Official Disability Guidelines ODG Treatment Texas SelfInsurers Conf

Official Disability Guidelines ODG Treatment Texas Self-Insurers Conf. Note: Where this handout uses screenshots, the actual presentation will be a live demo TSIA Austin 8, 2009 June Pat Whelan, Publisher Denniston, President Work Loss Data Institute www. worklossdata. com phil@worklossdata. com Phil

Work Loss Data Institute (WLDI) Full Disclosure l l l Publishes Official Disability Guidelines (14 th ed 2009) & ODG Treatment in Workers’ Comp (7 th ed 2009) Hired as research contractor for the ACOEM Practice Guidelines (2 nd ed 2004) Research & exclusive rights to publish the yet-to-bereleased CCGPP Treatment Guidelines (1 st ed 2009) Under contract to provide guidelines data for Mc. Kesson Inter. Qual Guidelines & Intracorp Guidelines Publishes State Report Cards for Workers’ Comp

Background on WLDI l l 3 Independent Database Development Company Focused on Workplace Health & Productivity Mission: To create, maintain and market information databases to implement standards for managing workforce health and productivity based on strict principles of evidence-based methodology, with ongoing focus on healthcare cost containment Founded in 1995, publishes the ODG product line Offices in California & Texas

Agenda 4 PAT: l Define EBM and Types of Guidelines l Why Use EBM Treatment Guidelines l What to look for in EBM Guidelines l Issues That May Arise & How to Address l Online ODG RTW demo PHIL: l What States Have Adopted EBM Guidelines l Outcomes From Those States l Preliminary Outcomes from Texas l Online ODG Treatment demo

Guidelines in Workers’ Comp Three kinds of workers’ comp related guidelines: 1) 2) 3) Medical treatment guidelines (ODG Treatment, ACOEM Practice Guidelines, CCGPP, Mc. Kesson, Intracorp, state guidelines) Return-to-work guidelines (ODG, MDA, Milliman USA) Impairment guidelines (AMA Guides, IAIABC Guides) Our focus will be on (1) and (2).

Methodology of Guideline Development l Guidelines can be developed using two different, but overlapping methods: – – Consensus-based Evidence-based

Two methods of guideline creation Consensus-based: Evidence-based l Developed with the input of l Developed by employing a experts in a given field making strict process of literature recommendations based upon review including ranking the a literature review and their published papers by strength personal experience of study design with recommendations linked to the comparative scientific rigor of the studies used

What is Evidence-Based Medicine? l Evidence-based medicine (EBM) is the conscientious, explicit & judicious use of current best evidence in making decisions about the care of individual patients – David L Sackett, William MC Rosenberg, JA Muir Gray, R Brian Haynes, W Scott Richardson, Evidence-Based Medicine: What it is and what it isn't. This article is based on an editorial from the British Medical Journal on 13 th January 1996 (BMJ 1996; 312: 71 -2)

What is Evidence-Based Medicine? l l EBM is healthcare based on clinical studies of what works best and what does not EBM is NOT healthcare based on opinion, personal observation or tradition Treatment guidelines put EBM into action (in the hands of treating doctors and payors) Highest quality care at lowest possible cost

Why EBM Treatment Guidelines? l “The only way to achieve real and lasting costsavings in workers’ comp is through the delivery of quality and timely care” -Charles W. Kennedy, MD, Senior Medical Editor, ODG Treatment in Workers’ Comp l This is best achieved by adopting evidence based treatment guidelines

Why EBM Treatment Guidelines? l l EBM Guidelines benefit all stakeholders: Employee, Employer and Providers practicing in-line with EBM Guidelines are insured of timely payment – l l In ODG, this is NOT “cookbook medicine” (options are many) Injured workers' receive early access to quality care, therefore health & wellness are restored Employee returns to work, and so the drain on the business community is contained

What to look for in EBM Guidelines In Workers’ Comp, a two-horse race: ODG and ACOEM l So, ODG or ACOEM? l Review/compare for yourself l Consider key issues l

What to look for in EBM Guidelines l l 13 Rand Study: Evaluating Medical Treatment Guideline Sets for Injured Workers in CA (11/04) Technical Quality Evaluation—AGREE *Mc. Kesson/Interqual WC Guidelines have been discontinued by Mc. Kesson

What to look for in EBM Guidelines l l l l 14 Evidence-Based with Explicit Links Ongoing Updates, Annual Editions Independent, Multi-Disciplinary Comprehensive Clear and Unambiguous Designed for UR as well as Clinical Practice Integrated Treatment and Duration Guidelines Proven Results

Provider Issues: “Cookbook Medicine? ” l l l 15 EBM Guidelines are not “cookbook” medicine – The guidelines identify many different approaches to therapy, noting which ones work and which do not – No single approach is right for every patient – Providers can make decisions using own judgment enhanced by access to the latest scientific studies Solution: Education, Outreach and Training AADEP offers ODG provider training courses for CME credit throughout states adopting ODG)

Provider Guideline Issues (cont’d) l Rules adopting treatment guidelines make it easier for providers to do what they do best – – Treatment guidelines can minimize uncertainty Providers who follow the guidelines can be assured they will get paid, and minimize “managed care” headaches and paperwork They will have more time to focus on patient care Results in faster treatment, avoiding delayed recovery, litigation, other friction, etc.

