Official Disability Guidelines ODG Treatment

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Official Disability GuidelinesODG Treatment

• Texas Self-Insurers Conf.
• Note Where this handout uses screenshots, the
  actual presentation will be a live demo

Pat Whelan, Publisher Phil Denniston,
PresidentWork Loss Data Institutewww.worklossdat
a.comphil_at_worklossdata.com
TSIA Austin June 8, 2009
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Work Loss Data Institute (WLDI) Full Disclosure

• Publishes Official Disability Guidelines (14th ed
  2009) ODG Treatment in Workers Comp (7th ed
  2009)
• Hired as research contractor for the ACOEM
  Practice Guidelines (2nd ed 2004)
• Research exclusive rights to publish the
  yet-to-be-released CCGPP Treatment Guidelines
  (1st ed 2009)
• Under contract to provide guidelines data for
  McKesson InterQual Guidelines Intracorp
  Guidelines
• Publishes State Report Cards for Workers Comp

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Background on WLDI

• 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

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Agenda

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

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Guidelines in Workers Comp

• Three kinds of workers comp related guidelines
• Medical treatment guidelines (ODG Treatment,
  ACOEM Practice Guidelines, CCGPP, McKesson,
  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).

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Methodology of Guideline Development

• Guidelines can be developed using two different,
  but overlapping methods
• Consensus-based
• Evidence-based

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Two methods of guideline creation

• Consensus-based
• Developed with the input of experts in a given
  field making recommendations based upon a
  literature review and their personal experience

• Evidence-based
• Developed by employing a strict process of
  literature review including ranking the published
  papers by strength of study design with
  recommendations linked to the comparative
  scientific rigor of the studies used

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What is Evidence-Based Medicine?

• 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 13th January 1996
  (BMJ 1996 312 71-2)

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What is Evidence-Based Medicine?

• 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

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Why EBMTreatment Guidelines?

• The only way to achieve real and lasting
  cost-savings in workers comp is through the
  delivery of quality and timely care
• -Charles W. Kennedy, MD, Senior Medical
  Editor, ODG Treatment in Workers Comp
• This is best achieved by adopting evidence based
  treatment guidelines

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Why EBMTreatment Guidelines?

• EBM Guidelines benefit all stakeholders
  Employee, Employer and Provider
• Providers practicing in-line with EBM Guidelines
  are insured of timely payment
• 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

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What to look for in EBM Guidelines

• In Workers Comp, a two-horse race ODG and ACOEM
• So, ODG or ACOEM?
• Review/compare for yourself
• Consider key issues

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What to look for in EBM Guidelines

• Rand Study Evaluating Medical Treatment
  Guideline Sets for Injured Workers in CA (11/04)
• Technical Quality EvaluationAGREE
• McKesson/Interqual WC Guidelines have been
  discontinued by McKesson

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What to look for in EBM Guidelines

• 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

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Provider Issues Cookbook Medicine?

• 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)

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Provider Guideline Issues (contd)

• 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.

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Provider Issues Specialty Bias

• Each medical specialty has their own guidelines
• Each specialty represents the interest of their
  members (i.e. hand surgeons recommend hand
  surgery)
• Orthopedic Surgeons dont want to follow
  guidelines from Chiropractors (and vice versa)
• Solution Dont adopt the treatment guidelines
  from a medical specialty society
• Independence and multidisciplinary approach
  crucial

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Labor Issues Denial of Care?

• 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

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Summary

• 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

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Implementation Issues

• 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 (Natl
  Guideline Clearinghouse from AHRQ)

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ODG Live Demo to be Provided

• TSIA members should already have their own access
  to ODG

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Return-to-Work Guidelines ODG Demo/Screen Shots

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

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State Adoptions of Workers Comp Guidelines

• Many States have written their own guideline (AR,
  CO, CT, MA, MN, RI, WA)
• Problems exist w/State Guidelines
• 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

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What States Have Adopted EBM Treatment Guidelines?

• California ACOEM (2003), now being replaced with
  ODG (2007) for pain, etc.
• Ohio ODG (2003)
• Florida AHRQODG (2003)
• North Dakota ODG (2005)
• Texas ODG (2007)
• Kansas ODG (December 2007)
• Other (Own, AHRQ, State Funds, etc)

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Ohio ODG Pilot 2005 -UR Advisor, CompManagement

• ODG adopted statewide in Ohio by BWC in
  November 2003
• Pilot study by CompManagement, 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
  (CompManagement, Inc. 07/22/05)

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Ohio ODG Pilot 2005 (contd) Provider Feedback

• 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 MCOs.
• 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.

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Ohio Recent Findings 2009 Deloitte Study

• 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

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North Dakota Outcomes Data

• 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 Dakotas economy that the state has
  seen, said ND House Majority Leader Rick Berg

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Other Outcomes

• 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)
• 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

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Texas Outcomes Data (preliminary meaningful
studies underway)

• Adopted ODG (January 2007, effective 5/1/07)
• Since adoption of ODG, number of disputes has
  declined by 44 ("from 450 per day to 250 per
  day)
• 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)
• At an average cost of over 100,000 each, this
  represents a savings of 52,800,000 over the
  four-month period, or annualized savings of 211
  million for this one treatment alone
• Source DWC presentation AADEP Annual Meeting San
  Antonio

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Texas Outcomes Data (preliminary meaningful
studies underway)

• Average Medical Cost Per Claim
• 2006 (Before reforms) 2,813
• 2008 Non-network 2,075 26.2 decrease
• 2008 Network 3,014 7.1 increase
• Percent Reporting No Problem Getting Needed Care
• 2008 Non-network 67
• 2008 Network 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

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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
• Too soon to tell data is preliminary networks
  not effective yet.
• Non-network care required to use ODG networks
  are not.
• Ideal network concept not being realized (also
  see California)
• 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

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California Outcomes Data Recent Results

• Workers' comp rates realized a 70 reduction
  since 2003 actual carrier costs declined even
  further.
• Source Insurance Commissioner Poizner 1/1/08
• 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
• Why are medical costs going up?

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California Outcomes Data Why are medical costs
going up?

• 75 of CA treatment in MPNs (versus 9 in Texas
  in 2008)
• MPNs not working as cost-containment for insured
  employers
• Evidence that self-insureds have done better with
  MPNs
• Carriers can't handpick MPNs because they never
  know where their next policyholder might be
  located
• Carriers forced to contract with vast networks,
  list of doctors who've agreed to treat injured
  workers at discounted rates
• Employers who are limited to one or only a few
  physical locations are in a better position to
  hand pick physicians
• 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

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Kansas Outcomes Data Preliminary Results

• 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
• 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

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What States Considering Adopting EBM Treatment
Guidelines?

• 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.

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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 ICD9-CPT Crosswalk
• State Adoptions

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