ODG Update: Guidelines Gain Momentum In The Battle To Boost Care, Control Costs
By their nature, injuries sustained on the job often are complex, difficult to assess and, as result, expensive to treat. It requires multiple, reliable information sources to help ensure appropriate diagnoses and treatments, so that injured workers receive the most appropriate care. One such reliable information source gaining traction among various state workers’ compensation organizations is the Official Disability Guideline (ODG) and ODG Treatment Guidelines in Workers’ Compensation.
In fact, a growing number of states have adopted ODG and/or ODG Treatment for Workers’ Compensation program management. The acceptance of ODG and ODG Treatment is due in part to their reputation as “evidence-based” approaches. Plus, the Advisory Board for managing these guidelines includes extremely experienced professionals, including physicians, nurses, pharmacists, scientists, insurance professionals and employers in a wide variety of specialties applicable to injured workers’ conditions and care.
Currently, the ODG Treatment is updated and expanded monthly and so far several areas have been reviewed. See Table above for a listing.
Antibiotic and chronic obstructive pulmonary disease (COPD) therapies are currently in the review development pipeline.
Adopting ODG/ODG Treatment guidelines requires procedures for handling several changes. One critical consideration for many payers is how to handle “legacy claims,” claims with dates of injury prior to the effective date of the ODG/ODG Treatment guidelines implementation. The State of Texas recently went through this process and is a prime example for other states to consider as a prototype for change. Texas revised its Administrative Code to delineate how legacy claims were to be handled. Texas established the date for guideline adoption. Subsequently, the revised code addressed how to handle claims from that date (and forward) until the legacy claim could reasonably be transitioned to the new guideline requirements for medication selections. Texas also has established a deadline of September 1, 2013 for converting legacy claims.
Another factor related to the ODG Treatment guidelines is making the monthly drug plan or formulary changes with each updated “Y” and “N” drug list (“Y” identifies all medications that may be compensable without prior or pre-authorization; “N” indicates drugs that are not considered appropriate and require pre-authorization). For states that require plan compliance, quick action is needed to make revisions. Information is posted on the ODG website at the end of each month and the changes are effective the first day of the next month. ODG allows a 30-day grace period to make changes. Depending on the systems that require attention and resources available to make changes in drug plans or formularies, that timeframe can be challenging.
At times, it also takes clarification as to what is intended with a revised listing. For example, Ryzolt®, which was on the “N” list in December 2011, was removed with the January changes. However, it did not appear on the January “Y” list. As a result, a number of inquiries arose from uncertainty as to how the product is now classified. It is reasonable to anticipate other drugs will convert from “N” to “Y” in the future and there may be the need to clarify what the changes actually mean.
What The Future Holds – More Questions
Right now it is premature to determine the full impact of ODG Treatment guidelines. As part of its overall strategy for clients, Healthesystems is currently analyzing data to evaluate the program’s initial phase in Texas. Other variables that may affect implementation success for an ODG-based program include:
- Are the ODG Treatment guidelines being followed?
- Have the clinical outcomes and overall patient well-being improved?
- Is there improvement in reducing length of disability?
- What is the cost impact of avoiding “N” drug use?
- Are cost savings realized by following the guidelines for diagnosis and treatment?
- What other additional therapeutic class reviews are coming?
As the utilization of ODG Treatment guidelines increases and therapeutic drug classes are added, Healthesystems will keep a close eye on the outcomes. It is safe to say, however, that the use of a standard set of treatment guidelines — when applied across all jurisdictions — is a welcome step in the right direction. This step should help our industry move toward much needed evidence-based clinical standards of care.
Dr. Ralph Kendall, Vice President of Clinical Services at Healthesystems, is a member of the Work Loss Data Institute’s (WLDI) Official Disability Guidelines (ODG) Editorial Advisory Board.