Provider Issues: Specialty Bias l l l 17 Each medical specialty has their own guidelines Each specialty represents the interest of their members (i. e. hand surgeons recommend hand surgery) Orthopedic Surgeons don’t want to follow guidelines from Chiropractors (and vice versa) Solution: Don’t adopt the treatment guidelines from a medical specialty society Independence and multidisciplinary approach crucial

Labor Issues: Denial of Care? l The primary beneficiaries of evidence-based guidelines are injured workers – – The scientific studies are focused on one thing: what is most successful in getting the patient better Many therapies are proven to be harmful to patients, and guidelines can minimize these Prolonged unnecessary treatment in and of itself, along with delayed return to activity, has also been proven to be harmful Injured workers should get faster care, which can happen if guidelines reduce uncertainty

Summary l Result can be better outcomes for all stakeholders – Healthier workers e. g. , “Use of evidence based guidelines resulted in a denial rate for inappropriate lumbar fusion 59 times as high as denial rates using non-guideline based UR. ” (Wickizer, 2004) – Successful employers e. g. , “Employer claims where treatment does not comply with guidelines cost 3. 67 times more. ” (Integrated Benefits Institute, 2004) – More productive doctors e. g, “Use of evidence based guidelines along with increased physician pay, ultimately resulted in a decrease in workers' compensation costs as well as better patient outcomes. ” (Atcheson, 2001) – Proven cost savings

Implementation Issues l l l 20 ODG fees include support and training AADEP courses available for CME credit Toll-free ODG Helpdesk staffed 7 AM – 5 PM 50% discount in States where adopted (price is $162. 50 each) Web version, textbooks, data integration Summaries are free at www. guidelines. gov (Nat’l Guideline Clearinghouse from AHRQ)

ODG Live Demo to be Provided TSIA members should already have their own access to ODG 21

Return-to-Work Guidelines ODG Demo/Screen Shots l l Using Return-to-Work Guidelines to Cut Indemnity Costs Presentation will review a guideline accepted by AHRQ, and available in NGC – l l Screen shots of Official Disability Guidelines Show to use guidelines to return injured employees back to work safely and efficiently Show to use guidelines to benchmark outcomes

State Adoptions of Workers’ Comp Guidelines l l Many States have written their own guideline (AR, CO, CT, MA, MN, RI, WA) Problems exist w/State Guidelines – – l l Not necessarily evidence-based Tend to be more political (lobbyist influenced) Big states moving to drop own guideline, adopting national guideline (CA, FL, OH, TX, NY) Laws/rules adopting UR guideline under consideration in many states

What States Have Adopted EBM Treatment Guidelines? l l l l California: ACOEM (2003), now being replaced with ODG (2007) for pain, etc. Ohio: ODG (2003) Florida: AHRQ=ODG (2003) North Dakota: ODG (2005) Texas: ODG (2007) Kansas: ODG (December 2007) Other (Own, AHRQ, State Funds, etc)

Ohio ODG Pilot 2005 UR Advisor, Comp. Management • ODG adopted statewide in Ohio by BWC in November 2003 • Pilot study by Comp. Management, Inc. (a leading MCO) • Medical costs reduced 64%, lost days reduced 69% • Treatment delay reduced 77% (#1 benefit) Ohio BWC Official Disability Guidelines Diagnosis Related Authorization Pilot. Average Lost Days and Average Medical Costs per Diagnosis (Comp. Management, Inc. 07/22/05) Pre-ODG Post-ODG Savings 30 Med. Costs $7, 298, 522 $2, 655, 338 64% Lost Days 116, 729 36, 143 69%

Ohio ODG Pilot 2005 (cont’d) Provider Feedback l l l l 31 “I think this program sounds like it will become a time saving & effective tool in bettering or improving the current process. ” “Best part was that the injured worker did not have to wait for the treatment. Also cut down on paperwork. ” “These innovative methods must be supported & further explored. ” “Would like to see this used with all MCO’s. ” “The physicians thought highly of the ODG program. ” “If I was able to pull up the ODG guidelines per patient on the web, that would be great. ” “We like the concept. ”

Ohio Recent Findings 2009 – Deloitte Study l l l $7 million comprehensive Deloitte Consulting study of Ohio's workers' compensation system completed 04/2009 Mandated by Ohio Assembly to measure the performance of Ohio WC & benchmark against other states (due to "Coingate") One of Deloitte's major recommendations was to further strengthen Ohio's adoption of ODG: "Should require all MCOs to use ODG in UR” – "The bureau should be prescriptive and mandate the use of ODG" – "ODG is the emerging standard for UR decisions and expected disability duration" – "Specification of ODG for medical treatment is expected to yield a positive impact and needed consistency in managing providers" – Recommends Ohio adopt ODG for RTW as well www. ohiobwc. com/deloitte – 32

