At the 2015 California Coalition on Workers’ Compensation Conference, Denise Zoe Algire from Safeway and Dr. Lawrence Miller from Anthem Workers’ Compensation presented a session entitled California MTUS: Past, Present Future.
The primary goal of adopting treatment guidelines should not be cost containment. The primary goal should be to expedite the injured worker receiving the appropriate treament. The MTUS guidelines have been in place for a number of years and they are specific to California. Treatment guidelines should follow evidence-based medicine, which is healthcare based on clinical studies of which treatments are the most effective for different conditions.
Recently, we are seeing an increased focus on quality of care and outcomes-based networks. By 2018, 80% of Medicare reimbursements will be based on quality of care standards. This is being driven by requirements in the Affordable Care Act.
Quality and outcome measurements in workers’ comp include:
- Return-to-work outcomes.
- Adherence to EBM guidelines.
- AHRQ clinical quality / appropriate care measures.
- Zero never events (such as operating on the wrong arm, which should never happen).
- Risk of harm – intended or unintended physical or psychiatric injury resulting from or contributed to by health care services.
Where does MTUS fit into this?
- Most of the MTUS guidelines were developed in 2004. These guidelines are outdated and need to be updated.
- If a person injures multiple body parts, the current MTUS guidelines use different guidelines from different years to determine what treatment is appropriate. The industry-accepted standard guidelines (such as ODG) are kept current and the physicians can always access the current guidelines online. The MTUS guidelines are different from the guidelines physicians utilize for treating non-occupational patients, which creates much confusion.
- The inability of workers’ comp carriers to pursue medical malpractice in California removes the disincentive for physicians to practice medicine in the best possible manner. There is no downside if the treatment is reckless and produces horrible results for the injured worker.
- In the current form, the MTUS guidelines have been heavily influenced by politics.
- Texas has adopted ODG treatment guidelines which has produced significant savings, an increase in the quality of outcomes for workers, and no decrease in access to care.
- California MTUS guidelines do not follow current evidence-based protocols based on current medical science.
- There are ongoing discussions about the need to update the medical guidlines in California. Some are advocating adopting ODG, which are used in most states that have treatment guidelines. Others advocate for ACOEM guidlines, which are not as widely used and not as thorough as ODG. Finally some are calling for California to create new state-specific guidelines similar to MTUS.