

Carlos Luna

Carlos Luna

Speaking with a prominent regulator and workers’ compensation expert at the #IAIABC103 conference in Portland, Oregon, two weeks ago rekindled my interest in determining what establishing national standards could do for a system where variances from one jurisdiction to the next seem endless.

The sources of variability in definitions and standards are numerous. Among the most prevalent are resources (expertise, budget, time, etc.). Is it reasonable to suggest that the varying availability of resources from state to state present limitations for regulators in their pursuit of appropriately researching prospective public policy that will improve system outcomes?

Take evidence-based medicine, for example.

Admittedly, EBM is a very complex concept that few people truly understand and appreciate (Note: This is particularly true, and ironic, in the workers’ compensation industry where misaligned incentives make it nearly impossible for stakeholders to share a common goal).

EBM goes beyond the review of literature and authoring of content. The path taken to form conclusions, interpreting scientific literature and answering defined clinical questions ultimately constitutes the content as evidence-based. Without an informed guide to point out technical deficiencies and/or important considerations, the outcome for the agency looking to adopt may result in the selection of a consensus-based resource, or worse, a resource with an undetermined basis.

Serving a Thanksgiving meal on a fast-food budget

In workers’ compensation, state officials routinely struggle to serve a Thanksgiving meal given little more than a fast-food budget. This type of limitation in resources hinders small markets from properly researching and vetting EBM tools when considering a source for adoption.

In a best-case scenario, the adopted solution goes through uncontested for quality and trustworthiness due to a lack of understanding, and provides a standard of care where there previously was none, albeit lesser in quality.

Worst-case scenario: The inadequately vetted solution becomes a liability to patient health, and is a source of significant system friction and cost due to errant research findings by the agency adopting it. With proper informed due diligence, which requires resources, both scenarios are entirely avoidable.

Stakeholders in the workers’ compensation system throughout the country are actively expanding the conversation on the necessary attributes in EBM treatment guidelines, and drug formularies, for state adoption. Increased scrutiny is placed on determining if guidelines and formularies are built atop a basis that aligns with public standards defined by the National Academies of Sciences, Engineering, Medicine (formerly the Institute of Medicine).

Interestingly, these standards, and the nonprofit entity that measures compliance (i.e., AHRQ’s National Guideline Clearinghouse), are de-emphasized and lessened in value by small market states that do not have properly experienced personnel evaluating the standards’ merits. This should prompt action by every person with an interest in workers’ compensation — employees, attorneys, employers, physicians, carriers, et al. 

Good public policy is never easy, and rarely inexpensive

Select state agencies have expressed concerns with limited options for adopting EBM content and tools due to absent resources such as a medical director, pharmacy and therapeutics committee, and staff with expertise in the area of scientific research. A state’s limitations supersede its needs under these restrictive circumstances. The more limited the resources, the fewer options for these agencies to consider.   

It is my sincere belief that small market agencies, much like their large market counterparts, work extremely hard to educate themselves on evidence-based medicine treatment guidelines and drug formularies — as well any other area they seek to reform — and aim to make the right decisions. In the end, they are left to act using the resources they have at their disposal, whether plentiful or scarce.

Perhaps a national standard for the evaluation and adoption — better yet a definition of EBM for workers’ compensation, as an example — would help afford better options for small markets managing with modest resources.

Carlos Luna is director of government affairs for ReedGroup, which publishes the American College of Occupational and Environmental Medicine treatment guidelines and drug formulary.

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