North Dakota Outcomes Data l l 33 Adopted ODG (May 2005) North Dakota workers' comp premiums -- already the lowest in the nation -- dropped another 40% $52 million in Premium dividend credits were returned to North Dakota companies “This is one of the largest direct cash infusions into North Dakota’s economy that the state has seen, ” said ND House Majority Leader Rick Berg

Other Outcomes l l l 35 states/provinces in NA have adopted TGs 23 selected ODG-TWC (of the remaining, WLDI provides links to their state specific guidelines) Associated with reduced WC costs outcomes (20 -70%) – – l l l CA - 70%; FL - 58%; HI - 61%; ND - 40%; OH - 64%; WV - 28% www. odg-twc. com/states. htm ODG used in every state and internationally Already under license by every carrier on Ranking List of the top 30 Workers’ Compensation Insurers Under license by every one of the top 20 TPAs/MCOs

Texas Outcomes Data (preliminary – meaningful studies underway) Adopted ODG (January 2007, effective 5/1/07) l Since adoption of ODG, number of disputes has declined by 44% ("from 450 per day to 250 per day”) l Number of inappropriate back surgeries has declined by 71% ("In the last four months of 2006, there were 741 spinal fusions, compared to 213 for the last four months of 2007 - a decrease of 71%”) l At an average cost of over $100, 000 each, this represents a savings of $52, 800, 000 over the fourmonth period, or annualized savings of $211 million for this one treatment alone Source: DWC presentation AADEP Annual Meeting San Antonio l 35

Texas Outcomes Data (preliminary – meaningful studies underway) Average Medical Cost Per Claim: 2006 (Before reforms) 2008 Non-network 2008 Network* $2, 813 $2, 075 26. 2% decrease $3, 014 7. 1% increase Percent Reporting No Problem Getting Needed Care: 2008 Non-network 2008 Network* 67% 61% * Only 9% of all Texas claims were being treated by certified networks in 2008. Source: TDI-DWC Biennial Report to the Texas Legislature December 2008 36

Texas Outcomes Data (preliminary – meaningful studies underway) Two major reforms from HB 7: Networks & Guidelines Why did medical costs go up for Networks & down for Non-network? Possible explanations: 1) Too soon to tell; data is preliminary; networks not effective yet. 2) Non-network care required to use ODG; networks are not. 3) Ideal network concept not being realized (also see California): – – – 37 Networks are supposed to be docs with good outcomes, & left alone. Instead they are docs who have agreed to cut their prices (& left alone). Are they making it up on volume? “Medical cost differences between network and non-network claims at this early stage in network implementation appear to be driven primarily by. . . higher utilization of certain medical services and diagnostic tests than non-network claims with similar types of injuries. ” TDI-DWC Biennial Report to the Texas Legislature December 2008

California Outcomes Data – Recent Results l Workers' comp rates realized a 70% reduction since 2003; actual carrier costs declined even further. Source: Insurance Commissioner Poizner 1/1/08 l But a 24. 7% proposed pure premium hike proposed in 2009, due to: – – Adverse impairment court decision on AMA Guides, and Rising medical costs. Source: Workers' Compensation Insurance Rating Bureau l 38 Why are medical costs going up?

California Outcomes Data – Why are medical costs going up? 75% of CA treatment in MPNs (versus 9% in Texas in 2008) l “MPNs not working as cost-containment for insured employers” l Evidence that self-insureds have done better with MPNs l Carriers can't handpick MPNs because they never know where their next policyholder might be located l Carriers forced to contract with vast networks, list of doctors who've agreed to treat injured workers at discounted rates l Employers who are limited to one or only a few physical locations are in a better position to hand pick physicians l Also growing dollars spent on utilization review and medical-legal reports, which is lumped into the "medical cost" category Source: Solutions Elusive on Fast Rising Medical Costs: Top [04/13/09] workcompcentral. com l 39

Kansas Outcomes Data – Preliminary Results l l 2009: Kansas announces they are seeing positive responses to the required use of ODG to help provide the best care for injured workers Secretary of the Department of Labor indicates that use of ODG Treatment is to be mandated starting on 01/2010 — rather than identified as the standard of reference Implementing major provider training program Possible impact of Kansas on national level: – – 40 Kansas Governor Sebelius appointed Health and Human Services (HHS) Secretary Part of new responsibilities include the American Recovery and Reinvestment Act of 2009 (HR 1) for HHS to establish standards in evidence-based medicine

What States Considering Adopting EBM Treatment Guidelines? l Alaska, Arizona, Delaware, Illinois, Kentucky, Louisiana*, Maryland, Michigan, Minnesota, Nebraska, New York*, Oklahoma*, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Washington, Wisconsin, Wyoming * TSIA support would be welcomed.

Treatment Guidelines ODG Demo/Screen Shots Methodology • • Explanation of Medical Literature Ratings Appendix B, Methodology Description using the AGREE Instrument Sample Recommendations • • Low Back Chapter, Procedure Summary Low Back Chapter, Treatment Planning Low Back Chapter, Codes for Automated Approval Pain Chapter, Procedure Summary Other Tools • • Appendix A, ODG Workers’ Compensation Drug Formulary Appendix C, Patient Information Resources UR Advisor ICD 9 -CPT Crosswalk State Adoptions