December 14, 2004 - San Francisco, CA - CAOMA President Michelle Lau provided oral testimony accompanying more detailed recommendations authored by CAOMA Executive Director Brian Fennen in professional testimony to the Administrative Director of the California Division of Workers Compensation.

December 5, 2004

Andrea Hoch, Administrative Director

Division of Workers Compensation

Department of Industrial Relations

455 Golden Gate Avenue

San Francisco, California 94102

	Re: 1) Medical Treatment Utilization Schedule

	2) RAND Report on Evaluating Medical Treatment Guidelines

	3) CHSWC Recommendations to DWC on WC Medical Treatment Guidelines

Dear Ms. Hoch:

On behalf of the California Licensed Acupuncturist profession, the Council of Acupuncture and Oriental

Medicine Associations would like to comment on the RAND report and the CHSWC recommendations

presented and adopted on November 15, 2004.

The new Workers Compensation laws that went into effect in 2004 require you to adopt a “medical

treatment utilization schedule” that is based upon “evidence-based, peer-reviewed, nationally recognized

standards of practice.” Unfortunately for us all, RAND has come to the same conclusion that we did:

namely, that there is no single truly comprehensive evidence-based, peer-reviewed medicine practice

guidelines that could be readily transformed into a utilization schedule. In fact, it will be difficult even to

merge multiple guidelines into a single utilization schedule; there are simply too many variations and

exceptions to evidence-based medicine standards in the published medical practice guidelines.

We would like to make the following comments and recommendations:

1. Medical Treatment Utilization Treatment Schedule (Labor Code 5307.27)

	1. Recognize and apply the standards of evidence-based specialty guidelines – such as those

	developed for acupuncture – to the medical treatment utilization schedule. Workers

	Compensation reform has inspired experts in our field, as well as others, to develop evidencebased

	specialty guidelines, based upon recent research, especially since it has become broadly

	recognized that the ACOEM guidelines are a combination of consensus-based and evidencebased

	guidelines, and that they did not include experts or extensive research review in developing

	their very limited acupuncture recommendations. The Council has been instrumental in the

	development of the Acupuncture and Electroacupuncture Evidence-Based Guidelines

	(Fennen and Esquivel, 2004). These new guidelines can be readily adaptable to a medical

	treatment utilization schedule.

	2. Allow a trial course of pre-authorized, low-cost treatments – such as acupuncture – that

	should reasonably be expected to relieve pain and speed recovery from an injury.

	Evidence-based medicine requires a positive response to a treatment intervention that is better

	than the natural course of recovery. One cannot always pre-determine whether a specific

	therapeutic intervention will work an any given case, or not, and the physician must make a

	judgement based upon experience and expertise. Acupuncture and electroacupuncture, for

	example, have been determined to be appropriate for many common work-related

	neuromusculoskeletal injuries - based upon published research - and are often recommended by

	injured workers’ treating physicians. Judging by the reports of members of our profession and

	others, the misapplication of ACOEM guidelines has resulted in the denial of treatment to

	thousands of injured workers who may never know whether a given treatment may have helped

	them or not. Allowing an immediate short course of treatments could establish whether

	acupuncture or other treatments are effective or not, potentially getting in injured worker back to

	work more quickly, helping the injured worker to feel cared for and respected, and allowing for

	improved diagnosis of the injury with incremental re-assessments given at each treatment session

	during a course of treatment. An initial course of acupuncture would consist of 8-14

	treatments.

	3. Require evidence of functional improvement before additional courses of therapeutic

	procedures – such as acupuncture – are authorized.

	Once an initial course of treatments has been provided, there should be evidence of structural,

	physiological, and/or functional improvement, before allowing further treatments of the same

	nature. For example, if an initial course of acupuncture treatments improved the range of motion

	in a shoulder injury faster than would be expected in the natural course of recovery, then further

	treatments might be authorized. However, if no such improvement could be demonstrated after an

	initial course of treatments, then further diagnostic studies and/or alternative therapies should be

	considered. For acupuncture, experts concur that functional improvement should be

	measurable within 6-8 sessions for most acute neuromusculoskeletal injuries of a workrelated

	nature.

