What Would ACOEM Say About Parachutes?

Friday, April 4, 2008 | 1

By York McGavin

I can remember a time when the biggest problem faced by many a workers' compensation judge was weighing medical reports between dueling qualified medical evaluators and the judge was focused on which of the reports were more substantial, better reasoned, and more accurately based on germane facts. Ahhh, the good old days.

Today, it is all about the American College of Occupational Medicine (ACOEM) and Medical Treatment Utilization Schedule (MTUS), or evidence-based medicine in support of why a variance from ACOEM/MTUS is warranted. The primary treating physician submits a PR-2 requesting a course of treatment. Utilization review says "no" based on ACOEM/MTUS, and oftentimes the injured worker objects, thus requiring the primary treating physician and and a panel QME to address whether a variance from ACOEM/MTUS is warranted. Even after the PQME issues his substantial and reasoned report medically resolving the dispute, the claims adjuster all too regularly refuses to acknowledge medical resolution, authorize the previously-questioned treatment, and issue reimbursement.

Once in a while, an injured worker actually has the audacity to seek legal resolution of the medical dispute, now between the claims adjuster and the primary treating physician/PQME, by filing a declaration of readiness for an expedited hearing on the need for treatment.

Geez. Now the WCJ is faced with resolving the dispute between the claims adjuster who is relying upon the expert medical opinion of their utilization review physician that the treatment in question is unreasonable per ACOEM/MTUS, and the injured worker who is relying upon the medical opinion of the PTP/PQME opining the treatment at issue is a reasonably required variance from ACOEM/MTUS.

The dispute now results in a trial of these dueling experts, with one side relying upon their experts report citing ACOEM/MTUS, and the other side relying upon the their experts citing EBM supporting why a variance from ACOEM is warranted.

As should be expected, a wise defense attorney will reach for administrative rule 9792.22 for support the evidence based medicine relied upon by the PTP/PQME is insufficient to overcome the presumption ACOEM/MTUS is correct.

Now the workers' comp judge has to weigh ACOEM/MTUS v. evidence-based medicine using the "strength of evidence rating methodology" as set forth in ADR 9792.22. Is the evidence-based medicine a randomized control trial study? Is the evidence-based medicine consensus based? Was the physician providing the treatment in the evidence-based medicine study blinded? Was the person who measured the success or failure of the evidence-based medicine treatment blinded to the treatment allocation? Was the assessor blinded? Was the patient who received the evidence treatment blinded? Was there appropriate randomization? Were there multiple interventions in the evidence-based medicine study? Were there improper exclusions of patients in the evidence-based medicine study due to comorbidities, age, past history, or gender? Was the drop out rate under 20%? Was there significant biases, some biases, or few biases?

My-oh-my, the workers' comp judge now has a full plate. One need not look far to determine why a judge will oftentimes rely upon the credible testimony of the injured worker as to the treatment in question resulting in restoring range of motion and increasing function to carry the day. But, what if the injured worker has not received the treatment, and thus cannot testify as to the efficacy? Well, I guess the workers' comp judge had better hone his analytical skills quick and in a hurry.

It is against this background that I share with you the attached evidence-based medicine study addressing the "strength of evidence rating methodology" for determining the efficacy of parachutes in preventing death.

A warning to the faint of heart: This study contains graphic language addressing psychiatric conditions. To view the study, go here:
http://www.bmj.com/cgi/content/full/327/7429/1459