Department of Labor and Industry

Minutes September 17, 2009


U & T Guidelines Project

Medical Provider Group Meeting
September 17, 2009
12:30 p.m., Great Northern Hotel, Helena

MPG members present: Alan Dacre, MD, Jim English, PhD, Ken Carpenter, MD, Pat Galvas, DO, Allen Weinert, Jr., MD, Paul Gorsuch, MD, Valerie Benzschawel, CFNP, Phillip Steele, MD, Mark Stoebe, DC, Gary Lusin, PT, John Petrisko, MD (participating by phone), Camden Kneeland, MD (participating by phone)

Project team members present: Jerry Keck, Anne Wolfinger, Diana Ferriter, Keith Messmer, Bruce Chamberlain, Ting Withers, Lea Coles

Others present: Ann Clayton, Ann Clayton & Associates, (participating by phone); Kris Wilkinson, Legislative Fiscal Division; Karen Wiles, Anni Druce, Employment Relations Division; Stacy Allen, RN, Benefis Health System; Ken Eichler, Lucy Shannon, Reed Group; Nancy Hiller, Advanced Pain and Spine Institute; Pat Murdo, Legislative Services; Dwight Easton, Farmers Insurance; Andy Adamek, Erin Sexton, Medtronic; Michael Marsh, Midland Claims/Industrial Injury; Trudy Winslow, Montana Health System; Tim Fitzpatrick, Montana School Boards Association; Bridget McGregor, Montana State Fund; Jacqueline Lenmark, American Insurance Association; Lance Zanto, Department of Administration

I. Welcoming & Introductions
Dr. Dacre, Committee Chair, thanked everyone for their participation and had everyone introduce themselves.

II. Overview of Utilization and Treatment Guidelines Project
Jerry Keck, Administrator, Employment Relations Division, gave a brief overview of why the Medical Provider Group had been formed. The primary goal of the adoption of guidelines is to improve the medical outcomes for injured workers. He said that 56 to 70 cents of every dollar spent in the workers’ compensation system is for medical expenses.

III. Defining Outcomes
Jerry Keck introduced Ann Clayton of Ann Clayton and Associates who is a consultant for the Employment Relations Division and asked her to review the report she had prepared on possible evaluation criteria to measure outcomes resulting from the implementation of U & T Guidelines. Ann reviewed the recommendations in her report which included five possible ways to evaluate the effectiveness of the guidelines. Jerry asked that the committee members review the report and time will be scheduled at the next meeting to get their reaction and thoughts on other measures that might be possible.

IV. Action Item Review
Anne Wolfinger, Project Manager, Employment Relations Division, handed out a report prepared by Ting Withers in response to a request from Dr. Galvas. The report broke down the most costly injuries Ting talked about at the first meeting by the workers’ compensation plan type. Dr. Galvas urged the members to review the report saying that the injuries did vary depending on the plan. 

V. Presentation on American College of Occupational and Environmental Medicine (ACOEM) Guidelines
Kurt Hegmann, Chris Wolfkiel and Matt Hughes gave an overview of the ACOEM guidelines. Dr. Hegmann stated that the guidelines have been in place for about 10 years and that the guides ensure that injured workers get the most appropriate treatment as early as possible. He walked the group through the review of evidence that is done on each area contained in the guides. The next edition of the guides due out next year will run about 3,600 pages. Dr. Carpenter questioned how ACOEM determines who will review a guideline. Answer: Any group they can think of that does any work in that area is asked to review. Dr. Gorsuch questioned if they really get unanimous agreement on a published guideline. Answer: Except for those areas where noted otherwise, they are able to achieve unanimous agreement.

Gary Lusin asked how providers will gain access. Answer: By subscription or book purchase. The cost of a subscription is $200 per year. They are also working on selling increments for providers who would only have occasional need to use the guides. This would entail 10 free uses and then increments of 10 could be purchased beyond that.

The representatives stated that the Official Disability Guidelines (ODG) does not grade the body of evidence as ACOEM does. They also said that ODG is open to influence by customers (Medtronic as an example) and ACOEM is not. Another example given was that California’s chronic pain guidelines became ODG’s guidelines.

