CWCI Study on Independent Medical Review Outcomes in California: Smoke and Mirrors

There are five kinds of lies—fibs, excuses, lies, damn lies, and statistics.

The CWCI "study"from a political standpoint has to say that the UR/IMR process is a "success." A great deal of energy was put into the political process of the members of CWCI and other organizations who represent employers in California to find cost savings in the workers' compensation system in order to justify higher payments for permanent disability. The UR/IMR process has to work or else SB 863 is a failure.

The data from the CWCI study shows that the UR/IMR process has proven itself as an effective cost containment measure to reduce medical treatment costs in the California workers' compensation system. This study demonstrates that the UR/IMR process has nothing to do with providing effective medical treatment to injured workers. Together with the new MTUS (MTUS applies; if not in MTUS or if rebutted, then current ACOEM or OPG or more recent research studies), the UR/MR process removes individualized patient-centered medicine from treatment for work related injuries. This is the effect of "one-size-fits-all" medicine. The "evidence-based" medicine is based on flimsy evidence to begin with, especially with UR/IMR physicians cherry picking the research or the alleged guidelines to rely on denying treatment requests. There is a built in bias from IMR physicians to uphold UR denials in the first place since this process was a known political payoff to lower medical costs and raise permanent disability awards.

Most of the physicians who perform IMR are not qualified to do the reviews. A large percentage of them are not even licensed in the State of California. The data shows that 38% of the IMR physician reviewers are Physical Medicine and Rehabilitation (PM&R) specialists and 15% of the reviewers are Occupational Medicine specialists. This means that 53% of the IMR reviewer physicians are not clinical practitioners in regular group or individual health plans. In conventional medicine, for example, a person who falls down a flight of stairs at home will probably never be treated or examined by an occupational medicine doctor or PM&R physician. We want treatment by hands-on specialists who have clinical knowledge, experience, and training to provide patient-centered treatment. Each person, each injury, and each treatment approach has to be tailored to each patient. The UR/IMR process takes away the "art" of medicine, which is a checks and balance against doing harm to a patient, by applying rigid treatment guidelines mandated by a minority of clinical practitioners. The guidelines that UR/IMR physicians rely on can be harmful to patients since one size does not fit all patients.

This study demonstrates the disconnect between standards of care medical treatment for the same medical conditions that are treated outside the workers' compensation system and those that apply to work injuries. As a result of the UR/IMR process, we are seeing clients suffering withdrawal symptoms from denials of medications that have been prescribed for years with previous histories of stable ADL functioning, no evidence of diversion of medications, no changes in types or dosages, and functional stability. In fact, the UR/IMR "evidence based" medicine completely lacks any consideration for stable functioning.

We are seeing many injured workers flocking to their group or individual health plans to obtain proper medical treatment with community standards of care with physicians whose hands are not tied by cost containment motivations but are tied by improving patient's health and functioning. We need to see the data that individualized and patient-centered medical care is more cost effective than what injured workers are getting in California now.

A recent and typical example is of an injured worker whose well respected joint replacement physician put in a request for authorization for bilateral knee replacements. UR/IMR denied them by indicating that the requesting physician failed to indicate in the RFA what the injured worker's BMI (body mass index) was and denied both replacements. The IMR physician stated that doing one at a time would be more reasonable. The claims administrator is still denying any knee replacement. The Applicant's own health plan approved the bilateral replacements with no question. This is wrong and inequitable. Let CWCI and the others behind SB 863 hide behind their statistics until the pendulum again swings the other way.

© Copyright 2015 Robert G. Rassp. All rights reserved. Reprinted with permission.