There has been much discussion about certain pre-set treatment guidelines, treatment parameters, treatment standards (referred henceforth as guidelines). Generally these guidelines are well intended efforts, and are intended to be just that, guidelines, not all encompassing treatment plans to be strictly followed. Unfortunately certain guidelines are misused by some IME doctors and some file reviewers. We all know that there are a few percent of our profession that are overutilizers. Each profession has this problem, but the forthcoming is for the rest of the doctors in practice.
At times the doctor doing the IME or file review will determine that some or all of the ongoing care given to the patient is not needed based on guidelines. For these examples, the records were documented properly supporting the need for the occurrence of care, the frequency of care, and the duration of care.
When evaluating guidelines, consider if more care is allowed for individual complicating factors.
Consider the following example.1
A 23-year-old Olympian and an inactive 80-year-old are in the same accident, having the same amount of pain and the same type of injury. The 23-year-old has a significant advantage in rehabilitation. He has a higher degree of spinal muscle strength and tone; better circulation to the spinal structures, that will aid in quicker healing; and has stronger ligaments. The 23-year-old will be able to more actively pursue rehabilitation of the surrounding spinal muscles.
The 80-year-old of course cannot be as physically active in his rehabilitation. He cannot pursue a comparable strengthening program of the surrounding spinal muscles. He has a poorer circulation to the injured spinal structures. He does not have the young man's ligament strength; his ligaments are more fragile. The 80-year-old will most likely need more care than the 23-year-old.
The young man's condition may be resolved before all the recommended care of guidelines is done. If the doctor followed the guidelines, care may be delivered that is not needed.
The elderly patient's complicating factors may go well beyond the care outlined by guidelines, even with the doctor doing the best possible care. If the doctor were to follow the care outlined in the guidelines, needed care may be withheld and the patient suffering needlessly. If the doctor goes beyond the care outlined in the guidelines, a file reviewer or IME doctor may state the doctor's care goes beyond the parameters. This may give the inaccurate picture that the doctor was overutilizing and unreasonable in the care given. The patient may question the doctor's ethics and competency, though the doctor is only following the guidelines.
Another example:1
Twin brothers lift a heavy box together at work and hurt their low backs to the same degree. One brother exercises the back muscles properly, has good spinal muscle tone and strength, does not smoke, and walks two miles to and from work each day. The other brother smokes, does not exercise, and drives a 100 mile round trip to work in a one-ton truck on rough roads. The smoking decreases the circulation to the spine; the poor muscle tone does not help support the injured spinal structures well; the vibration and bouncing in the truck is not favorable to the spine: all which may necessitate more care for the the brother with the less healthy lifestyle.
The healthier brother may have his condition resolved before the care outlined in the guidelines is reached. If the doctor then continues to treat, unnecessary care is being given to the patient.
The care needed with the second brother may go beyond that outlined in the guidelines. If the doctor follows the guidelines and withholds needed care, the patient may suffer needlessly and may have difficulty with staying employed. If the doctor proceeds with proper care, the file reviewer or IME doctor may state that the doctor exceeded the guidelines. The file reviewer or IME doctor may further state that such care was unreasonable and unnecessary, which may be an inaccurate picture of the doctor's treatment. The patient may then question the doctor's ethics and competency based on the IME doctor or file reviewer's comments, because the guidelines do not account for complicating variables.
From the previous two examples we can see the doctor may have the frequency and duration of care at a minimum, considering the individual case, yet the doctor's care may be inaccurately labeled as excessive and unreasonable under the guidelines. One can see where this may be adverse to the doctor's reputation, and may harm the patient with an interrupted treatment program.
A few questions for the file reviewer and IME doctor using guidelines. These are questions for the plaintiff's attorney to consider when questioning the file reviewer and IME doctor using guidelines as a basis for cutting care.
1. Doctor, please show us where in the guidelines where a variable amount of care is outlined depending upon the complicating factors and variables which may be present in certain cases. Where is each extra treatment needed outlined?
2. Doctor, considering that the guidelines were put together long before this patient was ever hurt, please identify where this individual case has care alloted for specifically.
3. Where is care allotted if an exacerbation were to occur any time during the treatment program? Certainly doctor, you would agree that an exacerbation may require more frequent care than what is outlined. And the extent of the exacerbation would vary the amount of extra care needed. Please show us where this is outlined.
4. Doctor, would you treat a l0-year-old child, a 300 pound professional football player, and a disabled 80-year-old the same way? Are you stating they would all need the exact same amount of care? Please identify in the guidelines where these individual cases are allowed the different care needed.
Reference
1. Dock D: Care Plan, Chapter 6, Desktop Guide to Care Plan Development and Records Documentation. Duluth, Dock D., l994.
About the author: Dr. Dock is the author of Desktop Guide to Care Plan Development and Records Documentation; A False Claim: Stroke from Manipulation; and Desktop Guide to the Orthopedic Spinal Examination.
Daniel P. Dock, DC, DACAN, DABCO, FACO
Duluth, Minnesota
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