Transcript Dr. Roy Lee - Louisiana Association of Occupational Health Nurses

Louisiana Medical Treatment
Guidelines Update
Louisiana Occupational Health Conference
July 30, 2015
Roy M Lee, MD, JD
OWC Associate Medical
Director
Louisiana Workers Comp
Louisiana is an
Employee Choice
State
Employee Choice
The Injured Worker
gets to choose the
doctor he/she wants!
That’s a Good Thing
Right?
Employee Choice
Most injured
workers don’t know
who is or is not a
Good Doctor
Many don’t even
have a personal
physician
Good Medical Care
Most injured workers want to get
good Medical Care and return
to work
Most Physicians want what is
best for the patient.
The Literature is pretty clear that
almost all injured workers do
better if they are kept working
Conflicting Financial Incentives
Don’t all Physicians do what
is best for the patient?
According to one WC Carrier’s data,
one very busy Orthopedic Clinic in
South Louisiana virtually sends
almost no workers comp patient
back to work - EVER
46% of that clinic’s workers comp patients
have legal representation
As opposed to 4 to 6% of most Ortho Clinics
Conflicting Financial Incentives
In Louisiana injured workers are often
referred to Physicians by Attorneys
I was ER Doctor for 19 years.
Some injured workers went to an Attorney
BEFORE they came to the ER.
Most Attorneys want the best outcome for their
client.
However, Workers Comp Attorneys are paid a
percentage of the injured workers indemnity,
The longer the patient is out of work, the more
money the attorney makes
Physician Outliers
Examples of cases I have reviewed
Requested:
1.
2.
3.
4.
5.
6.
7.
8.
Bilateral thoracic medial branch blocks at T9,
T10, T11 and T12
(10 injections)
Lumbar medial branch blocks at bilateral L4,
L5, and L1
(8 injections)
Lumbar discogram
(multiple injections)
Repeat left L4 and L5 lumbar transforaminal
epidural steroid injection (2 injections)
Lumbar spine orthotic bracing
TENS unit
Physical therapy 3 times a week for 6 weeks
Lab testing for liver and kidney function
Minimum of 22 injections
Physician Outliers
Total Number of
Pages submitted for
review
By one doctor; On one patient;
In one day
4945
Other Medical Provider Outliers
Not Just Physicians
Pre-surgical Psychological Assessment
•
•
•
Psychological testing suggest a strong
somatic focus
Patient expressed a strong
dissatisfaction with his job
Psychotherapy is strongly recommended
Patient’s post-procedural prognosis is
GOOD?
Other Medical Provider Outliers
Not Just Physicians
Physical Therapy and Chiropractors
• Patient has Physical Therapy Visits
before surgery
• Patient has 86 Physical Therapy
visits after surgery
• No unusual complications
• Most of therapy provided was passive
Physical Therapist request an additional 4
to 6 weeks of Physical Therapy
Louisiana Workers Comp
Patient thinks he
or she is getting
the best medical
care
Attorney tells patient he/she is being
referred to one of the BEST doctors in the
WORLD for his/her condition
Cultural Issues
Workers Compensation Research Institute
Long Term Use of Opioids, 2nd Edition
May 2014
Summary of Major Findings
“Longer-term opioid use was most
prevalent in Louisiana, where 1 in 6
injured workers with opioids were
identified as having longer-term use of
opioids in 2010/2012.”
If Physician writes prescription for an
opioid, the guidelines allow that Physician
to see the patient 12 times a year.
Medical Treatment Guidelines
In 2009, the Louisiana Legislature
passed RS 23:1203.1 which provided
the process of adopting a medical
treatment schedule with the purpose of
assisting with the decision making
process regarding proposed medical
treatment for the injured worker.
The Medical Treatment
Guidelines became effective
July 13, 2011.
What is the Purpose of Guidelines?
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To describe appropriate care based on the
best available scientific evidence and
broad consensus;
To reduce inappropriate variation in
practice;
To provide a more rational basis for
referral;
To provide a focus for continuing
education;
To promote efficient use of resources;
To act as focus for quality control,
including audit;
To highlight shortcomings of existing
literature and suggest appropriate future
research.
http://www.openclinical.org/guidelines.html
What is the Purpose of Guidelines?
 Education
 Police the
Outliers
http://www.openclinical.org/guidelines.html
The Process Before 2011
Physician wants over $750.00 nonemergent care
• Office visit
• X-rays
• Therapy
• MRI, CT Scan
• Surgery
A 1010 Request is made to the
Workers’ Comp Carrier
If denied the provider had to file a
1008 Request and go to Workers
Comp Court
The Process Before 2011
If Request denied by WC
Carrier?
