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Utilization review and physician outreach are ways that workers compensation payers can prevent diagnostic testing that may lead to unnecessary, costly treatment and surgery, experts say.
A retrospective study by researchers with the Liberty Mutual Research Institute for Safety, which appears in the September issue of the medical journal Spine, found that despite guidelines discouraging MRIs for uncomplicated cases of acute lower back pain, the practice is “highly prevalent” and varies widely by geography.
Various clinical practice guidelines — including the Official Disability Guidelines, the American College of Occupational and Environmental Medicine guidelines and state-specific evidence-based clinical practice guides — say MRIs should not be performed for acute low back for at least one month.
According to the study, MRI rates for patients with low back pain ranged from 6.0% in Vermont to 58.4% in Arizona (see charts).
"The overutilization of this tool … is something we see across the country,” said David Lupinsky, Folsom, California-based vice president of medical review services at third-party administrator and managed care services provider CorVel Corp. “You have to have some clinical idea of what you're looking for with your imaging. … If it's four to six weeks of pain, that doesn't necessarily warrant it.”
An MRI typically costs at least $500, though the maximum amount varies since it's set by states' workers comp fee schedules, experts say. But workers comp payers are looking to avoid more than just the cost of the test.
Early MRIs, CT scans and other tests can lead to treatments — such as epidural steroid injections and facet joint injections — and surgeries that are either ineffective or not medically necessary, experts say. Back surgery can cost about $100,000.
Nonhospital MRI sites and injured workers with lower median incomes were associated with higher rates of early MRIs, according to the study.
“Decreased median income may be a marker for patients' lower education and less ability to understand complex explanations that may result in providers not communicating the proper course of action, and resorting to a less time-and-effort-consuming path of ordering an inappropriate diagnostic test,” the study authors said.
Not all physicians follow best practices and use medical treatment guidelines, said Jacob Lazarovic, chief medical officer at TPA Broadspire Services Inc. in Sunrise, Florida.
Mr. Lazarovic said Broadspire is “constantly reinforcing the guidelines, which we do through our utilization review processes and our case management processes, and various other communications to physicians, to ensure that the treatment we're providing to claimants is following best practices.”
The study examined medical bills of workers with back injuries from 2002 through 2007 who received an MRI within 30 days being injured.
It excluded workers who had other injuries or diseases as well as nine jurisdictions that had less than 50 cases — the District of Columbia, Maine, Nevada, New Mexico, Rhode Island, South Dakota, Washington state, West Virginia and Wyoming.