New York: New guidelines described as 'most fundamental change'

New treatment guidelines taking effect in New York may serve as a model for other states. What's unique is the inclusion of all participants from the very beginning to the Dec. 1 implementation date.

"This is the most fundamental change in our workers' comp system since it began," said Elizabeth Miller, special assistant to the chair of the New York Workers' Compensation Board. The treatment guidelines were created by an advisory committee comprised of medical professionals and representatives from business and labor.

The involvement of business and labor representatives early in the process was seen as imperative to achieve one of the goals of the new guidelines: to reduce the litigiousness of the New York workers' comp system. That is considered a major obstacle to the other goals:

Expediting quality medical care to injured workers.
Improving medical outcomes for injured workers.
Increasing the speed of returning injured employees to work.
Increasing timely payments to medical providers.

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"The mission of the treatment guidelines is to expedite and facilitate the delivery of appropriate medical care to the injured worker with a goal of furthering functional improvement as quickly as possible," said Ken Eichler, director of government and insurance services for the Reed Group."A byproduct is that cost containment may be achieved, but that's not the primary goal. The injured worker has to be the number one priority."

The Reed Group is working with the board to develop and implement the crosswalk from the language of the state guidelines to the applicable International Classification of Diseases and Current Procedural Terminology codes, which will be commercially offered to all stakeholders as part of Reed Group's Web-based guidelines navigation software, MDGuidelines.

The guidelines are a conglomerate of the best tools available. They include pieces from the Colorado treatment guidelines, the American College of Occupational and Environmental Medicine Practice Guidelines, and Washington state along with some original ideas.

Initially, the guidelines will cover four body parts: neck, shoulder, back, and knee. "They make up about 40 percent of claims and 60 percent of costs," Miller said. Eventually, additional body parts will be covered by the guidelines.

Variance process. Under the new guidelines, physicians must get paid if the treatment is consistent with the guidelines. For treatments that are not covered, the developers created the optional approval process to improve the pre-authorization system.

"The current system takes 30 days," Miller said. "This process takes eight days."

The carrier sends information to the medical provider, who decides whether the proposed treatment is consistent with the guidelines. Some issues can be immediately resolved while others go through a process designed to speed the system.

The carrier must include a name and contact information so the provider can talk to the carrier and resolve it without going through the formal resolution process, Miller said.

Implementation. Communication is also key to implementing the new guidelines. To ensure everything was carefully thought through, the board initiated a pilot program.

Approximately 60 insurance carriers and 100 medical providers have been working with the new guidelines for the last several months, processing 1,400 cases. Three months into it, the WCB sent out a formal survey.

"It looked at the original goals and asked, 'Do you think this is working?'" Miller said. "We got really positive responses."

Using the information from the survey and follow-up roundtable discussions, the WCB developed the regulations to implement the program. The final piece of ensuring success of the guidelines is the far-reaching training program that has been established.

The board is offering extensive, free online training on its website. Continuing education credits are also available.

The WCB is sending three separate letters to the approximately 30,000 physicians who interact with the state's workers' comp system. Additionally, it is meeting with various stakeholder groups to discuss the treatment guidelines.

"We watched what happened in other states," Miller said. "We feel strongly that you need to implement this thoroughly if you want to have the effect you're looking for."

Read more at the WorkersComp Forum homepage.

December 9, 2010

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