Treatment Guidelines, Prospective Review, and Patient Safety

Friday, November 2, 2012 | 0

New Mexico is currently working through the process of adopting medical treatment guidelines. Thankfully, they appear to be leaning toward nationally recognized, evidence-based guidelines like the Official Disability Guidelines (ODG) and the American College of Occupational and Environmental Medicine (ACOEM) guidelines rather than the Medtronic-influenced, politically-driven brew of guidelines that states inevitably end up with when they try to develop their own guidelines.

Also encouraging is the presumption of correctness that the New Mexico rule contemplates. Holding treating physicians accountable to the guidelines (even if that means ensuring clear, documented rationale for treating outside of said guidelines) is the only way to improve patient care and reduce state-to-state, practice-to-practice and physician-to-physician variability in care.

Less encouraging is the proposed elimination of the requirement for providers to obtain prior authorization for medical services that are recommended by the guidelines. While that sounds logical and efficient, there may be unintended consequences.

Prior authorization (or pre-authorization or pre-certification) comes in several shapes and sizes. In many states, it's optional and something the provider will utilize only in circumstances where high cost care is being rendered and the provider wishes to ensure future payment (i.e., for a surgery). In some states, pre-authorization is mandated as something the provider must do prior to delivering care. There are pros and cons to both approaches. Optional pre-authorization is administratively simpler and less onerous on providers. Mandated pre-authorization is the opposite Normal 0 MicrosoftInternetExplorer4 − more demanding administratively and on doctors.

But the clearest and most compelling argument for mandated pre-authorization is patient safety. New Mexico may allow for retrospective review if a physician performs a surgery or procedure outside of ODG or ACOEM guidelines. But by then, the care has been rendered, potentially to the detriment of the patient.

Texas serves as a bright spot in this regard. Texas has adopted nationally recognized medical treatment guidelines and still maintains mandated pre-authorization, which now includes pre-authorization for certain pharmaceutical treatment as well. Does anyone doubt that measures such as these have made Texas one of the most cost-effective work comp systems in the nation?

High marks for New Mexico regarding treatment guidelines. Low marks for trying to remove mandated prior authorization. This strikes me as a quid pro quo with the physician community ("we're going to adopt these guidelines ... but you don't have to ask permission anymore ..."), but I don't think this bargain is in the best interest of patient safety.

Michael Gavin is chief strategy officer for Prium, a workers' compensation medical management firm. This column was reprinted with his permission from Prium's Evidence Based blog.