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

Health Care Provider Advisory Council Minutes May 6, 2016

Aurora Medical Center in Summit

May 6, 2016

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

Excused: Ted Gertel, MD; Barbara Janusiak, RN; Stephen Klos, MD; and Jim Nelson

Other Attendees: John Murray, Wisconsin Chiropractic Association

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. Mr. Jim Nelson was introduced as the newest member of the HCPAC. Mr. Nelson is the CFO for Fort Health Care.
2. Acceptance of the January 22, 2016 Meeting Minutes: Ms. Barbara Janusiak stated the term "abnormalities" was misspelled on page 3 in the section for the amendment to DWD 81.05 (2) of the Wisconsin Administrative Code. Dr. Capodice moved to approve the minutes of the January 22, 2016 meeting with this correction. Dr. Schubbe seconded the motion. The minutes were unanimously approved as corrected.

   Mr. John Levene appeared at the meeting in place of Ms. Jennifer Seidl on behalf of the Wisconsin Physical Therapy Association. There was a motion by Mr. Levene to amend the minutes of the meeting on January 22, 2016 to revise the language for the amendment to DWD 81.06 (1) (k) tentatively approved at that meeting. Following a discussion by the members of the HCPAC Mr. O'Malley ruled it was not appropriate to amend the minutes of the last meeting in this manner and that Mr. Levene could present the HCPAC with other language to revise the amendment to DWD 81.06 (1) (k) later in the meeting.

3. Future meeting dates: The HCPAC members agreed they will meet on August 12, 2016 and on October 7, 2016. A tentative meeting date of January 20, 2017 was also set.
4. 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 from where it left off at the last meeting, beginning at DWD 81.06 (1) (i).
   1. 81.06 1 (i) 6., rewrite the subdivision as follows: "Does the patient have a chronic pain syndrome or psychogenic pain disorder with related psychological factors?"
   2. 81.06 (1) (i) 7., rewrite the subdivision as follows: "In cases in which surgery is an possible appropriate treatment, are psychological factors likely to interfere with the potential benefit of the surgery?"
   3. 81.06 (1) (j), delete the term "differential". "All of the following are guidelines for diagnostic analgesic blocks or injection studies and include facet joint injection, facet nerve injection, epidural differential spinal block, nerve block, and nerve root block:"
   4. 81.06 (k) 1. to 4., rewrite the paragraph as follows: "Functional capacity assessment or evaluation is a comprehensive and objective assessment of a patient's ability to perform work tasks. The components of a functional capacity assessment or evaluation include neuromusculoskeletal screening, tests of manual material handling, assessment of functional mobility, and measurement of postural tolerance. A functional assessment or capacity evaluation is an individualized testing process and the component tests and measurements are determined by the patient's condition and the requested information. Functional capacity assessments and evaluations are performed to determine and report a patient's physical capacities in general or to determine work tolerance for a specific job, task, or work activity.
   1. A functional capacity assessment or evaluation is not typically necessary during the period of initial nonsurgical management.
   2. A functional capacity assessment or evaluation is may be necessary appropriate in any of the following circumstances:
      1. To identify delineate the patient's activity restrictions or physical capabilities.
      2. To resolve a question about provide information about the patient's ability to do a specific job.
   3. A functional capacity evaluation may is not the appropriate tool to establish baseline performance before treatment or for subsequent assessments to evaluate change during or after tratment.
   4. A health care provider may direct only one completed functional capacity evaluation per injury unless one or more of the following exceptions exist at which time another functional capacity evaluation may be appropriate:
      1. An exacerbation of the injury occurs.
      2. A major change in the patient's health status occurs.
      3. The patient undergoes surgery that significantly changes the patient's physical status.
      4. If the initial functional capacity evaluation was for a particular job and there is a change in the job to which the patient is returning.
      5. Final determination of PPD is necessary"
   5. 81.06 (2) (a) 2., add neurologic deficits as follows: "Subsection (12) governs radicular pain with no neurologic deficits or static neurologic deficits."
   6. 81.06 (2) (c) 1. to 4., create subdivision 2., rewrite subdivision 3., and renumber 2. to 4. In general, a course of treatment for low back problems is divided into the following 4 3 phases:
      1. First, all patients with low back problems, except patients with progressive neurologic deficit or cauda equina syndrome under sub. (1) (b) 3. or 4., shall be given initial nonsurgical management which may include active treatment modalities, passive treatment modalities, injections, durable medical equipment, and medications. These modalities and guidelines are described in subs. (3), (4), (5), (8), and (10). The period of initial nonsurgical treatment begins with the first active, passive, medication, durable medical equipment, or injection modality initiated. Initial nonsurgical treatment shall result in progressive improvement as specified in sub. (9).
      2. Second, for patients with symptoms persisting beyond six weeks who are not progressing towards functional restoration, a reassessment should be performed looking for barriers to recovery. This may include but is not limited to reconsidering the diagnosis, evaluating psychosocial issues, or motivational factors. The treatment plan should then be modified accordingly.
      3. Second Third, after consideration of sub. 2 patients with persistent symptoms may be considered for initial non surgical management is followed by a period of surgical evaluation. This evaluation shall be completed in a timely manner. Surgery, if necessary, shall be performed as expeditiously as possible consistent with sound medical practice and subs. (6), (11), (12), (13), and s. DWD 81.12. A treating health care provider may do the evaluation or may refer the patient to another health care provider.
         1. Patients with radicular pain with progressive neurological deficit or cauda equina syndrome may require immediate surgical therapy.
         2. Any patient who has had surgery may require postoperative therapy in a clinical setting with active and passive treatment modalities. This therapy may be in addition to any received during the period of initial nonsurgical care.
         3. Surgery shall follow the guidelines in subs. (6), (11), (12), (13), and s. DWD 81.12.
         4. A decision against surgery at any particular time does not preclude a decision for surgery at a later date.
      4. Third Fourth, for those patients who are not candidates for or refuse surgical therapy, or who do not have complete resolution of their symptoms with surgery, a period of chronic management may be necessary. Chronic management modalities are described in s. DWD 81.13 and may include durable medical equipment as described in sub. (8).
   7. 81.06 (3) (a), rewrite as follows: " General. Except as set forth in par. (b) and s. DWD 81.04 (5), a health care provider may not direct the use of passive treatment modalities in a clinical setting as set forth in pars. (c) to (i) beyond a total of 12 calendar weeks of continuous or interrupted treatment after any of the passive modalities in pars. (c) to (i) are initiated. There are no limitations on the use of passive treatment modalities by the patient at home."
5. Old Business. Dr. Vasudevan discussed an article in the Wisconsin Medical Journal about guidelines from the Centers for Disease Control and Prevention (CDC) on pain and the use of opioids. Dr. Capodice updated the HCPAC on the progress of the Wisconsin Medical Society (WMS) in developing training modules for physicians who treat employees with work related injuries. She stated the training modules that were developed were not patient centered and that Ms. Cindy Helsted from WMS was working on revising the training modules. Dr. Capodice said that the WMS will be asking the Worker's Compensation Division for feedback on the revised training modules.
6. Adjournment: There was no new business. There was a motion to adjourn by Ms. Janusiak, seconded by Ms. Gilliland. The motion carried unanimously. The meeting was adjourned at approximately 12:30 p.m.