Provider Pulse
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DOWC and the utilization of Medical Treatment Guidelines

In a recent conversation with Dan Sung, Manager of the Medical Policy Unit at the Colorado Division

September 25, 2018
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In a recent conversation with Dan Sung, Manager of the Medical Policy Unit at the Colorado Division of Workers’ Compensation (DOWC), Pinnacol asked Dan to discuss the utilization of the Medical Treatment Guidelines (MTG).

The guidelines were developed as a tool to help providers educate the patient, family, employer, insurer,  and community about the parameters and time periods for specific interventions that may lead to  optimized outcomes for injured workers.  Although MTGs are a fundamental tool for workers comp treatment in Colorado, and all healthcare providers are required to use the MTG as stated in Rule 17, awareness of and familiarity with the MTG are not universal among providers in Colorado.

When asked how medical providers should utilize the guidelines, Sung responded: “The guidelines are meant to start the conversation with the patient about their care. We’re really working to educate [the providers] and make sure that they understand how to use these tools.”  

Sung was asked to comment specifically on physical therapy utilization.  He said, “We want to see active management of claims and the nuanced condition of the individual versus a generalized treatment approach… I think unfortunately, we got to this point where things have evolved and settled into a routine where the expectation for everybody is more along the lines of maximum duration". Sung wants to help providers apply the pieces of the MTG that are relevant to therapists, "We have to hit the reset button with [provider and therapy] groups to understand what the other pieces [of the MTG] mean.”

Sung continues, “We see some providers who are overly conservative in the application of the guidelines.  But in other cases, [there] is a common perception out there [that] when it's the thirtieth physical therapy appointment, by itself [it] is no big deal, doesn't cost much and keeps the patient happy, whereas excessive physical therapy actually does have a potential for causing harm to the patient because the claim is open [and] the patients are not going back to work.  The therapist can focus too much on pain relief and can keep going and going. It's kind of the wrong orientation.”

Pinnacol’s program to manage the use of physical therapy is based on the MTG’s “time-to-produce-effect” sections.  Treatment needs to produce evidence of functional improvement to be continued and the responsibility for case management is a coordinated effort of the providers and the payer. Sung states “One of the challenges that we are working on in terms of medical policy is really moving our healthcare system in the direction where coordination of care is emphasized."

He went on to say, “I think the key point is we have put faith and trust in the provider. That's where we hold you [the authorized treating physician] accountable for that responsibility. Although you are given a lot of latitude and flexibility managing the claim, you also have the responsibility.” The DOWC and Pinnacol are committed to working with providers to improve the understanding and application of the  treatment guidelines.  

Good communication among the therapist, medical provider, insurer and the patient is the key to good outcomes and improved quality of care for patients. The MTG can help the physician and the therapist educate patients and establish realistic expectations for their care, which should aid in their recovery.

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