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A study from the Workers Compensation Research Institute found vast differences in state’s workers compensation treatment guidelines and how those guidelines are enforced.
In State Policies on Treatment Guidelines and Utilization Management: A National Inventory, researchers from Cambridge, Massachusetts-based WCRI found that less than half of the states, 23, have medical treatment guidelines for workers compensation to identify how those guidelines affected care, cost and worker outcomes.
Researchers Dongchun Wang, Kathryn Mueller and Randy Lea surveyed 22 of those 23 states about their workers comp medical treatment guidelines, policies for enforcing the guidelines and how the guidelines are used for utilization review and dispute resolution. The study did not examine whether the state’s guidelines were based on evidence-based criteria.
The survey results revealed that the guidelines adopted or developed by the 23 states ranged significantly. Colorado and Washington developed their own guidelines, while other states adopted, in full or in part, guidelines from the American College of Occupational and Environmental Medicine or Official Disability Guidelines. The researchers focused on low-back guidelines to more effectively compare the various state guidelines, noting that Colorado and Washington tied specific procedures “to specific and clinically confirmed objective guidelines” while states without guidelines often exhibited care inconsistencies.
For instance, in Colorado, the state’s medical treatment guidelines are evidence-based, updated every five years and used a mandatory clinical standard for UR and dispute resolution. Disputes go through the state’s Division of Workers’ Compensation’s Medical Policy Unit; unresolved disputes then go through the legal system. In Wyoming, the state’s guidelines are used for prior authorization, but providers are not held accountable and the commission does not have the authority to enforce the guidelines. Disputes go directly to the legal system in that state.
The study also looked at utilization review, which is mandatory in half of the states in the U.S. In 17 of states that require UR, the state’s medical treatment guidelines are the sole standard for UR, and in Colorado, Minnesota, New York and Texas, those state guidelines are required for both UR and dispute resolution.
The researchers noted that 37 states penalize payors who fail to adhere to state treatment guidelines and UR, and 22 states take other punitive measures for noncompliant providers. In Maine, Minnesota and Ohio, payors who don’t comply with treatment guidelines can have their participation in the state’s workers compensation system revoked.
WCRI noted in a release that the intent of the study is to provide information for policymakers and stakeholders seeking to identify opportunities to improve medical care delivery for injured workers, and to provide a framework for subsequent studies to examine what combinations of policies may affect utilization of services and outcomes.
Washington state's “Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain” is among the respected medical guidelines doctors look to for determining appropriate treatment for injured workers.