The IMR Debate is Focusing on the Wrong Metric

Wednesday, November 4, 2015 | 3

Now that California’s courts have ruled the independent medical-review process is constitutional, we can hope things will settle down, docs will start learning what is acceptable and what isn’t, and needless friction will decrease.

Unfortunately that isn’t likely. If history is any indicator, a very few docs will continue to flood the system with thousands of requests for IMR, most of them for drugs and procedures that fall far outside the state’s evidence-based clinical guidelines.

Let’s acknowledge that the system – like any – isn’t perfect. Let’s also acknowledge that all the data, research and credible study to date indicates it works quite well. What’s lost in the data-driven debate is the real problem – we aren’t looking at the right metric.

As CWCI has documented, well over 90% of all work comp medical procedures, tests, drugs and treatment are approved. And, when appeals do get to the last stage, it is the Independent Medical Review.

Data on the IMR outcomes show that 91% of all IMR decisions upheld or agreed with the physician-level utilization review opinion, while conversely, 9% of medical-service requests submitted for IMR after being modified or denied by a UR physician were approved by the independent medical reviewer.

I’d suggest the California utilization review and IMR process is approving too much care.

Does anyone think that 94% of all medical procedures requested or delivered to California’s work comp patients are medically necessary, appropriate and the best possible care?

Didn’t think so.

There’s no question too much care can be quite harmful. The rampant overuse of opioids in workers’ comp is but one example of far too much care causing grievous harm. Add in far too many spinal surgeries with lots of implants, and one can see that these “approved” services are far from optimal care.

What does this mean for you?

Why aren’t we focused on making the UR process tighter with more stringent controls and requirements before potentially dangerous and debilitating treatment is authorized?

Joe Paduda is a principal of Health Care Strategy Associates, a Connecticut-based employer consulting firm, and co-owner of CompPharma, a consortium of pharmacy benefit managers. This column was reprinted with his permission from his Managed Care Matters blog.