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Treatment Guidelines: Recommendations and Implications for Providers Dr. Robert Snyder, Medical Director Suzy Douglas, Moderator.

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Presentation on theme: "Treatment Guidelines: Recommendations and Implications for Providers Dr. Robert Snyder, Medical Director Suzy Douglas, Moderator."— Presentation transcript:

1 Treatment Guidelines: Recommendations and Implications for Providers Dr. Robert Snyder, Medical Director Suzy Douglas, Moderator

2 Treatment Guidelines: Recommendations and Implications for Providers Division of Workers’ Compensation Robert B. Snyder, M.D. Text and your Questions to 22333

3 Tennessee Workers’ Compensation Law 2013 Edition 2013 Edition (g), (effective on July 1, 2014) (g), (effective on July 1, 2014) “the administrator shall, by rules to become effective on January 1, 2016, adopt guidelines for the diagnosis and treatment of commonly occurring workers’ compensation injuries.” “the administrator shall, by rules to become effective on January 1, 2016, adopt guidelines for the diagnosis and treatment of commonly occurring workers’ compensation injuries.” Text and your Questions to 22333

4 Tennessee Workers’ Compensation Law 2013 Edition 2013 Edition (h), effective on July 1, (h), effective on July 1, “Any treatment that explicitly follows the treatment guidelines… or is reasonably derived therefrom, “Any treatment that explicitly follows the treatment guidelines… or is reasonably derived therefrom, …shall have a presumption of medical necessity for utilization review purposes.”{if it follows a ‘published’ guideline, then…} Text and your Questions to 22333

5 Tennessee Workers’ Compensation Law “…Guidelines for the Diagnosis and “…Guidelines for the Diagnosis and Treatment… ” Treatment… ” Clinical Practice Guidelines Clinical Practice Guidelines Clinical Guidance Clinical Guidance Text and your Questions to 22333

6 Clinical Guidance Different Forms: Different Forms: Consensus Statements Consensus Statements Expert Advice Expert Advice Appropriate Use Criteria (AUC) Appropriate Use Criteria (AUC) Clinical Effectiveness Research (CER) Clinical Effectiveness Research (CER) Evidence Based Medicine (EBM) Evidence Based Medicine (EBM) Practice Guidelines Practice Guidelines Text and your Questions to 22333

7 Clinical Guidance Practice Guidelines Practice Guidelines Institute of Medicine(2011) Institute of Medicine(2011) “…statements that include recommendations intended to optimize patient care that are informed by a systematic review of the evidence and an assessment of the benefit and harms of alternative care options.” Text and your Questions to 22333

8 Clinical Guidance Evidenced Based Medicine (EBM) Evidenced Based Medicine (EBM) “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Expert Advice Expert Advice “the opinions of our teachers…” “the opinions of our teachers…” Consensus Statements Consensus Statements A group of peer “experts” discuss and arrive at a conclusion as to a particular question. A group of peer “experts” discuss and arrive at a conclusion as to a particular question. Text and your Questions to 22333

9 Clinical Guidance Appropriate Use Criteria (AUC) Appropriate Use Criteria (AUC) “… to use a procedure…when the expected benefits exceed the expected risks by a wide margin…facilitate these decisions by combining the best available scientific evidence with the collective judgment of physicians.” “… to use a procedure…when the expected benefits exceed the expected risks by a wide margin…facilitate these decisions by combining the best available scientific evidence with the collective judgment of physicians.” Clinical Effectiveness Research (CER) Clinical Effectiveness Research (CER) “the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care.” “the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care.”

10 Trustworthy Guidelines Institute of Medicine (1) Institute of Medicine (1) 1. Based upon systematic review of the existing evidence. 2. Developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups. 3. Considerate of important patient subgroups and preferences. Text and your Questions to 22333

11 Trustworthy Guidelines Institute of Medicine (2) Institute of Medicine (2) 4. Based on an explicit and transparent process that minimizes distortions, biases, and conflicts of interest. 5. Clear in their explanation of the logical relationships between alternative care options and the health outcomes 6. Provide ratings of both the quality of the evidence and the strength of recommendations. Text and your Questions to 22333

12 Trustworthy Guidelines Institute of Medicine (3) Institute of Medicine (3) 7. Reconsidered and revised as appropriate when important new evidence warrants modifications of recommendations. Extra caveats: Extra caveats: a. Be easily accessible and user friendly (clear) for those who need to use them. b. Have a reasonable acquisition and use cost. Text and your Questions to 22333

13 Potential Focus “…the most commonly occurring…” “…the most commonly occurring…” 1) Most numbers of procedures 1) Most numbers of procedures 2) High cost-length of disability 2) High cost-length of disability (indemnity and medical) (indemnity and medical) 3) Payment under “open medical” Text and your Questions to 22333

14 Factors that will Influence the Decision Implementation Barriers Implementation Barriers Access Access “User friendly” “User friendly” Resources Available Resources Available Cost Cost Manpower Manpower Time Time Text and your Questions to 22333

15 Factors that will influence the Decision Input from Stakeholders Division and other state agencies Division and other state agencies Providers Providers Carriers, Utilization Review Agencies Carriers, Utilization Review Agencies Employers Employers Injured workers and their representatives Injured workers and their representatives Attorneys Attorneys Families Families Ombudsman program Ombudsman program Text and your Questions to 22333

16 The Decision The Medical Advisory Committee The Final decision rests with the Administrator Text and your Questions to 22333

17 First Guideline The Management of Chronic Pain Tennessee Department of Health Text and your Questions to 22333

18 Potential Sources Physician Specialty Societies Physician Specialty Societies Other States Other States Proprietary Companies Proprietary Companies Other Interested Stakeholders Other Interested Stakeholders Internal Tennessee Development Internal Tennessee Development Department of Health Department of Health Workers’ Compensation Committees Workers’ Compensation Committees Text and your Questions to 22333

19 Preliminary Review Washington Washington Colorado Colorado Other states Other states WLDI-ODG™ WLDI-ODG™ ACOEM ACOEM Specialty Societies Specialty Societies Department of Health Department of Health Medical Care Cost Containment Committee Medical Care Cost Containment Committee Text and your Questions to 22333

20 Use of the Guidelines If the Guidelines are used: If the Guidelines are used: After January 1, 2016: “presumed to be medically necessary” and not subject to utilization review. After January 1, 2016: “presumed to be medically necessary” and not subject to utilization review. “Carrot” versus “Stick” “Carrot” versus “Stick” Not like Medical Fee Schedule: “mandatory”. Not like Medical Fee Schedule: “mandatory”. Until January 1, 2016: all should get familiar with the recommended guidelines and start using them. Until January 1, 2016: all should get familiar with the recommended guidelines and start using them. Text and your Questions to 22333

21 References ODG: ASIPP: ASIPP: ACOEM: ACOEM: Washington State: Washington State: TN DOH: Guidelines.pdf TN DOH: Guidelines.pdf Guidelines.pdf Guidelines.pdf Text and your Questions to 22333


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