Before July 2011, if there was a dispute
about medical necessity, the injured worker
or medical provider had to file a
1008 Request to WC Court
And the decision was made by a non-medical
person
Average time to determination:
300 - 500 days
The Process After 2011
To initiate the request for
authorization of care beyond
the statutory non-emergency
medial care monetary limit of
$750 per health care provider,
the health care provider shall
submit LWC-WC-1010 along
with the required information by
fax or email to the carrier/selfinsured.
The 1010 Process
The carrier/self-insured has 5
business days to determine if
the information required has
been provided.
The carrier/self-insured may then
request a LWC-WC-1010A
identifying information that was
not provided.
The health care provider has 10
days to respond to the request
for additional information.
The 1010 Process
If the carrier/self insured employers
determines the request for
information has been satisfied
then the carrier/self-insured has
five business days to act on the
request.
The carrier/self-insured employer
who fails to return LWC-WC-1010
within the five business days is
deemed to have denied such
authorization, i.e. tacit denial
NOW – 1009 Process
If the request is denied
(including tacit denial) or
approved with
modification; and the
health care provider
determines to request a
variance from the medical
director, then a LWC-WC1009 shall be filed.
The 1009 Process
Two clerical personnel at the
Louisiana Office of Workers
Compensation initially review
the 1009 Request to
determine if the appropriate
items were submitted.
Claim set up.
Could be rejected for clerical
reasons.
The 1009 Process
Four nurses at the Louisiana
Office of Workers
Compensation review the
submission to determine if
question is related to
Medical Treatment
Guidelines
If yes, then claim is sent to
Medical Director for
review.
Louisiana Medical Treatment
Guidelines
What is MY Job as OWC
Associate Medical Director?
My Job is NOT to determine if
something is medically necessary
MY JOB
is to determine if a
1010 Request
is allowed by the
Medical Treatment Guidelines
Louisiana Medical Treatment
Guidelines
Number of 1009’s Received
2011
341 (6 months)
135 Made it to Medical Director
Average Days to Decide 2
2012
APPROXIMATELY
250/month are filed
2281
1432 Made it to Medical Director
Average Days to Decide 5
2013
3001
2198 Made it to Medical Director
Average Days to Decide 6
2014
2968
2110 Made it to Medical Director(72.3%)
2212 Separate Decisions
Average Days to Decide 3
2015
1277
988 Made it to Medical Director
Average Days to Decide
It is like making a Judicial Decision.
Takes me about an hour to assess
each appeal and write up Decision.
Louisiana Medical Treatment
Guidelines
Results of Reviews
2011
2012
2013
2014
37% Approved
60% Denied;
3% No Decision
25% Approved
71.4% Denied
3.6% No Decision
35.6% Approved
61/1% Denied
0.06% No Decision
31.5% Approved
63.4% Denied
0.05% No Decision
How Long Does It Take
to Decide a 1009 Appeal NOW?
Remember how long it
took to appeal a
Workers
Compensation Carrier
Denial before 2011?
300 to 500 Days
Louisiana Medical Treatment
Guidelines
How soon are denials
decided in 2015?
Average time to determination:
12 days
1 day for clerical
1 day for nurses to set up
7 days (5 business days) to allow WC
Carrier to respond
3 days for medical director to decide
Louisiana Medical Treatment
Guidelines
Reasons For Denials
3092 Distinct Cases
Clinical
467
404
227
201
123
94
91
72
Clinical findings do not correlate to requested
service
Clinical indications have not been met
Positive patient gain, improved pain scale or
functional improvement not noted
Conservative measures have not been initiated
or documented
Maximum Duration of Treatment has been
exceeded
Therapy records do not note dates of prior
treatment…
Other
Results of testing must be known prior to
additional
Louisiana Medical Treatment
Guidelines
Statistics
Most Workers Comp claims are less than
$750.00 (Especially by Occupational
Medicine Clinics)
The Medical Treatment Guidelines only apply
to non emergency requests over $750.00.
Workers Comp Carrier approves
approximately 90% of requests over
$750.00 (without need for appeal to WC Court)
Medical Director overrides approximately a
third of the WC denials within 12 days
Louisiana Medical Treatment
Guidelines
Bottom Line
About 93% of all
requests over $750.00 are
Approved within 18 days of
Request
As opposed to over 300 days
previously if not approved by the
WC Carrier
Louisiana Medical Treatment
Guidelines
and
The patient gets
BETTER CARE
Evidence Based
Peer Reviewed
1008 Process
If the Physician, Injured Worker, or
Worker’s Attorney feel the
patient should be an exception
to the literature based medicine
They can still file a
1008 Request
to be reviewed by a
WC Judge
And it takes less time now to get a Court Decision!
