CHSWC AND THE QME SYSTEM
CHSWC will be receiving an October 2017 report on the workers’ comp QME system.
The report, to be delivered to the commission at its October 19 meeting in Oakland, is authored by Frank Neuhauser of UC Berkeley and has been posted online on the CHSWC. The CHSWC site notes that the report (see link to it below) could be subject to revision and replacement, so the final report could look somewhat different than what I’ll reference in this post.
The report is designed to update an earlier 2010 review of the QME process for CHSWC. An update had been requested in 2016 by Senate Labor and Industrial Relations Committee Chair Tony Mendoza.
It appears that the report is principally based on data from the DWC’s Medical Unit and the DEU, though Neuhauser does indicated it was “supplemented with summary data from several sources”, none of which re specified. If Neuhauser interviewed any QMEs, QME doctor aggregator groups, QME doctor associations, judges, applicant attorneys or defense attorneys , or claims unit staffers about the problems in the QME system, he did not specify that.
So there may be some questions about the completeness of the report’s methodology.
Here are a selected sample of conclusions from the report, along with some brief comments I’ll make:
- QME provider numbers have declined 17% since 2007 but the number of panel requests increased 87% since 2007 (Comment: the report does not appear to reference the recent actions of the DWC Medical Unit to delay or deny recertification to scores of QMEs who are alleged to have violated a recent DWC interpretation of billing codes. The report does not acknowledge the “graying” of the QME pool)
- 10% of QMEs account for 55%-60% of panel assignments
- As a result of these trends the number of requests per QME have doubled
- Requests from unrepresented workers are down by 55% since 2007, while represented case requests (from applicant and defense) are up 400%
- The SB 863 limitation to 10 locations per QME appears to “have had the effect of distributing QME panels more evenly and widely among registered providers.”
- The report claims that QME access does not appear to be an important current problem but “there are signs that delays in getting an evaluation may be developing” (Comment: the report glosses over the problem of getting a QME in specialties such as dermatology, ophthalmology, gastroenterology, cardiology, pulmonary medicine, etc; although the demand for such specialties may be lower, it creates a real problem in cases when it is needed)
- Neuhauser attempts to analyze high-volume QME ratings before and after the limitation to 10 office locations, concluding that “Overall, high-volume QMEs (the top 5%) are still conservative in their evaluations of workers for PD relative to all other evaluators.” On the other hand he claims that QMEs suspended/restricted due to anti-fraud measures gave higher ratings and less apportionment.
- The report claims that “the number of panels where a subsequent panel is requested because the QME was not available within 60 days (a measure of access), while still low, has increased from 1% to 2.8% for unrepresented cases and 0.7% to 4.7% for represented cases” (Comment: Anecdotal discussion with many attorneys would indicate that the 60 day availability problem is much greater than Neuhauser suggests; part of the problem may be that Neuhauser is looking at Medical Unit data re second panel requests, whereas many attorneys may be reluctant to file for a second panel even if the initial panel is setting more than 60 days out. The reason? Getting a second panel processed seems to create delays of its own, and the second panel may also contain doctors setting more than 60 days out. Clearly this needs more exploration. Neuhauser also does not discuss the problem parties have in getting a second panel in another specialty and the delays that this creates. For example, where there is an allegation of a compensable psychiatric claim where the worker seeks treatment, the parties may seek a psychological or psychiatric QME.If the Medical Unit fails to issue a second specialty panel, the parties may have to seek an order for the WCAB judge. These are the types of real world problems that Neuhauser fails to discuss).
- 40% to 50% of pain specialist panels (PAP, MAA & MPP) are said to have at least one provider who has been suspended or restricted under the recently enacted anti-fraud statues. The numbers were lower for categories such as MPA, MPR, and MMH (15-17% of those QMEs were restricted or suspended). Neuhauser also noted that “the proportion of cases for which “60 days” is the reason for second panel is three times as high for the pain medicine specialty.”
- Neuhauser makes several recommendations, including:
- Looking at more data to examine “whether the increases observed in average cost of medical-legal reports is driven primarily by providers acting through aggregators“
- A suggestion that “the very high concentration of restricted and suspended doctors in the “Pain” specialties suggests the DWC could examine the cost-benefit of maintaining separate pain specialties in the QME system“. He suggests education outreach and special monitoring
- Considering additional weight in the selection process to boost assignments to QMEs who have few locations
This report will undoubtedly trigger CHWC questioning and robust debate in the California workers’ comp community. Clearly, the report needs more work.
While the report has a number of interesting data findings and recommendations, it appears that the author needs to seek out a wider range of sources for their perspective on the problems in the QME system.
Here is the draft report on QMEs posted on the CHSWC site before the October 19 meeting: