UPDATE (January 17, 2012)
The Montana Guidelines went into effect JULY 1, 2011.
The first set of Montana Guidelines training webinars are now available, along with PDF files of the training materials.
This document is provided as a customer service. It includes the five new administrative rules that adopt and implement the U&T guidelines and select existing rules that were amended to coordinate with the U&T guidelines. It does not include all workers' compensation medical services rules that are applicable to medical service provided on or after 7-1-11. In the event of a discrepancy between this document and the official printed text of the rules maintained by the Secretary of State, the official printed text will be considered correct.
The Montana Utilization and Treatment Guidelines are now available in a printed and spiral bound two-volume set for the cost of production. Volume 1 contains the guidelines for Low Back Pain, Shoulder Injury, Upper Extremity, and Lower Extremity. Volume 2 contains the guidelines for Complex Regional Pain Syndrome, Cervical Spine Injury, Chronic Pain, Traumatic Brain Injury, and Eye Injury. The cost is $100 (includes shipping). To order, e-mail Anne Wolfinger (firstname.lastname@example.org).
For more information on the Montana Guidelines, contact Maralyn Lytle, email@example.com, (406) 444-6604
Clinical Content Ratings- Final (pdf)
Technical Content Ratings- Final (pdf)
Colorado Guideline Experience: Process and Principles(Dr. Kathryn Mueller, Medical Director, State of Colorado) (pdf)
ODG Guidelines and Codes for Automated Approval(memo from Gary Lusin, MPG member) (pdf)
MDGuidelines--Montana's Workers' Compensation TreatmentGuidelines (Ken Eichler, Reed Group) (pdf)
Preliminary Ratings Summary--Clinical Content
Request for Comments on Preliminary Recommendation(Letter from Dr. Alan Dacre, chair, Medical Provider Group) (pdf)
The View from Interventional Pain Mecidine(Eric Hauth, Neuromodulation Therapy Access Coalition) (pdf)
Washington State Medical Treatment Guidelines(Dr. Lee Glass, Washington Department of Labor and Industries) (pdf)
Washington State Medical Treatment Guidelines Review of U&T Scenarios--Instructions
Medical Dispute Resolution Presentation(Diana Ferriter, Employment Relations Division) (pdf)
Proposal for Review of Utilization & Treatment Guidelines Disputes(Keith Messmer, Employment Relations Division) (pdf)
Public Comment: Letter from Matthew F. Gornet, MD, The Orthopedic Center of St. Louis (pdf)
Official Disability Guidelines - Treatment in Work Comp(Phil LeFevre, Work Loss Data Institute) (pdf)
Draft "Program" evaluation criteria for implementation of treatment guidelines in workers' compensation cases (Ann Clayton, Ann Clayton & Associates)
Montana Workers' Compensation Data Supplement: Most Costly Injuries by Plan Type(handout by Ting Withers, data analyst, Employment Relations Division) (pdf)
Opening Remarks (Keith Kelly, Commissioner, Montana Department of Labor and Industry)
Summary of the Workers' Compensation Study Project (Jerry Keck, Administrator, Employment Relations Division)
Presentation slides (pdf)
Montana Workers' Compensation Data (Ting Withers, Workers' Compensation Analyst, Employment Relations Division)
Presentation slides (pdf)
Medical Provider Group Charter (Anne Wolfinger, Project Manager, Employment Relations Division)
Medical Provider Group Review Process (Jerry Keck, Anne Wolfinger)
Presentation slides (pdf)
Technical Review (pdf)
Clinical Content Review--Appropriateness (pdf)
Clinical Content Review--Quantity (pdf)
Clinical Content Review--Entire Guidelines (pdf)
Clinical Content Review--Ranking (pdf)
Alan Dacre, MD, Chair
Gary Lusin, PT
Paul Gorsuch, MD
Steve Kemple, DO
Camden Kneeland, MD
Patrick Galvas, DO
John Petrisko, MD
John C. Schumpert, MD
Phillip Steele, MD
Allen Weinert, Jr., MD
Mark Stoebe, DC
Ken Carpenter, MD
William Stratford, MD
James English, PhD
Great Falls, MT
Great Falls, MT
Great Falls, MT
Medical Provider Group on Utilization & Treatment Guidelines
Wednesday, February 24, 2010
Jorgenson’s Inn, 1714 11th Avenue, Helena, MT
Welcome and Introductions
Utilization & Treatment Guidelines Project to Date
Colorado Medical Treatment Guidelines
MPG Clinical Content Rating of Colorado Guidelines
Final Recommendation Discussion
Alan Dacre, MD, Chair
Jerry Keck, Administrator
Dr. Kathryn Mueller, Medical Director
Alan Dacre, MD
Alan Dacre, MD
Anne Wolfinger, Project Manager
To participate by teleconference: Number (toll-free): 1-866-414-2828
Access code: 359025 (your phone will be on mute; the lines will be unmuted during public comment)
U & T Guidelines Project
February 24, 2010
