Making Treatment Guidelines Matter

Our industry puts a lot of trust in guidelines that present best evidence of good medical care.  Does medical practice endorsed by these guidelines ensure better outcomes? Or are they window dressing?

A third-party administrator says that guidelines definitely matter, but not in ways that most people think. Its research is a big step forward in the decades-long effort to improve the quality of medical care for injured workers.

Gallagher Bassett reached this conclusion after an intensive review of its claims history. It applied a research method that had been successfully used by a Johns Hopkins-related study of workers’ comp claims in Michigan. The Gallagher Bassett study was nationwide.

The TPA says that guidelines are a valid means to better understand the course of treatment and predict duration of disability and medical costs. Importantly, the firm does not expect complete compliance. Medical care is too complicated to be shoved into a cookie cutter regime of rigid adherence. Its research shows that non-compliance is not necessarily wrong, only that in certain circumstances it might be wrong. This is a major departure from common expectations. 

So, it is not surprising that Gallagher Bassett does not, at least for today, use guideline adherence to profile the overall performance of a provider, over many cases, to create a provider score.

A brief history of the workers’ comp industry efforts to improve quality of care will show how important these new findings are. Since about 1990, states been introducing statutes designed to ensure that medical care stays reasonably close to what is considered good medicine. These laws have clearly been ineffective where powerful providers have their own idea of good medicine. Fusion surgery and extensive use of opioids are examples. 

Nonetheless, state legislatures stood by their laws. According to the Workers Compensation Research Institute, 23 have prescribed medical treatment guidelines, and 24 have mandated prior authorization of treatment.

There is a very small body of research into whether these laws make a bit of difference in outcomes. One first has to find out if medical treatment varies. A small handful of studies show, in fact, dramatic variation by providers in medical costs and duration of disability, and these studies associate the variance at least in part to medical treatment decisions. 

Gallagher Bassett’s research found that compliance with medical treatment guidelines matters. Significant departures from the guidelines leads to longer disability durations and higher medical costs.

Its researchers defined significant departures in two ways. First, it used ODG/MCG’s designation of specific treatments as “black” – unsupported by any credible evidence. Second, it looked at how unsupported treatments arise in a case. 

The researchers divided claims into severity classes based on factors not related to the actual care delivered, such as state, litigation, and normal disability duration by diagnosis. They found the difference in outcomes for light severity cases was not much, but increased along higher and higher severity classes.  

After discussing the research with the firm, I came away with the following take-aways, which I consider unique among all the research I have encountered.

First, problems with treatment worthy of attention can be quickly identified as they happen.  Non-compliant treatment that tends to seriously worsen outcomes tends to include a cluster of non-compliant treatments, and these very often take place roughly around 50 to 60 days after the date of injury. Prompt analysis of care and follow up are feasible.

Second, I question utilization review’s use as a universally applied tool. For many injuries, when a provider makes a single treatment not in compliance with treatment guidelines, that may not adversely affect outcomes. On the contrary: the provider knows the patient, and may know what works. If a claims payer trusts a provider, it should not worry about single or infrequent treatments that are non-compliant. A confident, effective physician or physical therapist has good reason to regard many UR or peer review interventions as a kind of harassment.

A third take-away concerns medical care when it entirely adheres to guidelines. Many of these cases will still have poor duration outcomes, for reasons unrelated to the quality of care. Don’t expect that a top-class medical provider network will solve all your problems.

These findings sum up to a profile of a how a claims payer should manage provider relations. A chronic weakness in medical care for injured workers is the low investment claims payers make in seeking constructive relationships with their provider community. They need to know whom to trust and to treat them accordingly. They need to be alert to when real problems arise. They cannot expect even their best providers to be magicians.

They should, in sum, regard medical providers as what they should be: partners.

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