Treatment Guidelines:Recommendations and
Implications for Providers
Dr. Robert Snyder, Medical Director
Suzy Douglas, Moderator
Treatment Guidelines:Recommendations and
Implications for Providers
Division of Workers’ CompensationRobert B. Snyder, M.D.
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Tennessee Workers’ Compensation Law
2013 Edition50-6-124(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.”
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Tennessee Workers’ Compensation Law
2013 Edition50-6-124(h), effective on July 1, 2014.“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…}
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Tennessee Workers’ Compensation Law
“…Guidelines for the Diagnosis and
Treatment… ”
Clinical Practice Guidelines Clinical Guidance
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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
Clinical Guidance
Practice GuidelinesInstitute 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.”
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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.
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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.”
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.
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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.
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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.
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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”
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Factors that will Influence the Decision
Implementation BarriersAccess“User friendly”
Resources AvailableCostManpowerTime
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Factors that will influence the Decision
Input from StakeholdersDivision and other state agencies
ProvidersCarriers, Utilization Review Agencies
EmployersInjured workers and their representatives
AttorneysFamiliesOmbudsman program
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The Decision
The Medical Advisory Committee
The Final decision rests with the Administrator
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First Guideline
The Management of Chronic Pain
Tennessee Department of Health
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Potential SourcesPhysician Specialty Societies
Other StatesProprietary CompaniesOther Interested Stakeholders
Internal Tennessee DevelopmentDepartment of HealthWorkers’ Compensation Committees
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Preliminary ReviewWashington ColoradoOther statesWLDI-ODG™ACOEMSpecialty SocietiesDepartment of HealthMedical Care Cost Containment Committee
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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.
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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
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