MPN Regulations - A Perspective

Saturday, September 25, 2004 | 0

Our Administrative Director, Andrea Hoch, deserves much praise for demonstrating a forthright willingness to timely tackle the numerous Herculean tasks heaped upon her shoulders, to be accomplished in a the frightenly short time-frames mandated by the recent passage of SB 899. There can be no doubt that the directives of SB 899 change the very face of workers' compensation as the regulated public, and participants in the workers' compensation system, have come to know for decades.

The proposed draft regulations promulgated by AD Hoch appear to accurately mirror the legislative mandates created by our elected politicians who voted to pass SB 899, both in committee, as well as on the floor of the Senate, the House of Representatives, and as were signed into law by our Governor.

Despite the fact SB 899 contains many drafting errors and ambiguities, AD Hoch has done a fine job of attempting to interpret the language of SB 899 into a workable set of regulations that inform the regulated public of the responsibilities and obligations of the employers, insurers, and third-party administrators who will be forming the Medical Provider Networks pursuant to Labor Code 4616, et seq.

Although personally, I wear two hats, one as an employer in California, and the other as a provider of ancillary services to many injury workers, I strongly disagree with the concept of total employer control over an injured worker, combined with the presumptively correct and very conservative ACOEM treatment guidelines.

Despite the fact I may disagree with the very concepts of Labor Code 4616, the law is now carved in granite, and it is up to our AD to promulgate appropriate regulations implementing Labor Code 4616 --- proposed draft regulation CCR 9767.1 et seq., that will guide the regulated community.

My biggest area of concern is proposed draft regulation 9767.8, titled "Transfer of ongoing care into the MPN." Today, prior to implementation of the MPN, physician providers of treatment are already receiving ACOEM based objections rejecting proposed requests for authorization to treat an injured worker whose injury is clearly chronic, and who may never be cured from the effects of the industrial injury, but still need reasonable treatment to relieve the injured worker from the effects of the admitted industrial injury.

The ACOEM treatment guidelines do not address the appropriate treatment guideline for treating any body part injured as a result of an industrial injury that is now chronic.

For those injured workers, who are now in chronic intractable pain as a result of their industrial injury, I can already foresee the dictates of 9767.8 allowing an employer/insurer interfering in the established physician-patient relationship; interrupt the continuity of care now being provided by the injured workers current physician; and, after January 1, 2005, the injured worker will be forced to be treated by a strange physician in the MPN, who in order to avoid being economically profiled out of the MPN, discontinues treatment at the whim of the employer/insurer, pursuant to a misapplication of the ACOEM Guidelines by a Utilization Review physician who has never physically examined the patient, and who has been selected, and being paid, by the very employer who has a vested interest in reducing the employer's costs for providing treatment.

In the best interests of the injured worker, I believe the correct course for the AD to take, when promulgating the final version of 9767.8, is to allow the chronically injured worker to continue to be treated by his or her present Primary Treating Physician, until the injured worker's recovery has reached a plateau, and can be deemed by the Primary Treating Physician to be permanent and stationary.'

As an employer who provides non-occupational group health insurance coverage for my employees, my company is also a provider of ancillary services to any patient, regardless of whether the injury was industrial or not. My employees, who are intimately familiar with the workers' compensation laws of California, as well as the workers' compensation laws in 37 other States, have all been provided with a copy of SB 899.

After thoroughly reviewing the entirety of the laws (SB 899) affecting the rights of injured workers in California, where we are located, each and every of my employees have informed me that if they injure themselves on the job, they will not report the injury as industrial.

Despite the fact I have informed my employees that the law mandates they report any injuries sustained on the job, each and every one of my employees have told me that if they sustain an injury on the job, they will tell their physician that they injured themselves at home.

My employees understand that they will get better treatment from their group health physician then they will from an MPN physician selected by my workers' compensation insurer. These statements, shout volumes as to my informed and educated employees understanding of the lack of care they will receive if they report an injury as being work related.

I firmly believe that the permissibly self-insured employers, as well as the legally uninsured employers, will reap the most benefits from implementation of 9767.1, et seq.

In addition, I firmly believe that the majority of employers will not enjoy any significant financial benefits, in the form of reduced premiums, from the passage of SB 899.

However, the workers' compensation insurers, who provide the majority of California's employers with coverage, will certainly harvest record profits as a result of SB 899. This is borne out by the most recent WCIRB report of August 2004.

In summary, although I disagree with the concept of total employer/insurer control, the law is the law, and we must all do the best we can to work within the confines of the Statutes voted into law by our elected representatives; our AD is doing a magnificent job in interpreting LC 4616; but, 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.

Article by York McGavin, ymcgavin@socal.rr.com.

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The views and opinions expressed by the author are not necessarily those of workcompcentral.com, its editors or management.