12:30 p.m., Jorgenson’s Inn, Helena
MPG members present: Alan Dacre, MD, Gary Lusin, PT, , Jim English, PhD, Phillip Steele, MD, Mark Stoebe, DC, Allen Weinert, Jr., MD, Pat Galvas, DO, Paul Gorsuch, MD, Camden Kneeland, MD (participating by phone) John Petrisko, MD (participating by phone) Valerie Benzschawel, CFNP
Project team members present: Jerry Keck, Anne Wolfinger, Diana Ferriter, Bruce Chamberlain, Lea Coles, Keith Messmer, Ryan Morton
Others present: Bridget McGregor, Linda Reed, MSF; Andy Adamek, BKBH; Lucy Shannon, Reed Group; Dwight Easton, Farmers Insurance; Jessica Holmes, Boston Scientific; Pat Murdo, Legislative Services; Don Judge, LMAC; Trudy Winslow, MHS; Erin MacLean, MMA; Ryan Morton, Kristine Shields, Anni Druce, Karen Wiles, Teresa Graham, Barb Gullickson, ERD; Phil LeFevre, Work Loss Data Center (by phone); Ken Eichler, Reed Group (by phone)
I. Welcome and Introduction
Dr. Dacre opened the meeting by thanking those in attendance for coming. He had everyone introduce themselves.
II. Summary of Utilization & Treatment Guidelines Project to Date
Jerry Keck provided an update on the status of the project to date. The Department plans to take the recommendation made today to other stakeholders for their input, prior to making a final decision on the implementation of a guideline. He stated there may not be enough time for another meeting of this group before the rules are noticed, but the Department will keep the MPG members apprised through email. Prior to the final adoption, he plans to have a meeting to discuss outcome measures and implementation.
III. Colorado Medical Treatment Guidelines
Dr. Kathryn Mueller, Medical Director for the Colorado Department of Labor and Employment, discussed the guidelines that are being utilized in Colorado. The guidelines there are meant to be advisory and educational, but at the same time are mandatory for providers to follow. Prior authorization is not needed for anything that is allowed in the guidelines when treating an injured worker. Every guideline has evidence and a consensus portion contained within it, as she said there is not enough evidence out there to solely base them on evidence. Their consensus decisions will consider the morbidity and mortality rate, higher level of disability and cost (at times). Functional outcomes get emphasis in the guides. The guidelines are update at least every five years. Evidence statements and articles will be listed in the newer guidelines, but may not be found in some of the older guidelines.
Dr. Galvas: Do you do any studies on your own where you have had problems or do you rely on national studies? Response: No, we rely on the national studies.
Dr. Galvas: You do certification of physicians to do impairment ratings?
Response: Yes, there has been a significant reduction in litigation over impairment ratings since certification is required. Dr. Gorsuch: Who determines causality in CO?
Response: The doctor does the medical causation piece.
Dr. Gorsuch: How do you view return to work?
Response: We look at what do you want to do to get the patient better, faster. Return to work is a natural part of that process.
Dr. Galvas: With restrictions placed on an injured worker, small employers often don’t have positions that they can place the worker into.
Response: In that case you need to tell the patient what they can do at home to get better, faster.
Dr. English: I like your Traumatic Brain Injury (TBI) guideline, but we don’t have Craig or Spaulding, so we have to continue the care.
Response: We tried to address this; we address mild TBI because in the complex cases they are going to get the care they need.
Dr. Stoebbe: In CO you still use the 3rd edition of the impairment guides. Why?
Response: We did too good of a job in our education of the provider. Everyone is familiar with this guide and wants to stay with it. I am certified and teach the sixth edition and do not find it to be difficult.
Dr. Galvas: Your guidelines haven’t had that much of an effect on costs?
Response: I can’t say, because we had multiple changes that took place at the same time.
Gary Lusin: If you were trying to measure the effect of the guidelines, how would you do it?
Response: You need to look at functional outcomes and process measures. The patient met measures for surgery, for example.
Dr. Dacre: The functional outcomes may not correlate with RTW.
Response: That is correct; you want a number of measures.
Dr. Galvus: For RTW do you look at only the time of injury job or do other positions count?
Response: You look at them all.
Anne: Can you comment on your training or educational work?
