Monday, October 13, 2014

The Evidence is Consensual

Medicine has evolved substantially in the 100 years or so that workers' compensation has been around. For the most part now, the practice of medicine is based on science. Principles from rigorously reviewed studies of methodologies, pharmaceuticals, and other treatment protocol have refined the practice of medicine so that, for the most part, given any particular diagnosis we know what to expect, when to expect it, and what the after affects might be.

There are still new treatments proposed that are deemed "experimental" until they go through this process of peer review and critique, and there are plenty that fall within the stereotype of "snake oil" medicine, but for the most part we know the most effective way to treat an ailment with the technology available today.

Which is why treatment guidelines exist - guidelines represent a high level of agreement on the best way to deal with an injury or illness.

Of course there is always going to be debate about one set of protocol versus another because no two patients are the same, no two injuries are the same, no two doctors are the same.

But given any set of circumstances or diagnostic fact patterns that are generally in alignment, we can follow the guidelines and achieve an expected result.

General health insurance has done this for years. It helps those insurance companies to control costs, and theoretically such cost control is passed onto the consumers of insurance.

There are basically two types of guidelines: "evidence based" and "consensus based."

The alleged difference is that evidence based guidelines have some accountable scientific backing - generally peer reviewed studies that have gone through rigorous testing to validate the findings. Consensus based guidelines involve exactly what the name implies - consensus among people as to the best way to get the job done.
Tina doesn't know about guidelines...
Curiously though, consensus based medicine generally involves some evidence based fundamentals, because, unless there is some fraud or undue influence, people want to ensure that what they are agreeing on has some basis in fact; that it has been tested and proven to be effective.

Likewise, evidence based medicine generally involves some consensus based convention because the evidence itself is subject to review and critique, and must be agreed upon by a sufficient number of experts to achieve a level of medical acceptance.

What really seems to be the difference between the two is whether one is more politically manipulated over the other.

In general when one looks to evidence based medicine guidelines being deployed in workers' compensation there really are only a couple that are published.

When one looks to consensus based medicine in the work comp arena there are many more - consensus based medicine in workers' compensation tends to mean state specific: there is a state medical director who gathers up a bunch of experts and they all agree, for the most part, on what is going to guide treatment within a particular jurisdiction.

Much of the time the agreement is based on some evidence, sometimes it is based only on good, hard lobbying...

There is, regardless, a trend in workers' compensation to adopt some sort of medical treatment guidelines. The "big" states already have some guidelines in place - for instance California started with the American College of Occupational and Environmental Medicine Practice Guidelines, an evidence based standard, as the basis for its consensus based standard, the Medical Treatment Utilization Schedule. Colorado followed the same general pattern. Texas adopted the Work-Loss Data Institute’s Official Disability Guidelines without morphing into a consensus system.

States that don't have guidelines but are moving towards adopting them include Arkansas, Arizona, North Carolina, and Tennessee, all of them debating evidence based guides versus consensus based guides.

Guidelines have the effect of not only dictating the treatment regimen, but also what will be paid for and at what price. And this is where the sharp differences lie between workers' compensation and general health - the patient in general health knows that if the doctor wants to perform some treatment that is not approved or within the insurance company's guidelines then he or she is going to have to pay for it.

Most general health carriers have some sort of appeal process where the patient can contest a decision as to whether or not some proposed treatment is going to be covered - a sort of Independent Medical Review process. It is very difficult to overcome an IMR decision in general health once dictated because the relationship is contractual (within the confines of both state and federal law).

When workers' compensation won't permit some treatment, though, the flavor and expectations are different because the relationship between provider, carrier and patient is based on law and not contract, so often the dispute goes to some adjudication process - judicial review.

California sought to adopt some general health principles into the work comp process with an IMR system of review, and this caused a bit of consternation.

When the law changes there is huge disruption because we had been trained to behave in certain ways based on past experience. So it takes quite a bit of time to change expectations, and change behavior. Whether this is good or bad is a huge subject of debate, but a new reality gets created that may include some unanticipated consequences.

And it takes time for those consequences to be ferreted and dealt with - in the meantime we have uncertainty, and it's uncertainty that generates litigation. And, by the way, it's litigation that is responsible for a hugely disproportionate share of costs.

While the adoption of medical guidelines seems to be a good idea for most jurisdictions, they carry certain baggage that must also be dealt with. Changing expectations takes time. Processes get tested and evolve in response.

In the meantime, whether a guideline is evidence based or consensus based isn't really that big of an issue. The issue is the adaptation by the affected population to a guideline and how much that population will resist. Bigger changes incur greater resistance, but eventually there is acceptance and adaptation.


  1. Good points David. IN California, why aren't doctors being paid for reviewing records? Med-legal doctors are paid, why aren't the treating and consulting specialists being paid. Shouldn't they be paid? Especially if they are providing the P&S (MMI) reports?

  2. It's a real Gravy Train, isn't it.

    Some of us are hoping for Congressional investigations. ...starting in California and sweeping across the nation. Remember when maiming and killing the many for the profits of the few was considered a bad thing? Time to fly our flag upside down! ? ! Some might agree.

    Work Comp is much the same as the Nuclear Industry. ..PROFITS BEFORE LIVES. ...BY ANY MEANS NECESSARY. Bummer.

    Carry on, David. Work Comp needs some legit leadership to right the heinous wrongs.

  3. If the CHP can get a new leg, a prosthetic - AND get their job back why can't everyone qualify for that secret, higher level of benefits that only civil service and "their friends" are eligible for - like free 100% life pensions so they can get an illegal tax shelter for all the money they then make in "retirement" - an investigation is indeed needed and work comp needs to be exposed for what it is - a fraud, a con job and an illegal taint on the constituton as it was designed to secretly control California's work force - by excluding farmers it led to the absolute abuse of migrant farm workers and allowed a secret, illegal HIGHER level of benefits for those like the chp hence "Chief's Disease" cause they don't want you to know just how FAR this scandal extends.

    do politicians know it's never been voted on? sure do. it's history and the secretary of state shows on her website information to PROVE it was never voted on - hence the term "Constitutional Abomination"

    don't you agree, Dave?