Treatment Guidelines: Recommendations and Implications for Providers

1. Treatment Guidelines:Recommendations and Implications for ProvidersDr. Robert Snyder, Medical DirectorSuzy Douglas, Moderator

2. Treatment Guidelines:Recommendations and Implications for Providers Division of Workers’ Compensation Robert B. Snyder, M.D. Text 754730 and your Questions to 22333

3. Tennessee Workers’ Compensation Law • 2013 Edition • 50-6-124(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.” Text 754730 and your Questions to 22333

4. Tennessee Workers’ Compensation Law • 2013 Edition • 50-6-124(h), effective on July 1, 2014. • “Any treatment that explicitly follows thetreatment 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 754730 and your Questions to 22333

5. Tennessee Workers’ Compensation Law • “…Guidelines for the Diagnosis and Treatment… ” • Clinical Practice Guidelines Clinical Guidance Text 754730 and your Questions to 22333

6. Clinical Guidance • Different Forms: • Consensus Statements • Expert Advice • Appropriate Use Criteria (AUC) • Clinical Effectiveness Research (CER) • Evidence Based Medicine (EBM) • Practice Guidelines Text 754730 and your Questions to 22333

7. Clinical Guidance • Practice Guidelines • 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 754730 and your Questions to 22333

8. Clinical Guidance • Evidenced Based Medicine (EBM) • “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” • Expert Advice • “the opinions of our teachers…” • Consensus Statements • A group of peer “experts” discuss and arrive at a conclusion as to a particular question. Text 754730 and your Questions to 22333

9. Clinical Guidance • 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.” • 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.”

10. Trustworthy Guidelines • 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 754730 and your Questions to 22333

11. Trustworthy Guidelines • 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 754730 and your Questions to 22333

12. Trustworthy Guidelines • Institute of Medicine (3) 7. Reconsidered and revised as appropriate when important new evidence warrants modifications of recommendations. • 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 754730 and your Questions to 22333

13. Potential Focus “…the most commonly occurring…” 1) Most numbers of procedures 2) High cost-length of disability (indemnity and medical) 3) Payment under “open medical” Text 754730 and your Questions to 22333

14. Factors that will Influence the Decision • Implementation Barriers • Access • “User friendly” • Resources Available • Cost • Manpower • Time Text 754730 and your Questions to 22333

15. Factors that will influence the Decision Input from Stakeholders • Division and other state agencies • Providers • Carriers, Utilization Review Agencies • Employers • Injured workers and their representatives • Attorneys • Families • Ombudsman program Text 754730 and your Questions to 22333

16. The Decision The Medical Advisory Committee The Final decision rests with the Administrator Text 754730 and your Questions to 22333

17. First Guideline The Management of Chronic Pain Tennessee Department of Health Text 754730 and your Questions to 22333

18. Potential Sources • Physician Specialty Societies • Other States • Proprietary Companies • Other Interested Stakeholders • Internal Tennessee Development • Department of Health • Workers’ Compensation Committees Text 754730 and your Questions to 22333

19. Preliminary Review • Washington • Colorado • Other states • WLDI-ODG™ • ACOEM • Specialty Societies • Department of Health • Medical Care Cost Containment Committee Text 754730 and your Questions to 22333

20. Use of the Guidelines • If the Guidelines are used: • After January 1, 2016: “presumed to be medically necessary” and not subject to utilization review. “Carrot” versus “Stick” • Not like Medical Fee Schedule: “mandatory”. • Until January 1, 2016: all should get familiar with the recommended guidelines and start using them. Text 754730 and your Questions to 22333

21. References ODG: http://www.odg-twc.com/ ASIPP: http://www.asipp.org/Guidelines.htm ACOEM: http://www.acoem.org/Guidelines Washington State: http://www.lni.wa.gov/ TN DOH: http://health.tn.gov/Downloads/ChronicPainGuidelines.pdf Text 754730 and your Questions to 22333