Response: The primary provider is accredited. We do workshops in which we break into groups and go through case scenarios. Our evidence based statements are very important.
Dr. Gorsuch: I would think that employer choice has a lot to do with CO’s success.
Response: The insurer networks have been the most beneficial.
Dr. Mueller then discussed how the guidelines would be utilized in each of the seven injury scenarios that had been provided to her by the MPG.
Dr. Gorsuch: I like CO’s approach because you say it is not recommended, but say if you are going to do the procedure anyway this is what should be looked at.
Dr. Dacre: If we implement CO, what kind of support and education could we get from CO?
Response: No support. Everything we do is public, so we could give you our educational materials. I have very complete instructor sets, scripted out, that I can share.
Jerry: Physicians do the training?
Response: Yes, primarily.
Gary Lusin: It takes you longer to update than the other guidelines. Are you comfortable with that?
Response: We update every five years. If something came up that was a major issue, we would do an update more often. Gary Lusin: Anything you change is a rule change?
Response: Yes, but we can do interpretive bulletins.
IV. MPG Clinical Content Rating of Colorado
The members then completed the technical and clinical content rating forms for the Colorado Guidelines. The scoring was compiled and will be posted on the website. Colorado came out on top for all but one of the measures.
V. Final Recommendation Discussion
Jerry Keck led a discussion regarding the guideline preferred by the members of the committee.
Dr. Weinert: CO gets the nod. I am concerned that the guides are reviewed only every five years. Practice changes much quicker.
Dr. Dacre: In general practice that is the case. Overall, I don’t practice differently now than I did five years ago. Some things obviously change.
Dr. Steele: I do struggle with five years for review. It would help if I only have to review every five years. I am going to conferences all the time to stay up on things. Also, the practicality of what they recommend may not work here. Looking at these as a whole, general is not well addressed, the specialist is well represented.
Gary Lusin: From the PT standpoint, the six PTs that made up my review panel liked CO. I called PTs and physicians in CO and the guidelines really helped the general practitioners. Injured workers are primarily seen by Occupational Medicine doctors in CO. In rural areas these gave clear direction. I also talked with P’s using ODG and they felt a little restrained. The PTs are favorable towards guidelines.
Dr. Steele: The Front Range of CO is very different from the other areas in CO. I am very concerned about the rural areas.
Dr. English: The TBI section is 82 pages. This is an enlightened document. It is the right thing to do. The lack of resources that Dr. Steele addressed is a problem causing providers to leave. Guidelines will bring practitioners back into practice here.
Dr. Galvas: Just because we do not have resources is no reason to not adopt. We are aware of the problem areas like IDET without it being updated. TBI is really good and I agree with the spine part.
Dr. Stoebbe: The CO guidelines are way better because they allow more care. Is that good? Maybe/maybe not. I talked to chiropractors across the country; they dislike ODG and ACOEM. What works and what doesn’t in CO needs to be investigated, like their annual meetings. We also need guidelines for documentation. I do several hundreds of impairment ratings and many of the bad results I see could be helped by guidelines. Need training annually with functional instructions.
Valerie Benzschawel: Any one of the guidelines will be fine. CO covers the psycho-social areas missed in the other guidelines. I see that every day. These folks need to get treatment. ACOEM offers the most support. ODG offers support. CO offers no support. We already have a problem with primary physicians dropping out of the system and referring to me because I know workers’ compensation. Implementing the guidelines will be a big problem.
Dr. Gorsuch: The problems with the delays in updating may be a good thing because surgeons should be restrained from trying new procedures. CO guides say it is acceptable to do for a subset and here is that subset.
Dr. Dacre: CO does credentialing. I would like to hear more about it. The distance that a patient may have to travel to a credentialed physician will be a problem.
Dr. Petrisko: One thing to be aware of, no matter what we adopt we may have to meet again to see how they are working. Choose a guide and then try to improve it from there.
Dr. Galvas: From an Osteopath point of view, I liked CO because it addressed manual medicine and explained it. With this the primary care physician has a better comfort level when referring to a chiropractor. It will be good training material for adjusters as well. Chiropractors aren’t the only ones that don’t document well. PTs don’t either.
Dr. English: The clinical strengths of CO have been heard. What is the default for the areas that are not covered? Jerry: This is not well defined. CO has a lot of similarities with ACOEM. If we go with CO the default should be ACOEM. The Reed Group is already working with ACOEM and we could utilize them to integrate ACOEM with CO. We would like it to be comprehensive. We would like to make it easy to use. The training piece will be larger than this selection process. We will have to create our own if we are using CO. There are also the CPTs and DRGs automatically paid list in ODG that is not available in the CO guidelines.
