Workers Comp Zone


The recent California Department of Industrial Relations report on IMR (see link below) isn’t full of surprises.

The 2018 report is one of a series of annual reports on IMR. This one examines 2017 data on Independent Medical Review (IMR).

One gets the feeling we’ve seen this rodeo before.

Still, some of the stats seem uncannily odd. Total IMR applications have been almost the same for the past three years (i.e. (248,251 in 2017 vs. 249,436 in 2016 vs. 253,779 in 2015). The number of monthly “unique” applications (i.e. non-duplicates) has been almost the same each month for the past three years.

Monthly “eligible applications” are up slightly, but up only several hundred from 2016 to 2017.

While there was some decrease in the numbers of final determination letters, overall the system seems almost static.

Also uncanny is how similar the IMR determinations are from year to year. In 2016, IMR upheld the UR denial of the treatment request 91.6% of the time. In 2017 the IMR uphold rate was 91.7%.

I’m not a statistician, but if the uphold rate in 248,251 determinations is within .1% of the rate for the prior year, it strikes me as odd. The uphold rate seems to be almost exactly the same from year to year despite what you would think would be a range of different circumstances in different cases with different body parts, different treatment recommendations and so forth.

Also perplexing is why we have so many IMR disputes over five years after the IMR system went into effect and so many years after California adopted a treatment schedule.

I recognize that different stakeholders have different opinions on this.

Employer and insurer advocates are concerned that pharmacy disputes have driven up the numbers, and believe that establishment of a formulary will bring down the number of IMR disputes. After all, the DIR study reveals that 42.6% of the disputed treatment requests in 2017 involved pharmaceuticals. California’s formulary did not take effect til 2018, so the effect of the formulary on IMR is not yet totally clear. However, a CWCI analysis released in July 2018 claims that the percentage of UR decisions involving prescriptions declined by 8.5% during the first five months of 2018.

CWCI  also documents that a very small slice of physicians are driving a high volume of IMR. According to CWCI just under half of the IMR determinations involved treatment requests from 1% of the doctors. The implication is that many of those doctors don’t understand the MTUS rules or willfully ignore them repeatedly.

Predictably, some applicant attorneys see it differently. They cite anecdotes of clients with chronic pain that wind up with specialized pain management or physical medicine doctors who attempt to handle cases that occupational medical clinics and doctors with surgical practices don’t want to manage.

And some believe that UR and IMR reviewers sort of “stack the deck” by failing to look at the nuances of files, not spending sufficient time to examine the historical context of what tests were previously performed, what treatments were attempted, what alternatives may now be available, etc. They believe that some of the doctors with high IMR volume are justifiably advocating for patients.

They believe that the MTUS treatment guidelines are being weaponized against workers in some instances, citing situations where workers fed up with the comp system go to Kaiser or Medicare or union trust funds where they are given treatments refused by UR/IMR in the comp system. They charge that this results in cost shifting.

They also believe that UR has become a “profit center” for vendors and some carriers, and that the industry is not all that concerned with the high volume.

So there you have two perspectives. What to do?

With a new administration coming in January, soon there may be new policymakers weighing in on the comp system.

Perhaps it is time to do a study that not only mines data but actually reaches out to some of the high-volume IMR providers. Such a study could look at what treatments those providers are recommending and why those treatments are generating so many UR denials and IMR upholds. Are there perverse incentives at work? Are treaters insufficiently educated on MTUS? Are there paperwork procedural problems which are interfering with good patient care and good UR/IMR outcomes? Is this an MPN problem or is it mostly a situation generated by out-of-network physicians?

Over five years in, it is time for some better answers that will best inform policymakers going forward.

Here is the 2018 study on IMR:

And here is the press release from CWCI on its recent IMR study:

Stay tuned.

Julius Young