	4. Allow additional courses of treatment when evidence of continued functional improvement

	can be documented.

	Once an initial course of treatments has been completed, and if evidence of structural,

	physiological, and/or functional improvement is documented, then further treatments of the same

	nature should be authorized.

2. RAND Report: Evaluating Medical Treatment Guideline Sets for Injured Workers in California

	1. ACOEM Guidelines Are Inadequate and Inappropriate for Acupuncture

	RAND reports that “The ACOEM guidelines were not written for UR but were designed to

	guide physicians on treatment. One of the weaknesses of the guidelines is the absence of

	information on treatment modalities such as acupuncture” (p.52). Furthermore, RAND's

	multi-disciplinary panel of experts concluded that the five sets of guidelines they reviewed,

	including the ACOEM guidelines, “barely met standards,” that the ACEOM guidelines were

	appropriate (comprehensive and valid) for only one of six selected non-surgical topics, and that

	“they preferred specialty society guidelines over those marketed for utilization management

	purposes.” (p.71) We concur with RAND on this issue.

	2. ACOEM Guidelines Do not Apply to Acupuncture at this Time

	RAND states that “we are not confident that the ACOEM guideline is valid for nonsurgical

	topics. Deciding whether or not to continue using ACOEM for nonsurgical topics as an

	interim strategy remains a policy matter...

	“we recommend that the state issue regulations clarifying the topics for which the adopted

	guideline should apply.” “acupuncture, chronic conditions, and other topics our

	stakeholder interviews suggest may not be covered well by the ACOEM guideline.” (pp.74-

	75).

	We concur with RAND on this issue.

	3. ACOEM Guidelines Are not a Medical Treatment Utilization Schedule

	RAND states: “Our technical evaluation revealed that ACOEM and AAOS developers did a

	poor job of considering implementation issues, and our stakeholder interviews indicated

	that payors are applying the ACOEM guideline in an inconsistent fashion. Therefore, we

	recommend that the state develop a consistent set of utilization criteria (i.e., overuse

	criteria) to be used by all payors.”

	This would be consistent with our findings. The ACOEM guidelines are no substitute for a

	medical treatment utilization schedule.

	RAND recommends that “It would be resource-efficient for the state to develop the overuse

	and underuse criteria at the same time... The criteria could be developed from the literature

	and expert opinion, without the intermediate step of developing or selecting guidelines.”

	(p.76)

	We agree with this recommendation. Not only would it be resource-efficient, the development of

	a valid, evidence-based medical treatment utilization schedule necessitates the development of

	overuse and underuse criteria. In fact, the Administrative Director should encourage the various

	specialty societies to include overuse and underuse criteria on their own practice guidelines.

	RAND states that “Utilization management (UM) comprises a range of techniques

	performed by or on behalf of third-party payors to reduce health care costs...” (p.14). In

	other words, health care utilization management is the process of budgeting limited funds for the

	treatment of health conditions. Utilization management should make use of cost efficacy data to

	determine the optimal applications of specific therapeutic interventions.

	The primary difference between evidence-based, appropriate medical practice standards, and a

	medical treatment utilization schedule are that a utilization schedule can be readily adjusted by

	non-medical factors such as cost, while the former are determined solely on a risk/benefit and

	efficacy basis. In SB 228, the Legislature asked the Administrative Director of the DWC to

	address the benefits and costs of treating work-related injuries by developing a utilization schedule

	that could presumably be used to prevent overutilization by capping treatments, and to prevent

	underutlization by setting some lower boundaries of access to treatment for injured workers.

	4. The Medical Treatment Utilization Schedule “shall address, at a minimum, the frequency,

	duration, intensity, and appropriateness” of treatment procedures.

	While a utilization schedule can be incorporated into a guideline, a utilization schedule should

	address minimum and maximum thresholds that define underuse and overuse for any given set of

	procedures as applied to any given medical condition.