Dr. English: How many diagnoses fall through?
Jerry: Katherine said that 80% is covered.
Dr. Gorsuch: If Reed Group had some product for ODG, would you still prefer ACOEM?
Phil Lafevre: CO is already posted on the ODG website. CO as primary and ODG as back up could do just that. Ken Eichler: The Reed Group has fully integrated into a fully usable system.
Valerie Benzschawel: What you have proposed would be the perfect answer with the Reed Group front-end and ACOEM as the default.
Bridget McGregor: Dr. Carpenter’s preference is for ODG.
Lucy Shannon: The tool for CO guidelines is similar to the feel for ACOEM. We have placed tools for what is approved, etc. We have developed a tool for editing guidelines, so you could make them work better for MT.
Gary Lusin: When you look at the tool, CO primary, ACOEM default, would you distinguish between the diagnoses so there is no confusion.
Lucy Shannon: The user needs to select where they want to go for the information. Always show me CO or always show me the most recently updated.
Dr. Dacre: As a MT practitioner, if we go to this would you subtract out all of the ACOEM that is already covered by CO so we avoid competing guidelines?
Lucy Shannon: Yes.
Ken Eichler: We can customize into MT guideline. If you want part A from CO and part B from ACOEM, then that is what we would build along with the flexibility to modify as you progress.
Dr. English: ACOEM and CO had previous work relationships. Can we do that with ODG?
Phil Leferve: CO guideline is in public domain. We post changes in real time.
Jerry: Would a MT provider be able to go to the ODG website and see the MT guideline?
Phil Leferve: Yes we could customize that.
Dr. Gorsuch: I propose a motion to adopt CO as primary guideline. Dr. Dacre seconded.
U&T Medical Provider Group February 24, 2010
Dr. Weinert: Just an observation. CO is the most accepting, ACOEM is the most restrictive and yet they blend the best because of the Reed Group.
The vote was taken and it was unanimous for the motion.
Gary Lusin: We have scored ODG consistently higher, so I would prefer ODG but the Department may need to figure out how that can be done and may need some time to investigate.
Dr. English: Implementation, training and support. The Department may not know what is available from ACOEM and ODG. We should give you time to find that out.
Dr. Gorsuch: I am torn because Valerie likes ACOEM and Ken likes ODG, but I don’t know how strongly primaries feel about the default.
Dr. Steele: It is important for the Department to see how they can be integrated. Need user friendly interface. If it takes more time to check the guideline then will not do.
Valerie Benzschawel: I am very impressed with the Reed Group. Easy to get between the guides. It is seamless. I don’t see ODG as that way at all. We need to try to get the primary care docs back. I go over the psycho-social so I am with a patient for 30 minutes. I can’t sell ODG and you need me for implementation.
Dr. Dacre: I think there is a consensus; I make the motion that the Department can make this decision on the secondary guideline. Both of these are good guidelines, but the platform will be critical. I suppose that MT makes that decision based on the most cost appropriate and fiscally responsible. Dr. Weinert seconded the motion.
Dr. English: Would you see what those considerations are?
Jerry: We will investigate with Reed Group an enterprise license with seamless look and feel and explore the same thing with ODG. See what each will cost.
Dr. English: Will training resources be a consideration?
Dr. English: Will disability duration be a consideration?
Jerry: We do not want to interfere with the work being done by WorkSafeMT. I think we will have this tool. Whether it is mandatory to use, I don’t know.
Dr. Dacre: Look at ease of use as part of the consideration.
A vote was taken and there was unanimous agreement to let the Department select the secondary guideline.
VI. Next Steps
Dr. Dacre: I suggest that providers make themselves available down the road as ongoing evaluation will be critical. The outcomes subgroup needs to continue to work. To have another group review this would not work. We should meet yearly to see if we have made a difference.
Anne: We will contact ODG and Reed Group to evaluate and also work on the rules.
Jerry: The outcome subgroup will continue to work for awhile.
Dr. Dacre: Could we present the outcome results to this group?
Jerry: We could get together when the Department has this put together and talk about outcomes as well.
Dr. Dacre: You don’t have a physician on staff. How many of us would feel comfortable traveling to discuss this with other physicians around the state? I know I would. There was some general agreement around the table.
VII. Public Comment
Dr. Dacre asked for public comment.
Erin MacLean from the Montana Medical Association commented that she has heard a lot about the need for an educational effort. The Association is concerned about physicians leaving the system and she offered the help of the association in getting the word out.
Andy Adamek, BKBH, thanked the members of the committee and the Department for their efforts.