Clinical Care Update: UM Tool - A Means To Improve Quality

Saturday, September 9, 2006 | 0

By Dr. Bruce Sherman

Introduction

Sharply escalating medical costs prompted close scrutiny of health care utilization patterns, with a particular focus on quality and efficiency of care delivery. Perhaps no where is this more evident than in workers# compensation systems, where increasing costs are threatening state program viability.

In California, the search for a durable solution to this near-crisis led to the identification and legislation into use of the Occupational Medicine Practice Guidelines issued by the American College of Occupational and Environmental Medicine (ACOEM). These evidence-based treatment guidelines provide a basis for evaluation and management of health care conditions frequently seen by occupational medicine clinicians.

However, as a part of California's formal evaluation process, it was recognized that in addition to the clinical guidelines, development of an accompanying utilization management tool could provide a more defined approach to care management. As a result, ACOEM created the Utilization Management Knowledgebase (UMK), a tool to evaluate, track, and report the medical necessity and/or appropriateness of health care services. Recently released, the UMK is a software product that contains detailed care management information that is consistent with the Practice Guidelines and presented in a format that facilitates effective and efficient utilization management practices.

In keeping with the philosophy of the ACOEM Practice Guidelines, the UMK focuses not on medical "cure" as the goal. Instead, the focus is on medical treatment leading to functional improvement. This is an important distinction to make. Recommendations for initial and ongoing treatment modalities are based on measurable therapeutic response, as judged by improved functional capacity, reduced medication need, and subjective improvement.

Further, while pain management is an important component of the Practice Guidelines, return to physical activity may not necessarily include complete resolution of pain. Here, the treatment emphasis is directed toward functional recovery while minimizing risk of injury recurrence.

Structure

For each diagnosis topic included in the ACOEM Practice Guidelines, there is a corresponding topic in the UMK which includes two parallel components. The first of these is the treatment pathway, which includes a clinical vignette representative of the particular condition, followed by a series of up to four treatment pathways. These pathways -- conservative, intermediate, aggressive, and chronic -- are based on time from initial treatment and level of invasiveness of care.

The number of pathways for a particular diagnosis is based on the appropriate treatment options. While this structure appears at first glance different from the Practice Guidelines, it in fact reflects the time frames that are clearly ingrained in virtually all the Practice Guidelines algorithms. Red flags, yellow flags, diagnosis options, patient education, treatment options, work restrictions, and follow-up are included in each of the UMK treatment pathways.

The sections featuring diagnosis and treatment options contain details regarding the indications and appropriateness of diagnostic testing, physical therapy modalities, equipment, referrals, and surgery. The UMK treatment pathways present information in a condensed, easy-to-read manner. As such, the UMK does not provide the same degree of in-depth analysis and commentary found in the Practice Guidelines.

The second component of the UMK is the utilization management content, which makes this product unique. This information is listed as a series of utilization case management statements (UCMS), which parallel the treatment pathway content. Each statement includes the source reference and page number for either the Practice Guidelines or APG Insights, a quarterly publication developed by ACOEM to provide clarification and refinement of the Practice Guidelines content.

In contrast to the treatment pathway content, the UCMS include specific information regarding which tests and therapeutic options are indicated in accordance with the management timeframe and response to prior treatment. For example, as stated in the Practice Guidelines, an MRI to evaluate low back pain should be considered only after four to six weeks of treatment in a case without red flags because many individuals respond within that timeframe to conservative care. In this instance, the UMK UCMS says an MRI is "not indicated" during initial evaluation; it suggests MRI for persistent symptoms and functional limitation after four weeks. Importantly, details regarding physical therapy modalities are included in the UCMS with specific recommendations for both the type and number of recommended treatments.

Because some organizations may prefer to include different or additional utilization management details, the UMK also includes the opportunity to customize each UCMS. This flexibility permits identification, for example, of the need for preauthorization for particular interventions.

Updates

While most of the UCMS information can be found in the Practice Guidelines, additional details originate from APG Insights. Recent representative content has included detailed reviews of the use of acupuncture, therapeutic ultrasound, and chiropractic manipulation. Individuals seeking clarification regarding a particular Practice Guidelines question may have the opportunity to have their questions addressed in APG Insights.

The planned Practice Guidelines update process will occur on a scheduled basis, with all diagnoses reviewed during a three-year cycle, in accordance with the body part chapter format. The updates will incorporate a more comprehensive review of available studies and an expanding list of diagnoses and body parts or systems.

The goal is to expand the current Practice Guidelines evidence-based content to cover an increasingly broader range of work-related injuries and illnesses in more detail. Each year, a monograph including this updated information will be published. Subsequent editions of the Practice Guidelines will be published to coincide with the three-year review cycle. On an ongoing basis, the UMK will be revised to reflect updates in the Practice Guidelines and clarifications from APG Insights to ensure ongoing consistency between these resources.

Uses and Benefits

From a practical perspective, the UMK can be used to ensure timely and efficient care delivery for medical conditions often seen by occupational medicine providers. Health care professionals, insurers, administrators, and employers are all likely to benefit from use of the UMK because it presents relevant information regarding clinical care, utilization management, disability management, and return to work in an organized and concise manner. With the references for each UCMS, the user can refer to the Practice Guidelines text for additional information.