2011 - 2014 Average Delay for 1008's
Louisiana MTG’s
306
310
294
290
286.4
292
290
285
282.8
282
275
275
266
270
291
289
267
266
255
252
252
250
252
250
247
246
250
234
238.36
232.6
230.97
230
226.06
225.94
220.47
219
217.89
216.29
211.88
210
224.24
209.22
207.25
216.36
215.56
208.85
210
208.71
205
201.48
198.18
200.26
190
189
179.95
170
Jan
Feb
2011 Delay
282
266
2012 Delay
255
275
2013 Delay
219
230.97
2014 Delay
220.47
207.25
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
306
294
292
275
267
289
291
290
285
250
286.4
282.8
266
252
250
234
252
246
252
247
238.36
225.94
209.22
217.89
208.85
226.06
215.56
216.36
232.6
224.24
216.29
211.88
198.18
179.95
201.48
208.71
200.26
210
189
205
Louisiana MTG’s
The average time to
determination of a 1008
Request is now
LESS than 200 days
I am told that 1008 Appeals of
medical treatment guidelines
now gets expedited by
Workers Comp Court Judges
How do we make it BETTER?
Make the
Louisiana Workforce
Commission
Website
more user friendly
How do we improve the process?
Educate the Medical
Providers
1. On the literature
2. On what it takes
to get approval
Make the Guidelines easier to find
New Information Box
on the
Louisiana Workforce
Commission
Website Page
just for
Medical Providers
Make the Guidelines Readable
Improve the Format
 The current guidelines (if you can
find them) are published in the
same format as the Louisiana
Regulations
ALMOST
UNREADABLE
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§2009.
Therapeutic ProceduresNon-Operative
A. Before initiation of any therapeutic procedure, the authorized treating provider, employer, and insurer must consider these important issues in the care of the injured
worker.
B. First, patients undergoing therapeutic procedure(s) should be released or returned to modified or restricted duty during their rehabilitation at the earliest appropriate
time. Refer to “Return-to-Work” in this section for detailed information.
C. Second, cessation and/or review of treatment modalities should be undertaken when no further significant subjective or objective improvement in the patient’s
condition is noted. If patients are not responding within the recommended duration periods, alternative treatment interventions, further diagnostic studies or
consultations should be pursued.
1. Reassessment of the patient’s status in terms of functional improvement should be documented after each treatment. If patients are not responding within the
recommended time periods, alternative treatment interventions, further diagnostic studies or consultations should be pursued. Continued treatment should be monitored
using objective measures such as:
a. return-to-work or maintaining work status;
b. fewer restrictions at work or performing activities of daily living;
c. decrease in usage of medications;
d. measurable functional gains, such as increased range of motion or documented increase in strength;
D. Third, providers should provide and document education to the patient. No treatment plan is complete without addressing issues of individual and/or group patient
education as a means of facilitating self-management of symptoms
E. Lastly, formal psychological or psychosocial evaluation should be performed on patients not making expected progress within 6 to 12 weeks following injury and
whose subjective symptoms do not correlate with objective signs and tests.
F. Home therapy is an important component of therapy and may include active and passive therapeutic procedures as well as other modalities to assist in alleviating
pain, swelling, and abnormal muscle tone.
G.The following procedures are listed in alphabetical order.
1. Acupuncture is an accepted and widely used procedure for the relief of pain and inflammation, and there is some scientific evidence to support its use. The exact
mode of action is only partially understood. Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the brain, promotes deep
relaxation, and affects the release of neurotransmitters. Acupuncture is commonly used as an alternative or in addition to traditional Western pharmaceuticals. While it
is commonly used when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten the
return of functional activity. Acupuncture should be performed by licensed practitioners.
a. Acupuncture is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points). Needles may be inserted, manipulated, and retained for a
period of time. Acupuncture can be used to reduce pain, reduce inflammation, increase blood flow, increase range-of-motion, decrease the side effect of medicationinduced nausea, promote relaxation in an anxious patient, and reduce muscle spasm. Indications include joint pain, joint stiffness, soft tissue pain and inflammation,
paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.
b. Acupuncture with Electrical Stimulation: is the use of electrical current (micro-amperage or milli-amperage) on the needles at the acupuncture site. It is used to
increase effectiveness of the needles by continuous stimulation of the acupoint. Physiological effects (depending on location and settings) can include endorphin
release for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain stimulus, and muscle relaxation.
i.
It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in
multiple sites.
c. Total Time Frames for Acupuncture and Acupuncture with Electrical Stimulation: Time frames are not meant to be applied to each of the above sections separately.
The time frames are to be applied to all acupuncture treatments regardless of the type or combination of therapies being provided.
i.
Time to Produce Effect: three to six treatments
ii.
Frequency: one to three times per week.
iii.
Optimum Duration: one to two months.
iv.
Maximum Duration: 14 treatments.
v.
