No one likes preauthorization/utilization, review/physician peer review, or whatever term your specific jurisdiction uses to establish the process where the treating provider must seek the endorsement of their patient treatment plan, through the workers‘ compensation system. To attempt to control costs, many jurisdictions have adopted a process where healthcare interventions are reviewed prior to the application of said care. Fortunately, as an initial arbitrator, the concept of evidence-based medicine has been applied to this process.
The phrase “evidence-based medicine” has been in the medical lexicon for approximately 25 years. The original definition has been amended and expanded to fit a revolving healthcare culture. Evidence-based medicine does not represent the most current medical practice; it represents the best-established practice in the application of healthcare. It is designed to present the most effective and cost-efficient healthcare available to address a specific problem.
Critics claim that evidence-based medicine and other “guidelines” are “cookbooks” that limit medical practice. The utilization of such guidelines has been declared to be dogmatic, inflexible, and too uniform. However, applying the standards of evidence-based medicine and utilizing the adapted guidelines specific to any particular jurisdiction is anything but a limitation on appropriate/effective medical application. A combination of evidence-based medicine and appropriate guidelines is a formula where the provider can quickly understand the best practices based on published literature that has been thoroughly vetted and investigated. More specifically, the art of medicine is not forsaken, and the parameters noted in guidelines must be understood as guides and not “carved in stone”. The clinical judgment of the treating provider is paramount in successful applications of evidence-based medicine any determinations noted in published guidelines.
We have heard frequently that medicine is an art that applies science and therefore the insight of specific providers. It can be difficult for any specific provider to be current on all aspects of care, and utilize the parameters noted in guidelines as a strong starting point (in terms of best practices noted in current literature). However, this does not limit any provider to the specific notations, but it does give them an additional requirement to fully explain WHAT they are doing and WHY they are doing it (to both the healthcare recipient and healthcare payer) when the proposed treatment is outside the established parameters.
There’s a saying that the half-life of medical education is less than five years1, and the average physician works approximately 30 years. Given the astonishing changes in medicine, treatment, and approach to diagnoses, one must utilize all tools available to apply appropriate data entry points in the decision-making process. What we knew to be beneficial and cost-effective 10 years ago could be excluded as not being beneficial, cost-effective, or assisting the injured individual. Therefore, the use of evidence-based medicine and nationally published guidelines is designed for providers and not to be a burden to the delivery of healthcare.
To be clear, the parameters noted are not carved in stone and cannot be the end-all be-all. At every stage of the decision-making process, consideration of the specifics of the clinical scenario must be employed so that the most appropriate and cost-effective treatment can be delivered. Evidence-based medicine and the jurisdiction determination of applicable guidelines. If the requesting provider in the utilization review/preauthorization process understands aspects noted in the applicable guidelines and produces a clinical record consistent with the guidelines or offered a narrative explaining why the guidelines should not be followed in this specific clinical situation, there are real, potential cost savings.