MPN Regulations - An Alternative Perspective

Saturday, October 9, 2004 | 0

The following is a rebuttal view point to the article by York McGavin, which appeared in this space during the last article rotation period, on the issue of the presently proposed Medical Provider Network regulations. Since the article by McGavin, and this rebuttal, the regulations have again been amended and are presently the subject of the CA DWC public comment forum. However, this article, by Mike Cohen MD,MPH, Medical Director Sutter Health and Medical Partners @ Work, offers a different perspective from within the MPN community:

Greetings. I am the Medical Director of Medical Partners @ Work, a Medical Provider Network applicant per SB 899 and LC 4616. In your WorkCompCentral article regarding the MPN regulations you make several objections to the proposed draft regulation, CCR 9767.

You assert that 9767.8 "Transfer of ongoing care into the MPN" is not in the chronic pain patient's best interest since, "It interferes in the established physician patient relationship"; the ACOEM Guidelines "do not address appropriate treatment for any body part injured as a result of industrial injury that is now chronic"; and your "employees understand that they will get better treatment from their group health physician than they will from an MPN physician selected by (your) workers compensation insurer." You also state, "...more thought needs to go into promulgating 9767.8 in a fashion that allows the injured worker, who is presently chronic, to continue to be reasonably treated by his or her current physician, until that injured worker is permanent and stationary".

If I may respond on behalf of Medical Partners @ Work:

(1) The goal of worker's compensation medical treatment is to facilitate functional recovery for injured workers. We seek to avoid disability, chronic pain and dependency. Physicians who participate in the employer's MPN's will be allowed under 9767.8 (a) to continue to see their existing physician. For physicians not in the Employers MPN, 9767.8(b)2 describes the medical treatment "shall be provided for a period of time necessary to complete a course of treatment approved by the employer or insurer...." This treatment will, of course, be required to follow ACOEM guidelines since the California legislature has repeatedly (AB 227/228/SB899) mandated that ACOEM guidelines are presumed correct for all dates of injury. The ACOEM Guidelines are the state of the art, evidence based, peer reviewed practice guidelines for the treatment of occupational injuries. The ACOEM Guidelines are not perfect, but until the AD promulgated guidelines are available, they are far superior to the anecdotal experience and junk-science previously relied upon by many treating physicians and patient "advocates".

(2) Regarding the ACOEM Guidelines and Chronic pain: Chapter 6, pages 105-126 discuss the evaluation and treatment of chronic pain. The ACOEM chronic pain guidelines are not body part specific but do address pain management, chronic opiates, psychosocial factors and endpoints. Application of these guidelines will prevent and mitigate opiate dependence, unnecessary surgery, iatrogenic complications, depression and disability. As ACOEM states on page 106, "Patient and clinician should remain focused on the ultimate goal of rehabilitation leading to optimal functional recovery, decreased healthcare utilization, and maximal self-actualization."

In other words, the patient needs to be empowered to return to an active role in managing their life, and decreasing passive victimization. According to ACOEM, page 116, "The desired end point in pain management is return to function rather than complete or immediate cessation of pain."

(3) Your employees may believe they will get "better" treatment from their group health physician only if you define "better" as increased Temporary Total Disability, increased Permanent Disability and loss of employability with attendant depression and social isolation. On the other hand, if you define "better" as facilitating rapid functional recovery, avoiding disability and avoiding iatrogenic complications then an effectively functioning MPN is the employee's best advocate.

Group health physicians are not trained to manage disability, complete the required medico-legal documentation, or obtain appropriate Worker's compensation benefits. They generally do not fully understand occupational causation (AOE/COE), apportionment, ACOEM Guidelines, or how to apply the AMA Guidelines for the Rating of Permanent Disability, 5th. Ed. This may result in loss of benefits and delays in treatment due to Utilization Review denials and delay in receipt of benefits due to litigation. HMO's and Group health insurers have been economically profiling your employee's personal physicians for many years: Group Health providers are often incentivized to minimize utilization of expensive medications, diagnostic tests and referrals. Personal Physicians tend to take employees off work indefinitely, resulting in loss of income and benefits, rather than obtain the definitive medical treatment required to facilitate recovery.

(4) In your final statement you assert that chronic pain patients need to stay with their current provider and receive continued treatment until permanent and stationary. Unfortunately, it is too often the case that the current physician is the cause of the chronic pain due to performing ill advised surgery, refusing to allow the employee to return to gainful employment, and/or fostering dependence on temporary palliative treatments.

According to the current Labor code, "Reasonable and necessary" is now defined per the ACOEM Guidelines. An injured worker should be declared P&S when functional improvement ceases, not when complete pain relief is obtained, per ACOEM page 116. This allows the worker to obtain appropriate Permanent Disability benefits, Vocational voucher, and future medical treatment --effectively facilitating return to a productive life rather than receiving persistently ineffective treatment.

Finally, in defense of those who would impugn the motivation of physician s who serve in MPN's, let me re-iterate: Our primary mission is to facilitate functional recovery of injured workers. Ethical healthcare professionals do not allow financial imperatives to jeopardize their patient's health and recovery. As ACOEM's Code of Ethical Conduct eloquently states, "Physicians should accord the highest priority to the health and safety of individuals in both the workplace and the environment."

Mike Cohen MD,MPH
Medical Director
Medical Partners@ Work
Sutter Health @ Work
cohenmi@sutterhealth.org

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