IR, UR, We R in Need of Some Answers

Monday, January 13, 2014 | 0

The issues of utilization review (UR) and independent medical review (IMR) have risen to the top of the crisis list of California’s oft-changed and less so often reformed workers’ compensation system. While a concept well engrained in non-occupational health care, UR appears to be the millstone around the neck of the workers’ compensation system.

From a purely empirical standpoint, there is the very legitimate question of what, exactly, is the problem? Years of UR audits by the Division of Workers’ Compensation (DWC) and the Department of Insurance have not indicated a widespread abuse of the UR process. It has been estimated that upwards of 75% of all requests are approved. In December, at the meeting of the Commission on Health and Safety and Workers’ Compensation (CHSWC), DWC Medical Director Dr. Rupali Das stated that they expected around 4,000 to 5,000 IMR requests per month. That is three times more than the Department of Managed Health Care sees in an entire year, but far less than the tens of thousands of requests currently choking the DWC system.

At the same December CHSWC meeting, Dr. Das also noted that 79% of the IMR requests resulted in upholding the claims administrator's denial of the requested treatment. That leads to the conclusion that only a very, very small number of UR decisions are ultimately determined to be incorrect.

The number of requests for IMR is indeed staggering, but not entirely unanticipated when considering the application of IMR to all services regardless of date of injury. The medical treatment utilization schedule (MTUS) was supposed to bring the highest – not the cheapest – caliber of medical treatment to the workers’ compensation system. Instead, the med-legal process eroded that concept, especially when it came to AME opinions that deviated considerably from the MTUS and general evidence-based standards. When these decisions are reviewed by IMR because of the language in Senate Bill 863 (De León), there is undoubtedly going to be considerable friction.

And that leads to the conclusion that there were a large number of requests for authorization, and treatment that has in the past been approved by the Appeals Board, inconsistent with the MTUS.

Workers’ compensation medical treatment is not immune from the abuses that are seen in all health care delivery systems. This includes the well documented  Los Angeles Times series regarding prescription pain medication. Hopefully, the MTUS will revise its chronic pain guidelines to curb inappropriate access to these drugs. But without a prior authorization system, how can we be assured physicians will follow the guidelines? Until the medical community and so-called patient advocates embrace a more compassionate and holistic approach to pain management this tragedy will continue. The response to chronic pain is not more and stronger pain medications.

But there are those who would argue that pre-authorizing treatment for back surgeries or prescriptions for Schedule II controlled substances is not the problem. The problem basically is with claims administrators sweating the small stuff.

The theory goes that if a requesting physician wants to do something that costs $559.99 or less, there’s no reason to have a physician review it and then pay $560.00 for IMR if you delay, deny or modify the request. The Labor Code doesn’t have a monetary threshold for evidence-based medicine, and as we have seen time and again in this system, any service or procedure or process that falls within a legislative or regulatory gap, or that is not subject to scrutiny and accountability, will be abused.

There are better ways to deliver occupational medicine in California than currently are being used. Foremost is to encourage a prompt dialogue between medical professionals early in the treatment process, internally within the network when there is a dispute, and ongoing during the course of treatment to reduce frictional costs and delays while the injured worker is recovering. Second is to loosen the reins on the MTUS. There is no shortage of guidelines that are evidence based that can be used in a responsible discussion between medical professionals on what constitutes medically necessary treatment for acute and chronic conditions. At a minimum, the Legislature should reconsider the caps on physical medicine services in light of the evidence-based guidelines and IMR that have been adopted since the caps were put in place in 2003 in Senate Bill 228 (Alarcon). This is especially true if we are going to consider physical therapy options as part of chronic pain management.

There needs to be a more transparent process for the development of treatment guidelines and one that allows the guidelines to be updated in real time as medical science progresses. In addition, there should be an institutionalized dialogue not only between the DWC Medical Director and medical directors of medical provider networks (MPNs), but also with the various professional licensing boards whose educational and enforcement mandates should include scrutiny of occupational medicine licensees. Similar programs in Oregon and Washington have produced far better results than the too secret, too complicated California workers’ compensation system we are now dealing with.

As stated almost 20 years ago by Dr. David L. Sackett, the “father of evidence-based medicine”:

“Evidence-based medicine is not ‘cookbook’ medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice, it cannot result in slavish, cookbook approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision.”

If providers and payers can meet in this middle ground, the system will indeed be reformed. But if we remain wedded to a litigious status quo that pits maximizing disability against cutting costs, we’ll be spinning a tread-bare set of tires that have been running over the same ground for more than two decades.

Mark Webb is general counsel for Pacific Compensation Insurance Co. in Agoura Hills, Calif.