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

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

3. 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.

4. 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’: “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.

5. 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

6. 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

7. 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.”

8. 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

9. 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

10. State Medical Treatment Guidelines
New York
MTG – Medical Treatment Guidelines
Implemented December 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.

11. 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

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

13. WCMSA Reference Guide v2.7 (3/2018)
Section 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.

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

15. 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.”

16. 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

17. 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.”

18. 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.”

19. 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.

20. 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

21. 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

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

23. 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

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

25. 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

26. Questions?