treatment guidelines: recommendations and implications for providers dr. robert snyder, medical...

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.

Text 754730 and your Questions to 22333

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.”



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…}



“…Guidelines for the Diagnosis and

Treatment… ”

Clinical Practice Guidelines Clinical Guidance


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.”


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.


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.


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.


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.


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”


Factors that will Influence the Decision

Implementation BarriersAccess“User friendly”

Resources AvailableCostManpowerTime


Factors that will influence the Decision

Input from StakeholdersDivision and other state agencies

ProvidersCarriers, Utilization Review Agencies

EmployersInjured workers and their representatives

AttorneysFamiliesOmbudsman program


The Decision

The Medical Advisory Committee

The Final decision rests with the Administrator


First Guideline

The Management of Chronic Pain

Tennessee Department of Health


Potential SourcesPhysician Specialty Societies

Other StatesProprietary CompaniesOther Interested Stakeholders

Internal Tennessee DevelopmentDepartment of HealthWorkers’ Compensation Committees


Preliminary ReviewWashington ColoradoOther statesWLDI-ODG™ACOEMSpecialty SocietiesDepartment of HealthMedical Care Cost Containment Committee


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.


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


http://www.odg-twc.com/

http://www.odg-twc.com/

http://www.asipp.org/Guidelines.htm

http://www.asipp.org/Guidelines.htm

http://www.acoem.org/Guidelines

http://www.acoem.org/Guidelines

http://www.lni.wa.gov/

http://www.lni.wa.gov/

http://health.tn.gov/Downloads/ChronicPainGuidelines.pdf



treatment guidelines: recommendations and implications for providers dr. robert snyder, medical...

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