The California Workers’ Compensation Institute has issued a new study examining the development and history of evidence-based medicine (EBM) as a tool for assuring appropriate, quality medical care, and its potential for containing treatment costs and improving California workers’ comp patient outcomes.

SB 228, signed in October, requires the state to adopt EBM guidelines for workers’ comp by December 2004 to control overutilization of medical services, set parameters for effective care, and to reduce treatment costs. The law also made treatment protocols published by medical specialty societies admissible before the WCAB, and made medical utilization guidelines presumptively correct in regard to the extent and scope of treatment, with guidelines of the American College of Occupational and Environmental Medicine (ACOEM) given the presumption until a new schedule is adopted. ACOEM guidelines published last month will be presumed correct as of March 22. State lawmakers estimated the guidelines will reduce workers’ comp medical costs by $1 billion to $4.5 billion a year.

The study also gauges the reach of the guidelines, noting that just over half of California workers’ comp claims are trauma or non-specific diagnoses not covered by ACOEM. That means just under half of all claims will be subject to the guidelines — together representing 55% of all medical payments and 60% of indemnity payments. Analyzing current treatment levels and time off work for two types of low back injuries common to workers’ comp, the study finds utilization of x-rays, CT scans and MRIs, physical medicine, chiropractic care, and surgery, as well as days off work, all significantly exceed ACOEM recommendations, so in many cases, guidelines may have a big effect on the course and cost of treatment. But, CWCI notes, EBM guidelines are not absolute rules or intended to usurp physician judgment, and they will be interpreted on a case-by-case basis. Clearly, necessary conditions to realize system savings include more than just the presence of an evidence-base, and the gap between actual and ACOEM-expected levels of care illustrates the challenge. Workers’ comp is a complex system, and many parties contribute to medical decisions. While providers make initial testing, treatment and disability management decisions, claims adjusters, employers, nurse case managers, attorneys, workers’ comp judges and injured workers also make decisions about compensability, safety, return to work, pay for care and absence from work. These groups often use standards that are not based on evidence of effectiveness, but on traditional insurance industry practices, perceptions of regulations, legal precedents, threats of legal action, and physician statements made without scientific evidence. Achieving quality care in a cost-efficient system as intended by SB 228 will require all groups to work from the same scientific evidence base to ensure consistency across all aspects of medical quality.

The report, “Evidence-Based Medicine and the California Workers’ Comp System” is posted in the “Research” section of our website at www.cwci.org.