Searches can be conducted by diagnosis topic or ICD-9-CM code, or by specific body part. Results can be presented in sections (such as the overview, pathways, and utilization case management standards) or viewed as a single document. Once a diagnosis topic is selected, the user can also choose to view the available treatment pathways for that particular topic. If desired, chosen pathways can be saved in the "My Topics" area or as a PDF file.

Because the pathways reflect a care approach that evolves based on the duration of care and response to treatment, users can easily select and view the management appropriate for each patient. Indications for surgical intervention are clearly presented and help to decrease the risk of unnecessary procedures.

Precautions

While the pathways and UCMS provide medical management guidelines for a broad range of common conditions, the content by no means includes all work-related injuries. Further, the impact of co-morbid conditions on response to treatment is not specifically addressed. Finally, the level of detail and critical analysis found in the Practice Guidelines is not found in the UMK, which was developed to provide a summary of the Practice Guidelines Should users require additional details regarding particular diagnoses, they are encouraged to use the included citations to refer back to the relevant Practice Guidelines text.

Impact on Occupational Medicine Practice

According to a recent Institute of Medicine report, as much as 45% of medical care provided in the U.S. is either excessive or inappropriate. Thus, there is a compelling basis for implementing tools to ensure quality care delivery. Initial experience with use of the Practice Guidelines in the management of workers' compensation in California has been favorable. Implementation of the guidelines has resulted in a 35% reduction in medical costs, most likely resulting from reduced utilization of services.

A closer examination of the California data indicates that medical treatment of low back pain in excess of that indicated by the Practice Guidelines resulted in greater costs and delays in return to work -- despite the growing body of medical research that correlates early return-to-work with increased healing. This finding illustrates the fact that there is significant opportunity to improve the efficiency of care delivery by reducing the use of unnecessary treatment. With the use of the UMK and Practice Guidelines, there is clearly an opportunity to improve the quality of medical care.

In addition, users of the UMK can provide justification for their medical management decision making according to recognized and accepted guidelines, which should facilitate care delivery. And by reducing unnecessary services, more timely care can be provided.

As previously indicated, the potential cost savings is significant. Based on the California experience, the cost of introducing the UMK is likely easily recovered within months of initiating use. At least a portion of the additional cost savings could be redirected to injury prevention programs, further decreasing the cost of work-related injury.

Finally, disability durations have been a major focus of disability management, with return to work serving as a primary end point of care. In a sense, comparison of disability durations with benchmark data has served as an indirect measure of quality of care. Now, with the UMK, compliance with Practice Guidelines is a more direct measure of quality, and can be used to more objectively evaluate provider performance.

A Look Ahead

There is increasing acceptance that the total cost of injury or illness includes the cost of medical care, indemnity payments, and replacement worker costs.

Employers are taking a more active role in prompting health care providers to help control those injured worker costs. Meanwhile, many providers are using disability duration guidelines such as the Medical Disability Advisor to manage and benchmark disability durations.

Providers who are able to demonstrate compliance with treatment guidelines will generate an added benefit: They will likely have lower treatment costs per injury, and with the focus on functional recovery, injured workers are likely to return to work in a timelier manner.

Physicians and other medical professionals who align themselves with employer goals of improved quality and efficiency of care will have a competitive advantage relative to their colleagues, particularly if they can provide meaningful data. Employers may well choose to selectively incorporate these clinicians on panels of preferred providers, where state regulations permit.

With recent technological advances, it may become considerably easier for state workers# compensation boards to incorporate compliance with clinical guidelines as a measure of quality of care. Resulting information may be used to make decisions regarding provider eligibility for treating workers' compensation cases.

Alternatively, as pay-for-performance programs are being incorporated for personal health care delivery, it is certainly conceivable that a similar strategy could be incorporated into workers' compensation. Providers who comply with specific metrics from the UMK -- for example, surgery for appropriate indications -- may be better paid than those who fail to do so.

Strictly speaking, the UMK is a product that providers may not perceive as a need, since they've been doing their jobs without it. However, with increasing cost-containment pressures, clinicians are wise to consider more carefully evaluating their compliance with evidence-based medicine.

By clearly demonstrating value, UMK users have the opportunity to provide justification for their services -- and also show why they are potentially the vendor/service provider of choice. Employers who can identify guideline-compliant physicians will be more likely to utilize their services. Use of the UMK can certainly help.

This column was originally published Aug. 8 in Occupational Medicine Clinical Care Update by the National Association of Occupational Health Professionals.

Bruce W. Sherman, M.D., F.C.C.P., has a national consulting practice and is director of Health and Productivity Initiatives for the Employers Health Coalition of Ohio. He is a member of the American College of Occupational and Environmental Medicine Health and Productivity and Corporate Medical Directors Sections and an Assistant Clinical Professor in the Division of Pulmonary and Critical Care Medicine, Case Western Reserve University School of Medicine. Dr. Sherman is board-certified in internal medicine, pulmonary medicine, and critical care medicine. To correspond, send email to bws@case.edu.

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The views and opinions expressed by the author are not necessarily those of workcompcentral.com, its editors or management.