The federal Institute of Medicine defines a guideline as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." This is the definition RAND used in a late-2004 review of five sets of candidate guidelines. The study team found all sets wanting but suggested to California regulators that they continue to recognize as presumptively correct one set that was written into the 2003 law. This set was prepared by the American College of Occupational and Environmental Medicine, or ACOEM.
The medical-guideline business is a little like a 10-year maritime passage through a channel crowded with The Rocks of Dim (dissension, inertia, myopia). Guidelines need to be thoroughly renewed at least every five years. The efforts by several states to serve up their own guidelines failed to last more than a few years.
Why do I call ACOEM's guidelines fragile? Workers' comp guidelines should have crisp, well-defended rules on the quantity of physical therapy and chiropractic care. RAND reports that the ACOEM guidelines are weak in this area. (So are the other sets.) They are also light on when to use expensive diagnostic procedures such as MRIs, and pain medications on an ongoing basis. To understand how these guidelines got to where they are now, and where they may go, I had to study what is behind them.
It is very difficult to carry out gold standard-type studies of clinical effectiveness. You must track months and years of experience of many injured workers who have been divided into a treatment group and a control, or untreated, group. There are precious few such studies. And you should not blindly accept the study results from the group-health community, because the benefits and rules in workers' comp make a very different set of incentives and barriers.
And guidelines are very hard to implement, as an example from outside our field illustrates. Veterans Affairs has tried for years to get its psychiatrists to prescribe for mental disorders new drugs that are universally regarded as an improvement over earlier generations. The VA has one of the most advanced medical monitoring systems in the world. After a decade, one-fifth of VA doctors continued to use the older drugs.
ACOEM itself conveys a tweedy image that jars with its new prime-time role. Try to find the guidelines on its Web site. It will take some doing. But--considering the stakes involved, ACOEM is clearly the best pony in the stable. That guideline definition says "practitioner and patient decisions." I trust ACOEM to promote the collaborative nature of clinical decisions. I also trust ACOEM to grasp the need to root out undercare as much as overcare, and to address work-injury recovery as a continuum of care, not just isolated events.
Claims payers and regulators can help these guidelines succeed, by regulation, bully pulpit and practice. Pay more attention to quality in your informal or formal network of providers. Forget the mantra that you can never go wrong by discounting a medical invoice. Bring these guidelines into your neighborhood.
PETER ROUSMANIERE, a Vermont-based consultant and writer, is the workers' comp columnist for Risk & Insurance®.
August 1, 2005
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