Department of Labor and Industry

Child Labor Law

Draft "Program" evaluation criteria for implementation of treatment guidelines in workers' compensation cases


To: Jerry Keck, Administrator   9/11/09
      Anne Wolfinger, PMP

From: Ann Clayton, Consultant

Re: Draft “Program” evaluation criteria for implementation of treatment guidelines in workers’ compensation cases

Although it may be premature to identify specific clinical outcomes expected of the implementation of utilization and treatment guidelines, it is important to identify outcomes that need to be base lined for program evaluation purposes. (Most simply stated, the question public policymakers will ask is, “Did the implementation of treatment guidelines achieve their intended public policy purpose?”

Based on the stated goal of “Improve quality of care and patient outcomes while controlling costs”, a public policy statement that would allow the development of measures might be:

“To ensure all injured workers have access to medical treatment that has significant evidence of improved patient outcomes; to reduce the incidence of inappropriate or unnecessary care; and to improve employee recovery of health and functioning after a work related injury while at the same time, controlling costs.”

Based on this public policy purpose and on the intent that such implementation not to negatively affect worker access or satisfaction with care after the implementation, here is what I think policy makers will ask and how you can establish a baseline and develop a plan to measure and report on the success (and effectiveness) of implementation of guidelines:

1. In those claims where the treatment guidelines were followed, do workers have better health and functioning based on return to work rates and patient reported recoveries?

Base line: Record current distribution of TTD disability durations by year of accident at one year after injury and do a baseline worker survey (Jan. of 2010?) using WCRI like survey on patient’s reported levels of health before injury, right after injury and at time of survey.

Future measure for comparison: Run distributions of TTD disability durations by year of accident at one year after injury after implementation (and separate compliant and non-compliant with treatment guideline cases); and annually thereafter for each accident year. Also repeat workers’ survey annually after implementation and separate by compliant and non-compliant with treatment guideline cases.

Hypothesis: More injured workers will have faster recoveries and be able to return to work more quickly as well as report better overall recoveries.

2. Did injured workers report better or worse access to care and patient satisfaction with care than prior to implementation of treatment guidelines?

Base line: Add questions about whether or not employees reported having trouble getting to see a physician for their injury and why to the worker survey and their level of satisfaction with the care they received (use WCRI language if possible) (Jan of 2010?).

Future measure for comparison: Repeat survey after implementation and separate compliant vs. non-compliant with guidelines cases and do annually.

Hypothesis:  The level of access to care and satisfaction with care will not be negatively affected by the implementation of the guidelines.

3. How many physicians treating Montana injured workers are using the utilization and treatment guidelines as of (insert date)? (They cannot possibly be successful if they are not being used, nor can all injured workers have access to the best evidenced based care if most physicians are not using the guidelines)

Base line: Assume physicians are not currently using the “to be adopted” guidelines

Future measure for comparison: 1. Survey physicians who have treated injured workers since implementation of the treatment guidelines in the ERD data base to ask if they are using the treatment guidelines; 2 .Revise medical reporting or billing forms to allow physicians to check off if treatment is consistent with treatment guidelines and record it in the claim data; or 3. Do a claims audit of a random sample of physician’s cases to see if they are consistent with treatment guidelines. (Option 3 is probably too costly)

Hypothesis: Physicians that regularly treat injured workers are using the guideline due to the incentives of not having to wait for pre-authorization in cases where treatment is consistent with the guidelines. Therefore, they are widely used by physicians treating injured workers in MT.

4. Are there more or less disputes over the provision of inappropriate or unnecessary medical care being filed with the Employment Relations Division? (Be careful this does not reflect any changing of attorney fees for medical cases instead of the reduction of unnecessary or inappropriate care)

Base line: Report the number of disputes filed (monthly/quarterly/annually) with the department for inappropriate or unnecessary care prior to the implementation.

Future measure for comparison: Number of disputes filed (monthly/quarterly/annually) after full implementation of the guidelines

Hypothesis: If physicians are using the guidelines, there should be fewer disputes over inappropriate or unnecessary treatment. 

5. Have medical costs decreased since the implementation of the treatment guidelines?

Base line: Calculate the average cost of medical payments on workers compensation claims with dates of accident of 2008 with payment of all services through December 31, 2009.

Future measure for comparison:  Calculate the average cost of medical payments on workers compensation claims with dates of accident after the implementation of utilization and treatment guidelines with payments for services through the first year (or an average of the first year). Plus also monitor the cost of average medical payments on workers’ compensation claims by running reports with payments by year of injury with all payments for services through December 31, of each year.

Hypothesis: Once implemented, average medical costs per claims should decrease since there are fewer payments for inappropriate or unnecessary care.

Later you can add whatever additional metrics the physicians believe are necessary for the determination of clinical outcomes.