Evidence-Based Medicine treatment guidelines and the msa WCI – August 22, 2018 P.O. Box 915619 • Longwood, FL 32791-5619 • P 866.858.7161 • F 407.389.0299 • mynuquest.com

Evidence-Based Medicine Treatment Guidelines Part One Evidence-Based Medicine Treatment Guidelines

Evidence-Based Medicine Originally defined (1996): The conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individuals. Revised (2000): Systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values.

Origins Phrase coined in 1990s and credited to Gordan Guyatt – JAMA article David Sackett former professor of medicine at McMaster University regarded as the Father of EBM” Concept runs much deeper Meant to deal with the ‘deficiencies’ in ‘expert based’ medicine Learning from problems of patients. Epidemiology and statistics to be taught together with clinical disciplines. Share the results through ‘critical appraisal’: 1985 “Bible of EBM” Clinical Epidemiology: A Basic Science for Clinical Medicine EBM differs from critical appraisal because it combines research evidence with clinical skills and patient values and preferences.

Steps for Utilizing EBM 1. Ask Defining the problem Converting information needs into answerable questions: How to treat a disease or condition? Whether to use a diagnostic testing or screening procedure 2. Acquire Search for relevant evidence that will provide answers Finding quality/on point evidence may be difficult/take time

Steps for Utilizing EBM Appraise Critically evaluate the information gained Source type, statistical validity, clinical relevance, currency and peer-review acceptance 4. Apply Can be difficult – change constantly happening but implementation can be slow Assess How did application confirm/differ from research? Assist to update EBM based on results

Official Disability Guidelines (ODG) Over 20 years of publication Based on an aggregate of over 10 million cases “Most comprehensive and up-to-date medical treatment and return-to-work guideline worldwide, providing evidence-based decision support to improve as well as benchmark outcomes in workers’ comp, non-occupational disability and general health insurance.”

American College of Occupational and Environmental Medicine (ACOEM) Founded in 1916 – Nation’s largest medical society “dedicated to promoting health of workers through preventative medicine, clinical care, research and education.” Specialists from a variety of practices united to develop positions on vital issues relevant to the practice of preventative medicine within/without workplace. Often provide information to Federal (Congress/agencies) and States Looking to have policies based on sound science

State Medical Treatment Guidelines California MTUS – Medical Treatment Utilization Schedule Adopted in 2007 Updated effective December 2017 – To be in line with ACOEM evidence-based guidelines 16 sections revised – Spine, shoulder, elbow, wrist and knees. Disorders involving stress and lung diseases. AND chronic pain and opioids. MEEAC – Medical Evidence Evaluation Advisory Committee

State Medical Treatment Guidelines New York MTG – Medical Treatment Guidelines Implemented December 2010. Updated March 2013. Included four “comprehensive, evidence based guidelines for treatment of injuries and illnesses involving neck, back, shoulder knee.” Update included Carpal Tunnel and revisions of original Non-acute pain guidelines and additional updates 2014 Regs require carriers to incorporate MTG into their policies and pay providers in accordance with guidelines.

State Medical Treatment Guidelines Florida Mandates use of evidence based medicine State’s proprietary guidelines were withdrawn in 2003 Now providers are left to find their own way Many rely on ODG or AHRQ

CMS Interpretation of Evidence-Based Medicine Treatment Guidelines Part Two CMS Interpretation of Evidence-Based Medicine Treatment Guidelines

WCMSA Reference Guide v2.7 (3/2018) Section 9.4.3 WCRC Review Considerations: “The WCRC team reviews all of the submitted records and attempts to determine the future care required for the individual claimant, taking into consideration the claimant’s specific condition, other comorbidities, and the claimant’s past use of healthcare services. Reviewers use evidence-based rationale for their determinations, taking into account both published guidelines and current peer-reviewed medical literature.” “There is currently no plan to establish a set of standards for specific conditions.” “The WCRC relies on evidence-based guidelines for prescription medication and medical treatment allocations; however, these are guidelines, not rules.

Resources Referenced Appendix 4. WCRC Proposal Review Reference Tools Includes: CMS memos, FDA, DailyMed, Red Book, MicroMedex PubMed https://www.ncbi.nlm.nih.gov/pubmed Compromises more than 28 mil. citations for biomedical literature MEDLINE Life science journals Online books

Medical Review Section 9.4.4 Medical Review Lays out the 10 steps in its medical review process Step 9: review records and submitter’s proposed plan. Price the appropriate future medical and pharmacy services. “The WCRC references evidence-based guidelines as resources in determining future treatment. Examples include Milliman and the Official Disability Guidelines.” “For medical expenses, the treating physician opinion carrier the greatest weight unless there is a court order to the contrary.”

Medical Review Guidelines Diagnostics Intrathecal Pumps Intrathecal Pump Surgery/Procedure Pricing Spinal Cord Stimulators Pricing for Spinal Cord Stimulator (SCS)Surgery Labs Transcutaneous Electrical Nerve Stimulation (TENS) State Specific Statutes CMS Medical Record Guidelines Treatment Recommended Outside a Provider’s Area of Expertise

State-Specific Statutes “CMS will recognize or honor any state-legislated, non compensable medical services and will separately evaluate any special situations regarding WC cases. CMS will recognize WC state-specific statutes addressing the limits of future treatment regarding the length and nature of the future treatment, provided that the submitter has demonstrated that Medicare’s interests have been adequately protected. A submitter requesting that CMS review the applicability of a state WC statute must include a copy of the statute with the submission, and indicate to which section topic in the submission the statute applies.”

State-Specific Statutes (cont.) “Submitters requesting alteration to pricing based upon state-legislated time limits must be able to show by finding from a court of competent jurisdiction, or appropriate state entity as assigned by law, that the specific WCMSA proposal does not meet the state’s list of exemptions to the legislative mandate.”

State-Specific Statutes (cont.) For those states where treatment is varied by some type of state-authorized utilization review board, the submitter shall include the alternative treatment plan showing what treatment has replaced the treatment in question from the beneficiary’s treating physician for those items deemed unnecessary by the utilization review board. Failure to include these items initially will result in pricing at the full life expectancy of the beneficiary or the original value treatment without regard to the state utilization review board recommendation. Failure to include the required documentation at the time of original submission will not constitute a reason for the request of re-review.

Treatment Recommended Outside a Provider’s Area of Expertise If a treating provider and no recommendation to contrary, will consider Reasoning: Licensed physicians are not limited to given specialty Chiropractors Considered if related to chiropractic care only and not general medical treatment

Sample Projections – CMS v EBM Doctor Visits Physical Medicine Methodology Service X per year Over total of years CMS Methodology Physical Therapy 12 3 EBM 6 Physical Therapy Postoperative 24 1 18 MRI X-rays 5 Methodology Service X per year Over total of years CMS Methodology Orthopedic Specialist 1 15 EBM 5

Part Three Best Practices for Mitigating Treatment Projections Using Evidence-Based Medicine Treatment Guidelines

WCMSA Best Practices Pursue state law limitations on treatment Establish revised treatment pattern Consider Non-Medicare Covered Treatment Alternatives Use court orders (hearing on the merits) when available Avoid CMS submission/review

Greater Flexibility With Non-Submission Do nothing Non-submission of traditional MSA following CMS standards Compromise allocation Evidence based medicine/standards of care allocation

EBM/Standard of Care Allocation Standards of Care/Evidence Based Medicine vs. CMS Methodology, 35-50% savings MSA is based on the probable versus the possible Medically and legally defensible Increases the ability to settle the medical portion of the claim

Questions?