Navigating the Rocks of Dim

Saturday, August 27, 2005 | 0

The following article, by Peter Rousmaniere, appears in the August 2005 issue of Risk & Insurance. It is republished here with the permission of publishers:

California passed a law in 2003 which endorsed treatment guidelines to govern healthcare for injured workers. This provision was further advanced in the large scale reform package SB 899, passed in 2004. The nationwide consequences of this reform could be huge. We should watch how the initial, fragile set of guidelines are strengthened in the next year. We must invest more broadly in improving the quality of medical care, to legitimize these guidelines.

The federal Institute of Medicine defines a guideline as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." This is the definition RAND used in a late 2004 review of five sets of candidate guidelines. The study team found all sets wanting but suggested to California regulators that they continue to recognize as presumptively correct one set that was written into the 2003 law. This set was prepared by the American College of Occupational and Environmental Medicine, or ACOEM.

The medical guideline business is a little like a ten year maritime passage through a channel crowded with The Rocks of Dim (dissension, inertia, myopia). Guidelines need to be thoroughly renewed at least every five years. The efforts by several states to serve up their own guidelines failed to last more than a few years.

Why do I call ACOEM's guidelines fragile? Workers comp guidelines should have crisp, well defended rules on quantity of PT and chiropractic care. RAND reports that the ACOEM guidelines are weak in this area. (So are the other sets.) They are also light on when to use expensive diagnostic procedures such as MRIs, and pain medications on an on-going basis. So a lot of people are upset, even as ACOEM makes improvements.

To understand how these guidelines got to where the are now, and where they may go, I had to study what is behind them. It is very difficult to carry out gold standard-type studies of clinical effectiveness. You must track month, years of experience of many injured workers who have divided into a treatment group and a control, untreated group. There are precious few such studies. And you should not blindly accept the study results from the group health community, because the benefits and rules in workers comp make a very different set of incentives and barriers.

And guidelines are very hard to implement, as an example from outside our field illustrates. The Veterans' Administration has tried for years to get its psychiatrists to prescribe for mental disorders new drugs that are universally-regarded improvement over an earlier generations. The VA has one of the most advanced medical monitoring systems in the world. After a decade, one fifth of VA doctors continued to use the older drugs.

ACOEM itself conveys a tweedy image that jars with its new prime time role. Try to find the guidelines on its website: it will take some doing.

But - considering the stakes involved, ACOEM is clearly the best pony in the stable. That guideline definition says "...practitioner and patient decisions...". I trust ACOEM to promote the collaborative nature of clinical decisions. I also trust ACOEM to grasp the need to root out undercare as much as overcare, and to address work injury recovery as a continuum of care not just isolated events.

Claims payers and regulators can help these guidelines succeed, by regulation, bully pulpit and practice. Pay more attention to quality in your informal or formal network of providers. Forget the mantra that you can never go wrong by discounting a medical invoice. Bring these guidelines into your neighborhood.

PETER ROUSMANIERE is a regular columnist for Risk & Insurance and is also a frequent reader of WorkCompCentral. He can be reached at riskletters@lrp.com.

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