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