Doctors, as much as Injured Workers, can be frustrated with the administrative process controlling work injury treatment. This frustration is in large part due to the rules, regulations and statutes which govern industrial medical treatment.
California Workers’ Compensation System medical treatment rules for authorization are different than regular health insurance. Thus, treatments that are may be authorized under regular health insurance without difficulty may not be authorized as part of treatment for a workers’ compensation claim.
Part of the difference in treatment between workers’ compensation and regular health insurance is that Workers’ Compensation Law has adopted Evidence Based Medicine (EBM) as a means of determine what treatment should be authorized. Labor Code 5307.27. adopted a medical treatment utilization schedule which is to incorporate evidence-based, peer-reviewed, and nationally recognized standards of care
This article will discuss Evidence Based Medicine (EBM), how medical providers view EBM, and what an Injured Worker can do to address their workers’ compensation treatment.
What Is Evidence Based Medicine (EBM)?
Evidence Based Medicine looks towards science to determine whether treatment helpful. Thus, they will look at scientific studies as a basis for treatment. These studies could include ones in which they look at the benefits of a particular mode of therapy within a population.
For example, if 90 percent of the individuals in a study report a significant benefit from a form of therapy, then, there would be a likelihood that therapy would be recommended in an EBM format.
Also, EBM will look at the quality or strength of studies to determine which ones should be followed. This determination is made by experts who are qualified to make such an assessment. Benjamin Djulbegovic, Gordon H Guyatt, Progress in evidence-based medicine, The Lancet, Volume 390, Issue 10092, 2017, Pages 415-423, ISSN 0140-6736, https://doi.org/10.1016/S0140-6736(16)31592-6.
Note: My criticism of EBM is that each patient responds differently towards treatment. Thus, while a treatment may not be considered effective with respect to the general population, it may be something that is effective toward on an individual basis.
An individual may have a history with a particular form of treatment, i.e. chiropractic, which had been effective in the past for the individuals. Thus, a general scientific study is being chosen against real data concerning the real patient. It is important to note that it is the real patient who is going to get the treatment and not a statistical patient. It can be argued that a small scientific study based upon the individual’s success with a treatment is more valuable than a broader study. Arguably, it is far more relevant.
What Is Workers’ Compensations’ Interest In EBM?
In an article, the following was the commentary with respect to this issue: “[t]he workers’ compensation scheme expects that such a tool (EBM) could reduce the uncertainty about the appropriateness and effectiveness of a treatment. Reducing the uncertainty could speed up the decision-making process and reduce the need to seek second opinions from medical examiners. Health care practitioners would no longer have to complete additional paperwork for those evidence-based treatments. In general, it could facilitate a common understanding across those requesting treatment/services and those reviewing the services requested.” Elbers, N.A., Chase, R., Craig, A. et al. Health care professionals’ attitudes towards evidence-based medicine in the workers’ compensation setting: a cohort study. BMC Med Inform Decis Mak 17, 64 (2017). https://doi.org/10.1186/s12911-017-0460-2
Note: While this was the view in the study, this was not an assessment of the California Workers’ Compensation scheme concerning medical treatment. Despite the EBM approach, doctors are still subjected to considerable amount of paperwork to get treatment authorized. Further, EBM requests for treatment are still subject to a Utilization Review process and are not automatically authorized. Further, there is a training problem in that not all medical providers are adequately versed with respect to EBM. As a result, requests for treatment from certain providers may be denied as being improper.
What Is Insurance Companies’ Interest in Evidence Based Medicine?
In an article, it is noted that “[t]he tool is primarily developed to be used by claims managers. However, the treatment approval process is an interaction between claims managers and health care professionals.” Elbers, N.A., Chase, R., Craig, A. et al. Health care professionals’ attitudes towards evidence-based medicine in the workers’ compensation setting: a cohort study. BMC Med Inform Decis Mak 17, 64 (2017). https://doi.org/10.1186/s12911-017-0460-2
Thus, EBM is a means upon which Insurance Companies can assert control of medical treatment away from doctors. They can use EBM to dictate to providers as to what treatment will be authorized. Thus, Insurance Companies have supplanted doctors with decades of experience to determine necessary treatment.
