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N.Y. Treatment Guidelines: Investment Required for Return

  • State: New York
A report from the New York Workers' Compensation Alliance indicates that the application of medical treatment guidelines in the state has created an additional $60 million in costs for the workers' compensation system.  Let's place aside the fact that the source may be biased (the alliance "is a coalition of injured workers and other stakeholders committed to protecting the rights of injured workers") and assume the $60 million is a directionally correct number.

The report points out that the cost increase is due, in large part, to the application of the guidelines retrospectively.  As such, the Alliance argues, the state is now denying care it previously authorized and this is illogical and unfair.  I suppose it's somehow logical and fair to subject the care of newly injured workers to evidence-based medical treatment guidelines, but not apply those same standards of care to workers injured one year ago... or ten years ago.  I would argue that's patently unfair to workers injured prior to the adoption of the guidelines.  With new evidence comes new knowledge about treatments that work... and treatments that don't.  Why wouldn't we apply the best medical evidence we have to all claims involving ongoing medical treatment?  To do otherwise would create two different standards of care in New York.  (Personally, I would have liked to have seen a phased in approach - like Texas is using for the new closed formulary rules but New York chose not to do it that way.)

My view of the $60 million is that of an investment.  And I believe there will be return.

New York is experiencing the pain of establishing a new set of expectations for medical care delivery to work comp claimants.  This pain is political, cultural, and financial in nature.  But if the state will stick to its guns (and if the courts uphold the state's position), the return will come as providers adjust to the new treatment guidelines.  System costs will diminish as the clinical rationale necessary to secure a variance becomes clear to the provider community.

But perhaps the greatest return will come in form of improved health and function for injured workers.  This statement will be anathema to the Work Comp Alliance.  In fact, the report states "unlike medical treatment, which benefits the injured worker, the Medical Treatment Guidelines benefit no one in the workers’ compensation system."  This is unbelievably short-sighted and completely contrary to what we've learned about medicine over the past half century.  Not all medical treatment is good for the injured worker.

The right care at the right time delivered to the right patient by the right provider - that's the goal of evidence-based medicine.  That should be the goal of any work comp system.  And that's the recipe for providing value in the delivery of medical care to work comp claimants.

Michael Gavin is chief marketing officer for Prium, a utilization management company based in Duluth, Ga. This column was reprinted with his permission from the firm's Evidence Based blog.

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