The Method of Biopsychosocial Law:
Science, Government and Guidelines
Source: Bruns, D. (2010) The Method of Biopsychosocial Law: Science, Government and Guidelines. The Health Psychologist, 32 (3), 12-13.
Reprinted with permission
The convergence of changing concepts in psychology, medicine and law has led some jurisdictions to adopt laws and regulations that do not easily fit into established legal categories. While recognized branches of law include both medical law and mental health law, it has recently been noted that some laws simultaneously consider both the physical and psychological aspects of injury and illness within the framework of a biopsychosocial paradigm. These new laws and regulations have been said to represent a new category, that of biopsychosocial law, and have been adopted by a number of US states and Canadian provinces. These laws have their origins in trends that can be observed in psychology, medicine, business and law.
Within the medical community, there is constant pressure to innovate and to improve outcomes. Beginning in the in the late 1980’s, this goal has been pursued by the application of methods often referred to collectively as evidence-based medicine (EBM). As a surprising number of medical treatments were determined to have little basis in science, the goal of EBM ultimately was to identify new and effective treatments, and to eliminate treatments for which there was no scientific support. Through these methods, a central strategy of EBM was to develop treatment guidelines to identify interventions that were supported by evidence and expert opinion.
From the perspective of the insurance business, rapid rise of healthcare costs over the last two decades led to managed care. Through the use of techniques such as utilization review and audits, managed care sought to control costs through determinations of appropriate care: Appropriate care would be reimbursed, while inappropriate or excessive care would not. Payors could not make these determinations, however, without guidelines to determine what constituted appropriate care. As guidelines set by the whim of an insurer were ultimately indefensible, business needed medical treatment guidelines that were grounded in science.
Within the Courts, guidelines may sometimes be used for determinations of the adequacy of a patient’s care during legal proceedings. To be admissible in Court, however, guidelines will generally need to meet the Daubert legal standard. The Daubert test is a stringent scientific standard for evidence presented in Federal Court, and requires that an expert’s conclusions be derived from scientific method, including an acceptable theory or technique that is testable and falsifiable. Unless the expert’s opinions are based on methods that can pass the Daubert test, that expert’s opinions are inadmissible in Court.
The conflux of the EBM movement, business needs and legal standards have been strongly influenced by the fact that research clearly shows that there is a strong relationship between health and behavior. Driven by these findings, this had led some jurisdictions to adopt biopsychosocial laws to regulate medical treatment. At this time, all existing biopsychosocial laws regulate workers compensation, a complex medical system known for having high levels of secondary gain, delayed recovery, and litigation. Currently, there are a number of biopsychosocially-oriented treatment guidelines that have legal status in one or more jurisdictions. These guidelines include: the American College of Occupational and Environmental Medicine’s (ACOEM) Practice Guidelines, the Work Loss Data Institute’s Official Disability Guidelines (ODG), and the Colorado Medical Treatment Guidelines. These and other biopsychosocial laws have been reviewed recently (Bruns, Mueller, & Warren, 2010), and share certain features in common.
The biopsychosocial laws noted above were developed using evidence-based methods. Additionally, the ACOEM and Colorado guidelines were developed by panels that included physicians of various specialties, psychologists, physical therapists, nurses, chiropractors, attorneys, representatives from the business community, and patient representatives as well. The ACOEM guidelines later underwent review by various specialty organizations, and jurisdictions where these guidelines became biopsychosocial laws or regulations, they underwent further scrutiny in the form of public hearings, legislative review, and legal review by the state attorney general before becoming law. The checks and balances built into this method were meant to ensure that no one profession or interest group could bias the guidelines to benefit itself. Instead, this method attempts to integrate the best contribution of each profession, while pursuing the twin goals of improving care while controlling costs.
Existing biopsychosocial laws are noteworthy for three reasons. First of all, their method of development represents a novel means through which government has utilized the scientific method and professional expertise to shape policy. Second, they provide a roadmap for organizing the scientifically supported services of a variety of professions into a single, integrated guideline. Third, they represent a growing acceptance of a biopsychosocial paradigm shift, which recognizes that behavioral methods are an integral part of medical care. As our country struggles with healthcare reform, the method employed in the development of biopsychosocial laws warrants further consideration.
Bruns, D., Mueller, K., & Warren, P. A. (2010). A Review of Evidence-based Biopsychosocial Laws Governing The Treatment of Pain and Injury. Psyhological Injury and Law, 3(3), 169-181.
The following biopsychosocial treatment guidelines were developed using rules of evidence based medicine, and have the force of law in Colorado for patients being treated within the Worker's Compensation system. The official site for the guidelines, which are updated from time to time, can be found at www.coworkforce.com
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