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  • Ensuring Quality of Care in Workers' Compensation Programs: Fair Fee Schedules and Evidence-Based Guidelines

    The adoption of scientific, evidence-based treatment guidelines founded on a rigorous analysis of the scientific evidence provides a powerful means by which to increase the effectiveness and value of medical care to injured workers. Evidence-based guidelines also provide a rational framework from which to address and remedy shortcomings in workers’ compensation fee schedules.

    Traditionally, workers’ compensation fee schedules do not properly recognize and reimburse physicians who go beyond traditional medical services and do the extra work required to restore injured workers to optimal function and to promote rapid return to work. As has been documented, the provision of high-quality workers’ compensation services requires more physician attention and time to patient education and client communication, increasing the cost of delivering workers’ compensation services compared with routine health care.1-3 As a result, low fee schedules can discourage the participation of qualified occupational physicians and undermine the economic viability of occupational health programs designed to meet the needs of employers and employees. An appropriate fee schedule promotes the development of quality occupational medicine programs and services, which in turn ensure higher quality of health care to injured workers while reducing the costs to employers and insurers. Outpatient provider fees are not a major cost driver in the workers’ compensation system, but lack of access to high-quality, front-line health care drives up costs. Several studies have documented that improved reimbursement to occupational health providers and reduced administrative oversight can lead to better patient outcomes and reduced costs.4-10 

    Appropriate fee schedules, when used with evidence-based treatment guidelines, will ensure that workers receive appropriate medical care in a timely manner (by increasing the number of high-quality providers and programs) and will control costs by reducing unexplained variations in care and ineffective services.

    Adopting the American College of Occupational and Environmental Medicine (ACOEM) Occupational Medicine Practice Guidelines, 3rd Edition,11 and an appropriate fee schedule will improve quality of care, encourage participation by qualified providers, and reduce costs because:

    • The Practice Guidelines as developed are based on expert analysis of all of the best available scientific studies.12 All users (i.e., physicians and other health care providers, third-party payers, reviewers, and regulators) can have confidence that the services recommended by the ACOEM Practice Guidelines will lead to a meaningful improvement in patient care;
    • Where alternatives exist, the Practice Guidelines specifically incorporate “cost-effectiveness” when recommending particular treatment plans;
    • The Practice Guidelines emphasize early and scientifically rational treatment for injuries, a philosophy that has been demonstrated to reduce costs and improve patient outcomes; and
    • The Practice Guidelines emphasize preventive services as a way of reducing costs overall, especially costs for chronic care.

    Accordingly, ACOEM supports reimbursement policies that recognize expressed adherence to its Practice Guidelines as justification for a (to-be-determined) higher fee schedule (i.e., an appropriately determined conversion factor). Such a reimbursement system is totally consistent with a general move across public and private insurance programs and increasing physician acceptance of reimbursement systems that “pay for performance.” With particular respect to the workers’ compensation system, such a policy will likely result in: 1) enhanced physician participation; 2) ease of administration; 3) more occupational health programs in areas currently underserved; and 4) improved quality of care and patient outcomes.

    References 

    1. Dasinger LK, Krause N, Thompson PJ, Brand RJ, Rudolph L. Doctor proactive communication, return-to-work recommendation, and duration of disability after a workers’ compensation low back injury. J Occup Environ Med. 2001;43(6):515-25.
    2. Shaw WS, Zaia A, Pransky G, Winters T, Patterson WB. Perceptions of provider communication and patient satisfaction for treatment of acute low back pain. J Occup Environ Med. 2005;47(10):1036-43.
    3. Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI, and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J. 2005;5(1):24-35.
    4. Loisel P, Lemaire J, Poitras S, et al. Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six-year follow-up study. Occup Environ Med. 2002;59(12):807-15.
    5. Cheadle A, Wickizer TM, Franklin, et al. Evaluation of the Washington State Workers’ Compensation Managed Care Pilot Project II: medical and disability costs. Med Care. 1999;37(10):982-93.
    6. Franche RL, Cullen K, Clarke J, et al. The Institute for Work and Health (IWH) Workplace-Based RTW Intervention Literature Review Research Team. Workplace-based return-to-work interventions: a systematic review of the quantitative literature. J Occup Rehabil. 2005;15(4):607-31.
    7. Christian J. Physician Role Change in Managed Care: A Frontline Report. In: Occupational Medicine: State of the Art Reviews. Philadelphia, Pa: Hanley & Belfus, Inc; 1998:13(4).
    8. Wickizer TM. Center of Occupational Health and Education. Final report on outcomes from the initial cohort of injured workers, 2003-2005. University of Washington, School of Public Health and Community Medicine, Department of Environmental and Occupational Health Sciences, Occupational Epidemiology and Health Outcomes Program, 2007. Available at www.lni.wa.gov/ClaimsIns/Files/Providers/ohs/CombinedReportApril2007.pdf. Accessed June 15, 2011.
    9. Bernacki EJ, Tao X, Yuspeh L. An investigation of the effects of a healthcare provider network on costs and lost time in workers’ compensation. J Occup Environ Med. 2006;48(9):873-82.
    10. Swedlow A, Gardner LB. Provider Experience and Volume-Based Outcomes in California Workers’ Compensation – Does “Practice Make Perfect?” Oakland, Calif: California Workers’ Compensation Institute (CWCI); 2003.
    11. Hegmann K, ed. Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. 3rd ed. Elk Grove Village, Ill: American College of Occupational and Environmental Medicine; 2011.
    12. Harris JS, Sinnott PL, Holland JP, et al. Methodology to Update the Practice Recommendations in the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines, Second Edition. J Occup Environ Med. 2008;50(3):282-95.

    This statement was originally approved by the ACOEM Board of Directors on July 28, 2007. It was updated and reaffirmed by the Board on July 31, 2011. 

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