Dr. Gorsuch asked if ACOEM has any disagreement with the findings of Rand in the guideline review done for California. Answer: No; however, there have been a lot of changes made since then and the methodology has been revised. ACOEM would welcome Rand redoing the study.

Dr. Hegmann then walked the group through each of the injury scenarios that were presented and explained how the guidelines would define treatment.

Scenario 1: Dr. Hegmann explained that the MRI would not have fallen within the guidelines as appropriate with the facts given. Dr. Gorsuch questioned why this would not be appropriate. Answer: Since no treatment had been attempted to this point, the scientific literature would not support the need for an MRI. If, after the various conservative treatment options are attempted there is still no improvement, a MRI may be appropriate.

Gary Lusin asked if the guidelines contained diagnostic testing guides. Answer: Yes, they are included. Dr. Gorsuch asked if discography is ever approved. Answer: No, haven’t seen validity for this in the literature. Dr. Carpenter asked if they have seen anything studied where the discography provides corroboratory evidence. Answer: There are no studies that address this. Their use would be in the art of medicine. Dr. Dacre agreed that a single level discography gives you nothing. Disc replacement is the ultimate outcome if pain continues. Answer: Agree. Dr. Carpenter stated that you have to remember that these will be used for workers’ compensation cases and fusion is not appropriate and studies in WA and UT have found fusion to be only 33% effective.

Scenario 2: Dr. Weinert asked why not confirm with an EMG. Answer: This may be appropriate.

Scenario 4: Dr. Winert asked if cortisone injection frequency is covered in the Guidelines. Answer: Yes, along with the recommended dosages. If no improvement is seen with the injection, then would question the diagnosis. Gary Lusin questioned that if the guidelines do not recommend a treatment that the provider wants to perform, what kind of process do other states have. Answer: They make you justify it. You want to keep the hurdles low. Jerry outlined the review process proposed in Montana covered during the first meeting.

Dr. Steele asked if he could manipulate the website easily as an infrequent user. Answer: Dr Hughes said he finds it easy, Dr. Wolfkiel said it is not as easy as he would like, but they are working on making it easier. Dr. English pointed out that the AGREE criteria #11 requires they evaluate this.

Scenario 5: Dr. Carpenter said if what they meant by the 50% tear was this was a partial thickness tear, not torn all the way through. Answer: That information would change the recommendation to a subdecompression. Gary Lusin asked if studies account for function needed for returnt-to-work. Answer: Not addressed very well in the studies reviewed, but it is covered in the guidelines. Dr. Steele asked if patient motivation was covered in the study. Answer: Not sure. Dr. Steele added that workers’ compensation patient review in these studies is very important. Response: It is included where possible, but evidence is lacking.

Scenario 6: Gary Lusin asked if under the guidelines a patient would still be treated 18 months out. Answer: I hope not; if treatment is not working you would discontinue it and try something else.

Scenario 7: Dr. Steele asked what level the TENS study evidence was at. Answer: The evidence is level C.

Dr. Gorsuch asked if the goal is improved care, is there anything that tracks the effectiveness of the guidelines. Answer: Caterpillar is looking at this and preliminarily has found favorable results. California has looked at, but there are significant other factors included. Washington has the best database. Opiates statistics show a higher death rate than guns, cars etc. The guidelines have been rewritten to address this issue.

Gary Lusin asked if any states are using the same review criteria Ann Clayton recommended. Answer: Alaska and Louisiana are currently going through a similar process. Gary Lusin asked if he has seen liability for following some, but not all, of the guidelines? Answer: No, judgment is the key.

Scenario 3: Covered by Dr. Hughes. Dr. Weinert asked if there have been any studies of unloader braces. Answer: Have not seen research yet.

