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Bob Young

For Press Release:

CWCI Study Examines Utilization Review in California Workers’ Comp

The California Workers’ Compensation Institute has issued a new report that looks at utilization review and the use of medical treatment guidelines in California workers’ compensation and compares the low back treatment guidelines of the American College of Occupational and Environmental Medicine (ACOEM) to those of the American Academy of Orthopedic Surgeons (AAOS), which the state has been considering adding to the workers’ compensation medical treatment utilization schedule.

Debate over treatment guidelines took center stage following passage of SB 228, a 2003 reform bill that among other things, attempted to control runaway medical costs and assure that injured workers receive high-quality, scientifically proven treatment by requiring a medical care utilization schedule based on evidence-based, peer-reviewed, nationally recognized medical care guidelines, beginning with those developed by ACOEM. Legislators estimated the guidelines would reduce workers’ compensation medical costs by $1 billion to $4.5 billion a year. Following a recent RAND study and comments from some medical groups, the Commission on Health and Safety and Workers’ Compensation recommended that the state consider adding spinal surgery guidelines developed by AAOS and interim guidelines for other specified therapies to the medical care utilization schedule.

The new Institute report looks at how guidelines are used in California’s mandatory medical care utilization review process and examines the potential impact of incorporating multiple guidelines into the treatment utilization schedule by comparing ACOEM and AAOS recommendations for five types of medical services (X-rays, CT scans and MRIs, chiropractic manipulation, physical medicine, and back surgery) used to treat low back soft tissue and low back nerve involvement injuries. The study also compares the evidence used to support each recommendation. The study documents wide disparities in recommended treatments between the two sets of guidelines, and a lack of high-grade evidence supporting many of the AAOS recommendations. Because California law considers all guidelines in the medical care utilization schedule to be presumptively correct and gives them equal weight, the study concludes that without a minimal threshold test for the grade of medical evidence required to approve medical services, the adoption of multiple, often-conflicting guidelines into the schedule would likely compromise quality of care for injured workers as well as increase administrative disputes and litigation.

The report, “Utilization Review & the Use of Medical Treatment Guidelines in California Workers’ Compensation” is available online. To download a copy click here