Tuesday, May 17, 2016

Medical Standards

The Journal of Occupational and Environmental Medicine has published a study confirming the assumption that medical treatment in accordance with the current suite of published evidence based guidelines results in shorter disability duration and, ergo, better health outcomes for the subject.

The study used 45,951 indemnity claims with two years of development filed between 2008 and 2013 from the Accident Fund, United Heartland, Third Coast Underwriters and CompWest.

A compliance score was devised by comparing diagnosis and treatment codes, and seeing whether Work Loss Data Institute’s UR Advisor product rated the selected treatment as “green flag,” meaning the treatment is recommended for that diagnosis; black flag, meaning denial recommended; red flag when a review of the treatment is advised; and yellow flag if the treatment is allowed on a limited basis. Using a calculation based on how often green or yellow versus black flags appeared, claims were sorted into low-compliance and high-compliance groups.

WLDI provided access to the Official Disability Guidelines database but did not ask the researchers to conduct the study, didn’t participate in it and provided no funding, according to WLDI. The UR Advisor product used in the study is a tool for looking up information in the Official Disability Guidelines, they said.

According to the research, claim duration was 13.2% longer, and medical costs were 37.9% higher for claims in the low-compliance group compared to the high-compliance group. In a subset of the most medically complex claims, duration for the low-compliance group was 18% longer than for the high-compliance group, and medical costs were 38% higher.
More, similar conclusions were made based on the data.

Though the study used ODG, rival publishers were equally enthusiastic about the report and are interested in how the methodology used to test ODG can be applied to other guidelines.

It has always interested me why different jurisdictions have different treatment guidelines since, presumably, all humans possess the same anatomy and biology regardless of location.

Ultimately, the difference between ODG and the American College of Orthopedic and Environmental Medicine guidelines is in the presentation of information and timeliness of incorporation of new research.

Different states, however, essentially succumb to special interests pressure to develop their own guidelines at great expense.

More importantly, though, is that state guidelines will eventually lag behind the research, becoming out of date, because the cost of staffing, reading, cataloging, reviewing, and confirming the vast universe of medical research is too costly, too daunting.

While there is usually a provision in the law for other EBM guidelines to supplant the state presumed default, doing so is thwarted by costs to the subject, or by operation of law.

California is a classic example. There is really no reason for California to have separate guidelines, yet the state continues to rely on its own, antiquated, Medical Treatment Utilization Guidelines. The law provides that the MTUS may be rebutted with other EBM, but if the payer's Utilization Review doesn't accept that argument, and the matter goes to Independent Medical Review, it's over.

Because IMR will follow the MTUS. And, once in the rabbit hole of IMR, there's no getting out.

Other states don't have any guidelines, and the JOEM study is a great argument for those states to adopt one of the standards (and hopefully shy away from the special interests intent on creating their own standards).

For instance, Pennsylvania law makers have before them House Bill 1800, a proposal to adopt “nationally recognized,” evidence-based medical treatment guidelines in workers’ compensation. Opponents say the guidelines are a one-size-fits-all approach to treatment.

Nebraska's attempt failed last year against the same arguments.

Buying into those arguments simply reflects a lack of understanding what treatment guidelines are and ignores the fact that the general health insurance industry has been following guidelines since, basically, forever...

Whether I'm in California, Florida, Arkansas or Alaska, my physiology doesn't change, and neither should treatment protocol.

There has been a lot of talk lately about standards across state lines. Medical treatment protocol should be one of them.


  1. "It has always interested me why different jurisdictions have different treatment guidelines since, presumably, all humans possess the same anatomy and biology regardless of location." AGREED!

    All the more reason for a standardized SINGLE payer, or a Nationalized health care plan, where treatment guidelines are the same for everyone, regardless of their geographic location,and weather their harmed at work or not. Thus eliminating this need for States to compete against one another,and against the injured workers, for better comp rates, at the injured workers expense. Just to have those great job's trickled down to the State that harms their injured workers the most, with the most take away's from the laborers side of the grand bargain.

    Does this making State's compete,to see who can take the most away from their inured workers, help humanity, or the bottom lines of the profiteers the most?

    "Men naturally rebel against the injustice of which they are victims. Thus, when plunder is organized by law for the profit of those who make the law, all the plundered classes try somehow to enter—by peaceful or revolutionary means—into the making of laws. According to their degree of enlightenment, these plundered classes may propose one of two entirely different purposes when they attempt to attain political power: Either they may wish to stop lawful plunder, or they may wish to share in it." Frédéric Bastiat, The Law Just food for thought.

    See more about how A Single Payer System Will Solve the Fiscal Cliff here:


    Why do the words "single payer" and "nationalized health care", scare the conservative, ALEC led, Republican business community so much? Is it because the profit motives, behind denying, delaying, and defending against the injured workers, cost containment strategy, would be eliminated? Hmmm?

    Do these suggestion from injured workers of a single payer or a Nationalized health care plan, scare your inner conservative Republican profiteering motivations, as well David? Just asking. Is this profits before patients, competitive system we have now, really working out for all at the table, or just for the corporate profiteers? It really does make one pause and wonder which direction humanity is headed in today. Is it all really about profits, over human life? I wonder, what is to become of humanity,if we are to continue on this profiteering path were on now? It's not just the adversely affected injured workers asking these questions, the POPE seems to have the same concerns for our World as well.

    Peace, and go forth and prosper my friend, no matter for the injured workers who have insult, and injustice, added to injury,even though according to industry insiders, it's just the few, it's all for the good of the whole. Correct?

  2. Darren - I have always argued in favor of single source medical for everyone who works...

  3. Hey,
    Thank you for sharing such an amazing and informative post.

    Really enjoyed readig it. :)


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