Introduction by Allyn
Segelman DMD, SM, Dental Director of Blue Cross Blue Shield of Massachusetts.
The diagnosis of a Temporomandibular Joint Disorder (TMJ) while singular, represents a broad categorization of multiple disorders and conditions, which affect the temporomandibular joints and surrounding musculature. The lack of scientific knowledge upon which to base diagnostic accuracy and therapeutic effectiveness has led to significant variation in treatment of TMJ. Confusion is heightened by the management of these disorders by a wide variety of health care practitioners, including but not limited to: physicians, dentists, chiropractors, physical therapists, psychologists, and others. Obviously, a partial explanation for the wide variation in care rendered is the result of the multiple disciplines of practitioners rendering therapies.
While variation in care does not necessarily
indicate inappropriateness of care1, it does lead to the speculation
that there may be unconventional, or unnecessary care delivered as components
of the total spectrum of care rendered and more importantly; it does indicate
practitioner uncertainty2, 3 and lack of consensus of opinion
regarding medical management of patients.
In fact the uncertainty is so great that patients as well as the doctors
sense the uncertainty. "To an unprecedented degree patients are questioning
treatment modalities." "Patients sense uncertainty and clinicians are
burdened by the same uncertainty."4
Areas of
wide variation in application of types, intensities, volumes and satisfaction
of medical services provided to insured subscribers by various health care
practitioners for Temporomandibular Joint Disorders (TMJ) has led Blue Cross
Blue Shield of Massachusetts (BCBSMA) to develop Clinical Practice Guidelines.
Clinical Practice Guidelines are defined by the
Institute of Medicine as: “systematically developed statements to assist
practitioner and patient decisions about appropriate health care for specific
clinical circumstances."5 They improve the quality of the
delivery of health care services, by reducing uncertainty and unnecessary
variability in health care decision-making, in clinical practice.
Since the major overwhelming condition causing
variation in TMJ care is uncertainty, the major strategy in modifying clinician
behavior must be education, or education of the "facts" as they
exist. Adoption of clinical guidelines
appeared to be the single best strategy to decrease uncertainty and therefore,
variation for TMJ care. "Guidelines assure credibility to providers and
insurance companies, minimize controversy, and ensure access to high-quality,
cost-effective care."6
In keeping with these principles and in accordance
with our practices for formulating medical policy, BCBSMA constituted a panel
of local clinical expert providers. The panel evaluated the necessary and
appropriate application and utilization of medically necessary services for use
under the usual conditions of medical and dental practice, to improve outcomes
such as ability to function and quality of life, in accordance with our Medical
Policies.
Given that the absence of
reliable scientific data has led to confusion among dentists and physicians
regarding when and how to treat TMJ, it should be appreciated that another
educational benefit of the development of clinical guidelines is that
"publicized guidelines also offer the opportunity to inform patients of
medical standards and to encourage them to become more active participants in
and to assume more responsibility for their own care. An informed consumer can also encourage the physician to refrain
from providing a service that offers little potential benefit relative to its
cost, a decision that physicians may be reluctant to make on their own."7
The goal of the clinical guidelines would be to educate both the
clinician and consumer population and in so doing, reduce, not only, the amount
of variation, but also, to try and minimize unconventional, unnecessary and
inappropriate care and in so doing, provide the most cost-effective appropriate
care.
These clinical guidelines
represent a “work in progress” and are subject to future revision, at such time
that more definitive scientific data becomes available for review. Every individual case has varying factors
and situations around them and this is reflected in a system where the specific
diagnostic and therapeutic options, as defined by Physician’s Current
Procedural Terminology (CPT-4, 2001) were designated into four categories:
Appropriate, Inappropriate, Discretionary and Experimental. The categories were
determined on the basis of specific diagnostic conditions, diseases or
disorders defined by their International Classification of Disease, 9th
Clinical Modification code number (ICD-9-CM).
For managed care medical
patients, prior to utilizing the Clinical Practice Guidelines, the mechanism
for obtaining care is to get a referral from your primary care physician to a
participating network practitioner experienced in the treatment of TMJ. This may be a physician, such as rheumatologist,
or dentist such as oral and maxillofacial surgeon; however, in many
circumstances, if you desire a non-surgeon dentist, they may not be a
participating provider in our managed care medical network. This necessitates an out of network
referral, which is coordinated through the Oral and Maxillofacial Surgery
Utilization Review Unit. Your primary
care physician will arrange for this referral. If the primary care physician is
unfamiliar with an experienced clinician in this area your health plan will help
direct your care to any of several experienced practitioners or facilities.
To adequately utilize the following Clinical
Practice guidelines you should be able to find out from your specialist
practitioner exactly what diagnosis you have and its appropriate ICD-9-CM code
number. Then ask the practitioner what
procedures are being planned for you and the CPT code number for that
diagnostic or therapeutic procedure.
You can then check the guidelines by matching diagnosis number to
procedure code number to find out whether the procedures are considered by
BCBSMA to be appropriate, inappropriate, discretionary on the part of the
practitioner, or considered to have insufficient information at this time as to
their efficacy, which classifies them as experimental. You should be aware that BCBSMA insurance
coverage does NOT include payment for procedures considered experimental.
Self-advocacy is always beneficial. Always discuss with your practitioner what
alternatives are available to you in the management of your condition and if a
surgical procedure is recommended, always request a second surgical opinion
regarding the appropriateness of any recommended surgical procedure in your
specific circumstances.
1.
Leape,
L.L., Park, R.E., Solomon, D.H., Chassin, M.R., Kosecoff, J. and Brook, R.H. Does
Inappropriate Use Explain Small Area Variations in the Use of Health Care
Services. JAMA 1990;263:669-672
2.
Eddy,
D.M. Variations In Physician Practice: The Role of Uncertainty. Health Affairs
1984;3(2):74-89
3. Gerrity, M.S., DeVellis, R.F. and Earp, J.
Physicians' Reactions to Uncertainty in Patient Care. A New Measure and New
Insights. Medical Care 1990;28:724-736
4. Palmer, C. Panel asks questions but conference doesn't provide ready
answers. ADA News 1996,May 20;27 1(col 2), 10(col 1), 15 (col 1)
5. Institute of Medicine. (1990) Clinical Practice Guidelines: Directions for a
New
Program,
Field MJ and Lohr KL (eds.) Washington, DC: National Acad. Press p. 38
6. McNeil, C. ed. Temporomandibular Disorders
Guidelines for Classification, Assessment, and Management. American Academy of
Orofacial Pain. Chicago. Quitessence, 1993:110
7.
Pauly, M.V., Eisenberg, J.M., Radany, M.H., Erder, M.H.,
Feldman, R. and Schwartz, J.S. Paying Physicians Options for Controlling Cost,
Volume and Intensity of Services. Ann Arbor: Health Administration Press,
1992:67
Click on the actual policy TMJ Diagnosis and Treatment
[Policy #35] at http://www.bcbsma.com/hresource/035.htm
and TMJ Disorders Guideline [#608]
at http://www.bcbsma.com/hresource/608.htm