State Policies on Treatment Guidelines and Utilization Management: A National Inventory

By Kathryn Mueller, Dongchun Wang, Randall Lea, M.D.

February 5, 2019 Related Topics:

Evidence-based treatment guidelines are considered to be useful in the delivery of consistent and effective medical care for patients with injuries or conditions. However, there is substantial variation in what treatment guidelines are adopted and how they are implemented in workers’ compensation systems across the country.

This first-of-its-kind survey-based study is a national inventory of medical treatment guidelines and system features that help enforce compliance with medical treatment guidelines across states. The study highlights some of the key patterns that cut across the states. It also highlights several key policy variables that are most likely to influence compliance with medical treatment guidelines. For each state included in the study, there is a short summary of system features that are related to medical treatment guidelines, utilization review, and the dispute resolution process.

The results from this survey-based study are informative for policymakers and stakeholders who are interested in learning the current policy landscape in this area and identifying opportunities to improve the delivery of medical care for injured workers and enhance system function. It also provides a framework and lays a foundation for subsequent studies that examine how system features interact with treatment guidelines and what combinations of policies may affect utilization of services and outcomes.

State Policies on Treatment Guidelines and Utilization Management: A National Inventory. Dongchun Wang, Kathryn Mueller, and Randy Lea. February 2019. WC-19-01.

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Research Questions:

  • Which states have adopted medical treatment guidelines?
  • How do the state treatment guidelines compare based on two sets of criteria for (1) the level of restrictiveness and (2) their clarity and ease of use?
  • How do statutes and regulations address utilization review (in the form of prior authorization and post-procedural review) and dispute resolution for medical treatment issues?
  • How are state-adopted medical treatment guidelines used at various stages in the process?

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