2. Worker's Compensation
3. Councils and Committees
4. Health Care Provider Advisory Committee

Health Care Provider Advisory Council Minutes October 7, 2016

Aurora Medical Center in Summit

October 7, 2016

Members present: Mary Jo Capodice, DO; BJ Dernbach (Chair); Amanda Gilliland; Richard Goldberg, MD; Barbara Janusiak, RN; Maja Jurisic, MD; Jeff Lyne, DC; Jim Nelson; James O'Malley (acting chair); Peter Schubbe, DC; Jennifer Seidl, PT; Ron Stark, MD; Sri Vasudevan, MD

Excused: Ted Gertel, MD; Stephen Klos, MD; Michael McNett, MD

Other Attendees: Forbes McIntosh, Government Policy Solutions LLC; H.J. Waukau, Wisconsin Medical Society (by telephone conference call)

1. Call to Order/Introductions: Mr. O'Malley convened the Health Care Provider Advisory Committee (HCPAC) meeting at approximately 10:05 a.m., in accordance with Wisconsin's open meetings law. HCPAC members, Worker's Compensation Division staff and other attendees introduced themselves.
2. Acceptance of the August 12, 2016 Meeting Minutes: Dr. Vasudevan moved to approve the minutes of the August 12, 2016 meeting. Dr. Capodice seconded the motion. The minutes were unanimously approved without correction.
3. Future meeting dates: The HCPAC members agreed they will meet on January 20, 2017 with February 3, 2017 set as alternative meeting dates in the event of inclement weather. A future meeting date of May 5, 2017 was set. August 11, 2017 was set as a tentative future meeting date.
4. Correspondence: At the last meeting the HCPAC discussed the e-mail message dated June 9, 2016 from Dr. James Lincer, President of the American Board of Pain Medicine (ABPM) about the paper Chronic Opioid Clinical Management Guidelines for Wisconsin Worker's Compensation Patient Care not defining the qualifications for pain specialist and that these guidelines should clearly stipulate that pain medicine specialist should hold certification from the ABPM or subspecialty certification from the American Board of Medical Specialties. The HCPAC reviewed the language of a letter responding to Dr. Lincer. Mr. Dernbach will send the letter containing the finalized language to Dr. Lincer.
5. Update on education and training modules from the Wisconsin Medical Society Dr. Capodice explained the education and training modules that were previously completed were not patient centric enough. Mr. H. J. Waukau was recently hired to work on completing the education and training modules and appeared at the meeting by telephone conference call. Mr. Waukau updated the HCPAC about his activities and the current status of the project. It was the consensus of the HCPAC the members would review the modules before they were finalized. Mr. O'Malley agreed to provide assistance with completing this project. Dr. Capodice and Dr. Stark commented there is currently no useful resource for physicians to consult about giving permanent partial disability ratings and the modules could cover permanent disability ratings.
6. Review of ch. DWD 81 of the Wisconsin Administrative Code. The HCPAC continued its review of the worker's compensation treatment guidelines in ch. DWD 81 of the Wisconsin Administrative Code.
   The definition of chronic pain syndrome that was drafted by Dr. Jurisic and Dr. McNett should be included in DWD 81.03 (2).
   The HCPAC resumed its review of the treatment guidelines beginning at DWD 81.06 (4).
   1. 81.06 (4) Amend the title of the subdivision for the correct spelling of Modalities.
   2. 81.06 (4) (a) Amend the paragraph as follows:
      "Active treatment modalities shall be used as set forth in pars. (b) to (f). A health care provider's use of active treatment modalities may extend past the 12-week limitation as with on passive treatment modalities as long as acceptable reasons, as set forth in s. 81.04 (5), are documented. so long as the maximum durations for the active treatment modalities are not exceeded."
   3. 81.06 (4) (b) Amend the paragraph as follows:
      "Education shall teach the patient about pertinent anatomy and physiology as it relates to spinal function for the purpose of injury prevention. Education includes training on posture, biomechanics, and relaxation. The maximum number of treatments is 3 visits, which include an initial education and training session and 2 follow-up visits. Education is provided continuously and reflected through active treatment modalities."
   4. 81.06 (4) (c) Amend the paragraph as follows:
      "Posture and work method training shall instruct the patient in the proper performance of job activities based on essential job duties as reported by the employer. Topics include proper positioning of the trunk, neck and arms, use of optimum biomechanics in performing job tasks, and appropriate pacing of activities. Methods include didactic sessions, demonstrations, exercises, and simulated work tasks. The maximum number of treatments is 3 visits. This is an ongoing part of treatment and is reflected through active treatment modalities."
   5. 81.06 (4) (d)Amend the paragraph as follows:
      "Worksite analysis and modification shall examine the patient's work station, tools, and job duties. A health care provider's recommendations may be made for the alteration of the work station, selection of alternate tools, modification of job duties, and provision of adaptive equipment. The maximum number of treatments is 3 visits is 3 per individual injury."
   6. 81.06 (4) (e) Amend the paragraph as follows:
      "Exercise, which is important to the success of an initial nonsurgical treatment program and a return to normal activity, shall include active patient participation in activities designed to increase flexibility, strength, endurance, or muscle relaxation. Exercise shall, at least in part, be specifically aimed at the musculature of that impacts function of the lumbosacral spine. Aerobic exercise and extremity strengthening may be performed as adjunctive treatment, but may not be the primary focus of the exercise program."
   7. 81.06 (5) (b) 3. Amend this subdivision as follows:
      "All of the following guidelines apply to facet joint or nerve (medial branch block) injections:"
   8. 81.05 (5) (b) 5. Create 81.05 (b) 5 a. and renumber the other subdivision paragraphs as follows: "All of the following guidelines apply to epidural injections:
      a. Ideally the treatment is administered within the first 6 to 8 weeks
      ab. Time for treatment response is within one week.
      bc. Maximum treatment frequency is once every 2 weeks if there is a positive response to the first injection. If subsequent injections demonstrate diminishing control of symptoms or fail to facilitate objective functional gains, then injections should be discontinued. Only one injection per patient visit.
      cd.Maximum treatment is 3 injections."
   9. Amend 81.06 (5) (c) Amend this paragraph as follows:
      "For purposes of this paragraph, "lytic or sclerosing injections" include radio frequency denervation (ablation) of the facet joints. These injections may only be given in conjunction with active treatment modalities directed to the same anatomical site. All of the following guidelines apply to lytic or sclerosing injections:
      1. Time for treatment response is up to 6 weeks.
      2. Maximum treatment frequency may repeat 4 times per year or once every 3 months for any site.
      3. Maximum of 2 injections or ablations to any one site."