	A utilization schedule is a schedule or table of use that can be quantified. Schedules contain

	detailed listings, usually in the form of set of tables or matrices. For example, if a patient suffers

	from condition A, then medical interventions x, y, and z would be appropriate. If medical

	interventions x and y are generally given in a series of sessions (e.g. physical therapy,

	acupuncture), then the table should contain the number of treatments, the frequency and intensity

	or interval at which those treatments should be given, and the duration, in terms of days or weeks.

	We disagree with RAND’s “lite” definition of a utilization schedule as a “guideline that can

	assist payor decisions about appropriate health care for specific clinical circumstances,

	particularly about limiting inappropriate care. The guideline should also address, when

	relevant, frequency, intensity, and duration, i.e., quantity of care.” (p.7).

3. CHSWC Recommendations to DWC on WC Medical Treatment Guidelines

	1. Recommend Adopting Interim Guidelines for Specified Therapies

	“CHSWC recommends that the AD consider adopting interim guidelines for specified

	therapies, including podiatry, chiropractic, physical therapy, occupational therapy,

	acupuncture, and biofeedback, consisting of a prior authorization process in which the

	indications for treatment and the expected progress shall be documented, and

	documentation of actual functional progress shall be required at specified intervals as a

	condition of continued authorization for the specified modalities.”

	We recommend the adoption of the Acupuncture and Electroacupuncture Treatment Guidelines

	2. Recommend Establishing Ad Hoc Advisory Group, that Includes an Acupuncturist

	“CHSWC recommends that the DWC and CHSWC jointly establish an ad hoc advisory

	group to receive expert advice and stakeholder input on the many questions that must be

	addressed in assembling a comprehensive set of guidelines.”

	We recommend that an acupuncturist be appointed to the advisory group.

	3. Accept Colorado Guidelines, not limit to NIH Health Consensus Statements

	“CHSWC recommends using National Institutes of Health consensus statements and other

	states' established guidelines, such as Colorado, to compose guidelines containing:

	-  A list of conditions for which each modality may be appropriate,

	-  A documentation process to justify the initiation of a treatment plan,

	-  A documentation process to justify continuation of a treatment plan by

	demonstrating functional improvement at specified intervals, and

	-  A maximum number of visits and duration of course of treatment.”

	We have reviewed the Colorado guidelines, and find them to be reasonable, and very much in line

	with what we have recommended. We would suggest minor changes to the language, namely,

	that “acupuncture is acceptable for any neuromusculoskeletal injury.”

	However, the National Institutes of Health Consensus Statement on Acupuncture was published

	in 1997, and is out of date by RAND’s criteria. RAND stated in their report that “Our fourth

	selection criterion was that the guideline sets be reviewed at least every three years. This

	requirement was based on prior RAND research demonstrating that new research evidence

	makes about 50 percent of guidelines out of date after about 5.8 years and at least 10

	percent out of date after 3.6 years,” and “As a general rule, guidelines should be

	reassessed for validity every 3 years.”

	In fact the NIH Consensus Statement on Acupuncture opened the doors to acupuncture

	research, and the vast majority of credible acupuncture research in the United States has only

	been conducted since that report was released.

	4. Permit Continuation of Treatment with Documented Evidence of Functional Improvement

	“CHSWC recommends that the AD establish interim guidelines for specified therapies that

	will require the prescribing physician to establish meaningful measures of objective

	improvement in a patient's level of function. The guideline should permit the continuation

	of those modalities beyond a brief trial period, and up to a specified limit, if the patient's

	level of function meets objective progress criteria.”

	5. Evaluate Acupuncture Guidelines for Inclusion as a Supplement to ACOEM guidelines.

	The CHSWC recommends to“Evaluate additional guidelines for inclusion as supplements to

	ACOEM guidelines.”

	We agree.

Thank you for your consideration. Should you have any questions, feel free to contact us.

Sincerely,

Brian C. Fennen, L.Ac, QME, OBT, Executive Director