REGULATORY ANALYSIS
AMENDMENT TO RULE 17 – MEDICAL TREATMENT GUIDELINES
DIVISION OF WORKERS’ COMPENSATION
7 CCR 1101-3

1.	Description of the classes of persons who will be affected by the rules, including classes that will bear the costs of the rule and classes that will benefit from the rule.

This rule applies to all persons and entities subject to the Colorado Workers’ Compensation system, including but not limited to, injured workers, employers, health care providers, insurance carriers, and self-insured entities.

2.	Description of the probable quantitative and qualitative impact of the rule, economic or otherwise, upon affected classes of persons.

The revised Thoracic Outlet Syndrome (Exhibit 3) and Shoulder Injury (Exhibit 4) Medical Treatment Guidelines includes changes developed using a medical evidence-based approach in addition to a consensus model.  The medical evidence approach uses scientific studies to determine which treatments have been proven to be effective.  Evidence statements are qualified as being supported by 'some' evidence, 'good' evidence, and 'strong' evidence.  

The treatment guidelines will provide guidance to medical providers when making recommendations as to the appropriate treatment.  Similarly, these documents will provide guidance to the injured worker, insurance companies, and third party administrators on recommended treatment, diagnostic procedures, etc., in cases of Shoulder Injury and Thoracic Outlet Syndrome.  

Data from Colorado Division of Workers’ Compensation indicates that 8.0 percent of lost-time injuries in 2005 identified on First Reports of Injury were injuries to the Shoulder(s) (includes Clavicle and Scapula).1   

Because of the difficulty of obtaining and discerning information on medical diagnoses and costs, we did not have specific and reliable information on the costs related to medical care and indemnity for cases of Shoulder Injury and Thoracic Outlet Syndrome.  
	
There were diagnostic procedures that were discussed in the Thoracic Outlet Syndrome and/or Shoulder Injury medical treatment guidelines that were not described and/or not developed during the period of previous update. These include but are not limited to:  radioisotope bone scan, other radioisotope scanning, portable automated electrodiagnostic device, and computer-enhanced evaluation.   Several clinical tests that are completed within the usual clinical evaluation have been added. The clinical tests did not require specialized devices in order to perform them.   Many types of diagnostic procedures have been described in more detail and specificity in terms of frequencies, indications, and contraindications.  These changes in the diagnostic procedures sections should further aid in the diagnosis of a work-related injury and therefore initiate treatment that is more applicable to the diagnosis, ultimately leading to a positive influence on cost.
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	1 Division of Workers’ Compensation.  Research and Statistics Unit.  	Unpublished Work-related Injuries in 	Colorado-2005. Table 4 “Distribution of Lost-Time Claims by Part of Body (Detail)” 

There were a limited number of specific disorders added to the guidelines.  Most notably, we learned from receiving input from the Workers' Compensation community that Superior Labrum from Anterior to Posterior (SLAP) lesion is currently treated without guidelines.  We believe that having proper diagnostic procedures and treatment for this specific disorder outlined for the public will result in better outcomes.  We expect that this will ultimately control cost.  

There are therapeutic operative procedures that have been discussed in the Shoulder and Thoracic Outlet Syndrome Medical Treatment Guidelines that were not described or developed during the period of the previous update.   These include but are not limited to:  reverse shoulder arthroplasty, osteochondral allograft transfer system (OATS), and pectoralis minor tenotomy.   Although these procedures may increase initial medical costs, their use would most likely be infrequent.  Indications and contraindications are described to aid in patient selection.  Sections on post-operative care are expanded to maximize success rate.   

There were therapeutic non-operative procedures that were discussed in the Shoulder and Thoracic Outlet Syndrome medical treatment guidelines that were not described or developed during the period of the previous update.   These include but are not limited to:  smoking cessation programs, bone morphogenetic protein (rhBMP), bone stimulators, extra corporeal shock wave therapy, and evaluation and treatment for osteoporosis in cases of fracture.  The frequencies, optimum durations, and maximum durations of rehabilitative treatment procedures have been reviewed, updated, and newly discussed.  Such re-evaluation of treatment procedures will help to ensure that utilization of these treatments is reasonable and necessary, cost-effective, and aligned with current standards of care.

In general, effective medical treatment guidelines serve to make the system operate more efficiently.  Additionally, their utilization should have a positive impact on return to work, costs (both personal and monetary) of temporary or permanent disability, and in some cases, survival.  There are currently eight other medical treatment guidelines that are Exhibits to Rule 17.  The change in organization and structure in the Shoulder and Thoracic Outlet Syndrome Medical Treatment Guidelines make them more consistent with those other eight guidelines, and will likely improve overall clarity, readability, and help to increase implementation of the guidelines.

3.	Probable costs to the agency and to any other agency of the implementation and enforcement of the rule and any anticipated effect on state revenues.

    	No additional costs are anticipated.

4.	Comparison of the probable costs and benefits of the rule to the probable costs and benefits of inaction.

Medical Treatment Guidelines required updating to ensure that treatment recommendations are reasonable and necessary.  Recommendations on diagnostic and therapeutic interventions quickly become obsolete as medical technology advances.  As the efficacies of interventions are explored through the medical literature, changes on recommendations undoubtedly occur.  New technologies may incur higher initial costs, but good-quality medical studies can demonstrate favorable treatment outcomes, which may enable the injured worker to return to work sooner or suffer reduced permanent impairments.  Regularly updated medical treatment guidelines provide some important ‘tools’ for the public:  1) the ability to ensure reasonable and necessary care for the injured worker, 2) a guide for the healthcare provider on recommendations and standards of care for the individual patient, 3) a mechanism for the insurer to question and be informed of diagnosis and treatment procedures. 

There are two Workers’ Compensation Rules of Procedure that rely in part on updated treatment guidelines.  Rule 16 (Utilization Standards) requires that medical care and treatment procedures that do not fall within the medical treatment guidelines be subject to prior authorization.  Rule 10 (Medical Utilization Review) provides a vehicle in which the treatment rendered by a healthcare provider to a workers’ compensation claimant may be professionally reviewed on issues of whether such treatment is reasonable and necessary.

5.	Determination of whether there are less costly or less intrusive methods for achieving the purpose of the rule.

There were no known less costly or intrusive means to achieve the rule’s purpose.

6.	Description of any alternative methods for achieving the purpose of the rule that were seriously considered by the agency and the reasons they were rejected in favor of the rule.

Methods to achieve the purpose of the rule were initially propelled in response to a legislative action (Senate Bill 218) to institute medical treatment guidelines that would ensure reasonable and necessary care and help to control costs.  The medical treatment guidelines underwent a sunset review in 2002 and 2003 that resulted in an extension of this statutory program until 2014.  

The Colorado Medical Treatment Guidelines have been referenced in the Official Disability Guidelines.  They have been recommended in the Western Occupational and Environmental Medical Association Quarterly Newsletter (Spring, 2005).  Other state Workers' Compensation systems have adopted some of the medical treatment guidelines, either in part or in their entirety.  Such national stature is due in part to the regular updating of the medical treatment guidelines.

Copies of the Notice of Public Hearing were provided to the:

	Colorado Association of School Boards 
	Colorado Counties, Inc. 
	Colorado Municipal League 
	Special District Association of Colorado 
	Colorado Hospital Association 
	Colorado Association of Commerce and Industry 
	Mountain States Employers Council 
	Colorado Self-Insurers Association 
	Colorado Medical Society