Dr. Stoebe asked what percentage of treatment fits the guidelines in the states that have implemented. Answer: They are designed to cover about 80%, but no one has really studied. Gary Lusin asked when states select the guidelines, can they be altered in any way. Answer: Can tweak one or two, but don’t recommend a patchwork of guidelines as it creates problems publishing and disseminating the guidelines. ACOEM will work with the states on this. Jerry asked if the state can purchase a global license that all providers can use. Answer: Yes, tweaks can be added and can be hosted on their server.

Gary Lusin asked if he had any insight into why California was changing. Answer: They are incorporating chronic pain from ODG because when their guidelines were first implemented, ACOEM did not have a chronic pain chapter. Now they do. By mid next year, ACOEM will be publishing a new version. This will put them at about the same point with all of the treatment guides. Their update process should be quicker after that. ACOEM does not run the guides as a business aspect; the only question is how much ACOEM has to subsidize the process.

VI. Public Comment:
Dr. Dacre asked for public comment.

Nancy Hiller (Advance Pain and Spine Institute) said someone is always not going to be happy with guidelines. A process to handle outliers needs to be developed.

Mike Marsh (Midland Claim Services) commented that you don’t want to be put into a position as an adjuster to make a clinical decision; a clinical review board is needed.

Ken Eichler (Reed Group) commented that there are a small percentage of outliers. New York established an expedited process for addressing. He suggested a workers’ compensation board for the first two years at least following implementation.

Dr. Galvas pointed out that Montana is a small state and medical providers can call each other here. Jerry Keck said that for cases that go through Montana State Fund, this is exactly how it happens. If treatment is outside the guidelines, the reviews go to Dr. Carpenter. If you can’t settle it with him, you go to mediation. Dr Carpenter said another level of review would be good without attorney involvement. Currently, if he recommends against treatment, the plan can be reviewed by other physicians in Oregon, but it would be good to have this done in Montana. Dr. Dacre suggested a 5-7 member review board. Dr Carpenter asked if it would by possible to have a more binding level of determination. Jerry responded this would require legislation.

Ken Eichler (Reed Group) said there is a significant number of injuries where workers do not receive appropriate care. Guidelines will help them and get a more appropriate level of care. Dr. Dacre agreed and stated that early return to work is often the best approach. This is beyond the scope of this committee, but needs to be considered.

Dr. Steele asked ACOEM how often is review done that will change a recommendation in the guides. Answer: There is a rolling three-year update. Dr. Steele asked if there was any way to incorporate a shorter update if there is a major change, as three years is too long. Answer: There are various indicators built in and they are always looking for users to tell them what is needed.

Erin Sexton (Medtronics) stated the guidelines are a rebuttable presumption and how providers get through a review process is important and needs to be addressed. Jerry Keck responded that this is not significantly different from what happens now. Erin commented that this is now a higher standard. Dr. Dacre stated that what he is hearing is that the rebuttable presumption language needs to be revisited.

Gary Lusin asked ACOEM if each body part is reviewed every three years? Answer: Literature review is done every year. Each body part is revised every three years.

Since Dr. Kemple could not attend, he sent a letter to all of the members summarizing his thoughts on the ACOEM guidelines and provided a packet of supporting information. 

VII. Next Steps
Anne Wolfinger pointed out that the evaluation process for guidelines implementation covered by Ann Clayton should be reviewed and members should come prepared to discuss this document at the next meeting. MPG members should also review the ACOEM guidelines and use the clinical and technical evaluation materials to rate them.

Anne asked if the Department is giving the MPG the information needed. Dr Galvas: yes. Dr. Carpenter: yes. Dr. English: yes; do we need to have a process for varying from guideline? Valerie Benzschawel: yes. Dr Weinert: yes. Gary Lusin: yes; should he be disseminating this information to his colleagues? (answer: yes). Dr. Steele: yes; interested in seeing how easy the guidelines will be for a busy practice. Dr. Stoebe: yes; needs to be a process for the 20% of care falling outside. Dr. Petrisko: nothing to add. Dr Dacre: yes. He encouraged member to log on to website and review the guidelines and to email him or Anne if they have any questions.

The next meeting has been scheduled for October 21st at 12:30 at the Best Western Great Northern in Helena. A representative from ODG will be presenting on those guidelines.