At the 2018 Insurance Rehab Synergy Group Annual Conference, Ingrid O’Keefe from MCG Health discussed the use of evidence based medicine in the development of treatment guidelines and drug formularies in workers’ compensation. Evidence based medicine is healthcare based on clinical studies of what works best and what does not. It involves transparent literature review to determine what is considered the best supported treatments and standards.
Treatment guidelines take evidence based medicine one step further in providing medical treatment recommendation based on scientific studies. There are commercially developed guidelines, specialty treatment guidelines, and state specific guidelines.
Guidelines are based on the review of hundreds of thousands of studies ever year. They rank these studies based on a variety of factors to come up with the recommendations that have the strongest evidence to support them. Guidelines are updated constantly based on new studies that are reviewed.
Guidelines typically have four recommendation types ranging from strongly recommended, moderately recommended, recommended or insufficient evidence.
The last few years, we have seen several states adopt treatment guidelines or drug formularies. The first state to do this was California in 2003. They used a version of the ACOEM guidelines and eventually added their own MTUS guidelines on top of this. Updates were made to their guidelines in 2007 and again in 2018.
Nevada, Ohio, North Dakota, Kansas, Texas, Oklahoma, New Mexico, Tennessee, Arizona, New York, Montana, Colorado, Connecticut, Delaware, Louisiana, Massachusetts, Mississippi, Minnesota, Oregon, Rhode Island, and Wisconsin and West Virginia have all adopted treatment guidelines in some manner. Some used commercially available guidelines, some developed their own, and some used a hybrid approach.
Drug formularies are another trend being seen. Formularies are designed to reduce the use of potentially harmful drugs and speed authorization of approved drugs. A worker’s compensation drug formulary indicates which drugs are approved for use, and which require payer preauthorization. Open formularies list all FDA approved drugs and there is consideration given to payment depending on circumstances and closed formularies only reimburse drugs specifically listed by the formularies.
States with drug formularies for workers’ compensation are Washington, North Dakota, Texas, Ohio, Arizona, Tennessee, Oklahoma, Montana, California, Kentucky, Indiana,
The Pennsylvania legislature recently passed a bill requiring a formulary but the Governor vetoed this because he wants the state to develop their own formulary instead of adopting a commercially available one.
Studies show that the use of treatment guidelines both lowers medical costs and also speeds treatment to injured workers. Other studies showed the guidelines resulted in a reduction of lost work days. Studies also show that drug formularies significantly reduced the costs of prescription drugs.