      The HCPAC discussed possible changes to DWD 81.06 related to low back surgery including decompression procedures and arthrodesis. It was the consensus of the members that no further discussion should occur at this meeting and that any suggested changes should be made by surgeons. Mr. O'Malley will send a message to Dr. Gertel and request him to review and comment about the language contained in DWD 81.06 (6).

   10. 81.06 (8) (a) 2. Amend this subdivision as follows:
       "For patients using electrical muscle stimulation or mechanical traction devices at home, the device and any required supplies are necessary within the guidelines of sub. (3) (e) and (f)."

       The members discussed including the Wisconsin Medical Examining Board's Opioid Prescribing Guideline in ch. DWD 81 of the Wisconsin Administrative Code. Mr. O'Malley stated that the Attorney General's Office is required to approve any document that is incorporated by reference in the Wisconsin Administrative Code. Mr. O'Malley will contact the Wisconsin Attorney General's Office for additional information about this and report at the next meeting.

   11. 81.06 (9) (e). Amend this subdivision as follows:
       "(e) If there is not progressive improvement in at least 2 criteria specified in pars. (b) to (d), in par. (c) or (d), the modality shall be discontinued or significantly modified or a health care provider shall reconsider the diagnosis. The evaluation of the effectiveness of the treatment modality may be delegated to another health care provider. "
   12. 81.06 (10) (b) and (c). Repeal DWD 81.06 (10) (b) and renumber par. (c) as par. (b) as follows:
       "(b) Patients with radicular pain may require longer periods of treatment.
       (c) (b) A health care provider shall document the rationale for the use of any scheduled medication. Treatment with nonnarcotic medication may be appropriate during any phase of treatment and intermittently after all other treatment has been discontinued. The prescribing health care provider shall determine that ongoing medication is effective treatment for the patient's condition."
7. Adjournment: There was no new business. There was a motion to adjourn by Dr. Lynn, seconded by Dr. Vasudevan. The motion was unanimously approved. The meeting was adjourned at approximately 12:30 p.m.