Evidence-Based Medicine for Improved Outcomes
March 01, 2021 | Categories: ODG by MCG
The ever-growing list of new federal, state, and local leave mandates has made administrative functions more crucial than ever to the effective operation of integrated absence management (IAM) programs.
However, we sometimes let Health Insurance Portability and Accountability Act (HIPAA) constraints intimidate us into relinquishing medical case management. When we do this, we are forfeiting one of the key tools to reduce medical costs and disability durations in the workers’ compensation return-to-work process.
IAM professionals cannot apply medical management in the same way to non-occupational absence. But they can still influence the selection of treatment plans for short-term disability (STD) claims, potentially reducing the duration of the claims. According to The Standard’s Employee Disability Leave Study, employees with STD claims referred to a clinician for disease management — which includes treatment planning — had little more than half the disability duration as those who had not been referred.1
Most employers either use an insurance carrier or self-insure their STD claims using a third-party administrator (TPA) for case management. HIPAA bans the provision of medical information to employers. When employees sign consent forms to release information, carriers and TPAs can and often do receive attending physician statements, related disability forms, and other medical records summarizing the impairments, diagnosis, treatments, and RTW information. Using that information, case managers can perform three key functions:
- Educate providers about evidence-based medicine (EBM) treatment guidelines.
- Advocate for the treatment path promising the best health outcomes for employees.
- Improve adoption and alignment with EBM because the employee and provider are aware the case manager is following the treatment plan — supporting and advocating for the employee.
Resources are available to efficiently identify which treatments are appropriate and likely to result in a good outcome and which are more likely to result in a poor outcome. This type of information should be shared with all stakeholders involved, especially medical providers. Carriers or TPAs that have access to clinical information can perform these functions.
Educating all stakeholders on which treatments are considered appropriate based on EBM is another important function. So is being able to enlist additional resources, such as case managers or peer reviewers, when the treatment is not aligned with EBM. These are key strategies for carriers and TPAs to help improve outcomes, ensuring claimants receive the most effective care, achieve timely recovery, and avoid prolonged disability when treatment goes off track. Some commercially available programs provide these functionalities, such as MCG’s ODG guidelines and the American College of Occupational and Environmental Medicine’s guidelines.
Several other resources can also provide unbiased peer-reviewed information to help educate and guide treatment planning, avoiding unnecessary and potentially harmful treatments. The American Board of Internal Medicine provides Choosing Wisely with EBM guidance on many common treatments for disability claims.2 The American Academy of Orthopaedic Surgeons provides OrthoGuidelines with EBM guidelines for common musculoskeletal conditions.3 Your carrier or TPA needs to work with a broad list of such resources; many more are available.
Your organization may already be paying for these services. If not, employers may be able to negotiate pilots focused on musculoskeletal claims or other higher-risk or higher-cost claim categories. Effective education and advocacy should reduce disability costs and the number of “disability mindset” claimants who shuffle from doctor to doctor because they received inappropriate, non-EBM treatments early on.
– Jamie LaPaglia, RN, CCM, ODG Manager of Implementation and Clinical Education
Image courtesy Shutterstock/chuggo
This article was previously published in Disability Management Employer Coalition (DMEC) magazine @Work as the author of their November 2020 column, “A Clinician’s Viewpoint.”
The information contained in this article concerns the ODG or MCG care guidelines in the specified edition and as of the date of publication, and may not reflect revisions made to the guidelines or any other developments in the subject matter after the publication date of the article.
- The Standard. Employee Disability Leave Study: The Link Between Disability Management and Employee Productivity. May 2018. Retrieved from https://www.standard.com/employer/employee-disability-leave-study
- American Board of Internal Medicine Foundation. Choosing Wisely. Retrieved from https://www.choosingwisely.org/our-mission/
- American Academy of Orthopaedic Surgeons. OrthoGuidelines. Retrieved from http://www.orthoguidelines.org/