EBM’s Evolution in WC Means Better Care, Decision-Making

Nancy Grover

Sarasota, FL (WorkersCompensation.com) – Evidence-based medicine seems like such a good idea; using a systematic approach to treat patients based on the best available scientific research. It seems so simple. Why would anyone not love the idea? And yet, EBM has gotten a bad rap in the workers’ compensation system — among those who even understand what it is.

Providers believe it disregards their medical training and intimate knowledge of a case, forcing them to provide treatments with which they may object. Others say it’s used reactively, as a way to deny treatments or payments, rather than providing optimal care. But thanks to advanced technology and increased awareness, experts are finding ways to employ EBM in the workers’ compensation system to truly provide the right care at the right time for the right injured worker.

Defining EBM

“Most people I mention EBM to don’t understand what it is,” said Jeffrey Austin White, SVP, Workers’ Compensation, for Gallagher Bassett. “Many medical management organizations are familiar with it, but in general, 75 percent of the [workers’ compensation] industry adjusters wouldn’t know. They may have heard the term, but couldn’t say what it is, or they can’t describe it.”

There is no hard and fast definition for EBM. The National Center for Biotechnology Information says it is “the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients. EBM integrates clinical experience and patient values with the best available research information.”
But there are many variations of ‘clinical evidence.’ During a recent session at the Workers’ Compensation Institute’s annual conference, Teresa Bartlett, MD, senior Medical Officer for Sedgwick and Barry Bloom, managing partner of

The bdb Group outlined a hierarchy of the types:
Meta-analysis is a way of combining data from many different research studies; a statistical process that combines the findings from individual studies.
Systematic review is a summary of the clinical literature; a critical assessment and evaluation of all research studies that address a particular clinical issue.
Randomized controlled trials are clinical trials that randomly assigns participants to two or more groups.
A cohort study includes people with a certain condition or who receive a particular treatment who are followed over time and compared with another group of people who are not affected by the condition.
A case controlled study starts with the outcomes and interviews the groups or checks their records to ascertain what different experiences they had. Cross sectional studies observe a defined population at a single point in time or time interval.
Case reports and series report on a series of patients with an outcome of interest.

Then there are ideas, editorials, opinions; animal research studies; test-tube lab research
Despite the lack of a definition for EBM, many medical guidelines are based on the idea of the latest and best medical evidence. The American College of Occupational and Environmental Medicine and the Official Disability Guidelines are the main nationally available guidelines used in the workers’ compensation system. Ideally, they seek to improve the quality and effectiveness of care to injured workers. Whether they actually achieve that is questionable.

Uses in WC

EBM in theory is “a consolidation of best practices in medical care,” White said. “In workers’ compensation the EBM guidelines are used as a yard stick to measuring the type, frequency, timing and duration of expected care. The intent of the EBM guidelines is not to enforce a one size fits all approach but rather to combine best practice protocols and optimal care pathways to avoid potentially harmful, inappropriate care for the injured worker.”

However, the industry’s focus on cost and frequency has made the reality of EBM’s use in workers’ compensation something altogether different. According to White, EBM today is used mainly for decisions on authorization or adjudication of medical bills.

“The guidelines, in the context of workers’ compensation, have had a very negative connotation,” he said, “because it’s been used about decisions as to ‘whether we should pay for treatment.’ Its emphasis is pointing in the wrong direction.”
For example, a claims adjuster finds out that surgery has been recommended for an injured worker’s shoulder pain. The adjuster asks the nurse case manager, who consults the guidelines to see if surgery is the suggested treatment, how many physical therapy visits should be included, and the expected costs.

“A least a dozen states have selected one of the EBM guidelines for arbitration on payments,” White said, “meaning it gives TPAs or insurers a defensible grounds to reject [paying] bills based on EBM.”
Despite the ‘reactive’ use of EBM in the workers’ compensation system, two recent studies, one from the University of Utah and the other from Johns Hopkins Medical School, demonstrated that closer adherence to EBM-based guidelines does result in better outcomes.

EBM’s Evolution
Workers’ compensation experts are starting to look to EBM for new uses. Bartlett and Bloom recently outlined the idea of using it to determine causation of injuries. White highlights an additional use, where EBM is employed proactively to promote optimal care for the injured worker.

“It’s about mapping the EBM guidelines directly onto the medical billing data to derive a simple and easy to use index,” he explained. “The index represents the percentage of care out of the total that complies with the workers’ compensation treatment guidelines and serves as a proxy for quality of care.”

Called the Treatment Quality Index (or TQI), the new tool from GB provides a metric for the care the injured worker is receiving. Nurses can use it to proactively manage medical care by evaluating treatment plans and identifying deviations from clinical practices across the spectrum of care.

“It’s been one of the most elusive goals in the industry, to determine what the optimum care path is and who’s the best person to provide care,” White said. “The industry has traditionally struggled with how to identify providers with the best outcomes. What’s the right level of treatment? When to intervene on a claim? What resources to use? How to measure performance? TQI provides a proactive means to measure quality of care and address issues before claims go off the tracks … Just like with opioids, find a way to discourage use of inappropriate medications. Same thing for treatments – inappropriate use of MRIs, CT scans, fusions, steroid injections.”

White says the idea is to provide the best possible outcomes for injured workers and payers. He believes the monitoring of overall compliance with evidence-based guidelines can dramatically improve the workers’ compensation system.
“It will allow for industry-wide benchmarking and comparison across insurance carriers, TPAs, self-administered programs and states with clear and concise interpretation,” he said. “By learning how to use EBM more effectively and refining the standards, this could potentially change the way the claims are managed in the future.”

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