What Are the Criticisms of EBM?
There are a variety of criticisms for EBM.
Cookbook Medicine: This term has the implication as to whether a doctor is needed. Thus, all one needs to administer medical care is look at the guidelines. Thus, who needs training, experience and expertise to provide treatment?
Decreased Professional Freedom: The profession of medicine is referred to as both a practice and an art. EBM takes away a doctor’s experience, knowledge and acquired skills from being employed to treat patients. When I treat for my industrial injuries, I want to go to an experienced and talented doctor. I do not necessarily want to go to a doctor who knows EBM.
What are the Visions and Problems for EBM?
It may provide guidance to clinicians in that they would know what they can request for authorization.
It may limit over-servicing or over-prescription of a particular medicine or treatment.
It may work as a basis to guide patients’ expectations as to what they can receive and how long their course of treatment will last pending return to work.
It may cause problems in that treatment will be insurance company formulaic as opposed to being dictated by the provider.
It may conflict with patient’s concerns about their treatment and as to what would benefit them. Sometimes, they are confronted with a doctor wanting to perform surgery and an insurance company denying the authorization. Also, patients come in conflict with their doctors when they wish to try treatment which is not within EBM guidelines.
There are questions as to the quality and quantity of the evidence that is used. Studies can be generated to produce results favorable to insurance companies’ positions and then adopted within the EBM guidelines.
The article indicated that there may be more timeliness on approval of treatment. In California, however, as long as treatment requests are sent to UR, there will be delays in providing industrial treatment even if they fall within EBM based guidelines. Some claims departments have taken an approach of pre-authorizing some forms of treatment to eliminate this process. This has been helpful.
There are concerns with respect to those analyzing the data and recommendations within an EBM setting. There may be some bias involved which may relate to countries, legal systems and forms of medical delivery or insurance.
There are concerns that the Insurance Industry will use EBM as a tool to dictate medical treatment at the expense of the Injured Worker. There are medical providers who will reject EBM and discontinue treating cases on an industrial basis. This will leave the field of medical providers as ones who will simply comply with EBM rather than fight for patient’s medical treatment needs.
EBM creates problems. It creates distrust in medical providers who want to do their job. It throws out the window medical expertise from providers with decades of experience. It discourages Injured Workers who simply wish to get their treatment provided on a timely basis. It emboldens Insurance Companies and their representatives to tell Injured Workers that they are better off getting their treatment elsewhere. This is offensive in that the industrial treatment is mandated to be done through this system. It is unfair to force injured Workers to treat within a broken or ineffective system.
What are Doctors’ View of Evidence Based Medicine?
Per the study on doctor’s attitude, they noted that “Overall, HCP[health care providers] are supportive of EBM, but have strong concerns about implementation of EBM based decision making in the workers’ compensation setting.
The participants felt that an EBM tool should not be applied rigidly and should take into account clinical judgement and patient variability and preferences.
In general, the treatment approval process in the workers’ compensation insurance system is a sensitive area, in which the interaction between HCP and claims managers can be improved.” Elbers, N.A., Chase, R., Craig, A. et al. Health care professionals’ attitudes towards evidence-based medicine in the workers’ compensation setting: a cohort study. BMC Med Inform Decis Mak 17, 64 (2017). https://doi.org/10.1186/s12911-017-0460-2
What Should an Injured Worker Do?
It is very important that an Injured Worker find medical providers that both understanding the paperwork needed to be placed in for treatment requests as well as understand the treatment guidelines which are in part based upon Evidence Based Medicine concepts.
What if I Need Advice?
If you would like a free consultation regarding workers’ compensation, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. We have been helping people in Central and Southern California deal with their workers’ compensation cases for 27 years. Contact us today for more information.