Any of the above acupuncture treatments may extend longer if objective functional gains can be documented or when symptomatic benefits facilitate
progression in the patient’s treatment program. Treatment beyond 14 treatments must be documented with respect to need and ability to facilitate positive symptomatic
or functional gains. Such care should be re-evaluated and documented with each series of treatments.
d. Other Acupuncture Modalities. Acupuncture treatment is based on individual patient needs and therefore
Make understanding the
Guidelines easier
Links to:
 The Louisiana Medical Treatment
Guidelines
–
–
Register Version
Hyperlinked Version
 The Louisiana Revised Statutes
related to Workers Comp
 The Louisiana Administrative
Code related to Workers Comp
 Frequently Asked Questions
 Cheat Sheets outlining the
requirements for the most
frequently asked for modalities
Our job should be to help providers find
the information they need
Make the Guidelines Searchable
 Have a Table of Contents
 Hyperlink the Table of
Contents to the Sections in
the Guidelines
 Hyperlink the references in
the guidelines to the
bibliography
 Hyperlink the bibliography
to the online abstracts of
referenced articles
Keep the Guidelines Up To Date
 Update the References
 Clarify the expectations
 Clarify the requirements
needed for modalities
 HELP the provider
understand the purpose
Process
 Based off Colorado’s Guidelines
– Colorado has 4 full time working on
guidelines
 In the Process Now

CTS Update almost through Register Process
 Current Update
– Cervical Spine
– Low Back Pain
– Chronic Pain Disorder
 Future Updates
– Diagnostic & Therapeutic Injections
– Elbow and Hand (totally new)
Substantive Changes & New Issues
 New SI Joint Fusion Indications
 Clarify Drug Screen Indications
 Clarify indications for repeat
Advanced Imaging and
EMG/NCS
 Psychosocial Screenings
– Current Guidelines say should get
them at 6 to 12 weeks
– Recommend REQUIRE Full evaluation
by Psychiatrist or Psychologist at 6
months if not back to work
New Issues
Recommended
Drug Screening Requirements
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Prescribing physician is required to document risk stratification using
validated psychometric screening tool. Examples include:
– The Opioid Risk Tool (ORT)…
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1 to 2 drug screens a year for low risk patient.
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Maximum 4 drug screens per year for moderate or high risk patient,
unless physician documents aberrant conduct.
– No drug confirmation testing is required unless results of drug
screen is inconsistent with expectant result, i.e. positive for drug the
patient does not have a prescription for or negative for a drug the
patient is supposed to be taking.
– A 1010 Request is not required for the first two drug screens
ordered in a calendar year.
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New Issues
Indications for Repeat Advanced
Imaging or EMG/NCS Testing
– Progressive neurological change; or
– Onset of myelopathy; or
– Approved surgical intervention where
most recent scan is more than 12
months prior
New Issues
Recommended Psych Evaluation
Unless objective medical findings explain symptom persistence, any
patient who has not returned to work by 6 months
will be required
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to undergo a full Psychosocial Evaluation
Up to 90 minutes of clinical interview, and
Up to an additional 7 hours of psychological testing.
• A comprehensive assessment of psychopathology (such
as the current edition MMPI or the PAI).
• Test(s) of attitudes and/or beliefs regarding pain.
• Pain coping strategies.
• Assessment regarding return to work.
The formal psychological evaluation should address whether the
patient has any psychological factors which might alter symptom
reports in a way that could impact assessment or adversely affect
any future treatment, including rhizotomy, discography or surgery.
Next Guideline Update
 Update diagnostic
and therapeutic
injection indications
– This has been worked on for over
a year BUT had controversy and
over 130 suggestions
– Being updated separately from rest
of Cervical Spine, Low Back Pain
and Chronic Pain Disorder
subchapters
Suggestions
Suggestions for appealing a denial to
the Medical Director
Do’s:
1. Send specific information related
to your request
2. Recent history and physical
3. Pertinent tests results (MRI, EMG,
etc.) that document abnormality
4. Proof conservative therapy has
been used if required by
guidelines for your request
Suggestions
Suggestions for appealing a denial to the
Medical Director
Don’t:
1.
Send 100’s of pages
1.
2.
2.
3.
4.
5.
Makes me think you do not know your case
This is a clinical review
Send duplicates
Send administrative / billing
Bash the Workers Comp carrier
Don’t ask for more than the guidelines allow
If you do this,
it is clear you do not know the guidelines and
creates the impression you do not know what
you are asking for!
GOAL
Improve
Patient
Outcomes
Get injured workers back to work
CONCLUSION
The OWCA is not your enemy.
I want your patient to get the best possible care
My job is NOT to determine the
medical necessity of a claim!
That is the job of the Workers Comp Utilization Review
My Job is to:
1. Help Update the Guidelines; and
2. Determine if a 1009 Request
is allowed under the
Louisiana Medical Treatment Guidelines