Friday, May 25, 2012

UR Debate Has No Foundation

As reform rhetoric heats up in California, one area is creating battle lines - utilization review (UR).

Recently it was revealed by WorkCompCentral that there is no good data on UR. And it may be that there really isn't any way to get it, at least at this point in time with the current systems in place.

Regardless, business interests and insurance interests continue to support UR as a way to monitor and manage care which they say is necessary to protect injured workers from treatment requests that aren't supported by good medical or scientific evidence.

Those in opposition to UR, primarily the applicant's attorneys and injured worker lobbying groups, say that UR is used to deny necessary necessary treatment and to delay cases and/or put savings in the system onto the backs of injured workers.

Some UR companies do have some data, albeit incomplete - the reason the data is incomplete is because not all treatment requests are sent to UR, and those that are sent to UR aren't subject to follow up data so we don't know the true efficacy of UR approvals or denials. There's no way to make comparisons or see what the outcomes are.

In my view UR is a necessary component in workers' compensation. From my observations, most injured workers put way too much trust in the professionals managing their claims, be it physicians, attorneys, claims adjusters, whomever. Most injured workers do not take the time or have the expertise to research their conditions and make health choices on their own. They rely on professionals to steer them in the right direction.

This really is no different that what is found in the general health population - although trends do seem to be shifting now that most people use the Internet. Still, researching medical issues can be daunting for the everyday person and people in general put, in my opinion, way too much trust in professionals to make decisions for them.

When you really get down to it, the medical component of workers' compensation these days is just a more liberal managed care system. It is managed care to the extent that there are rules in place to direct how medical care is to be delivered. But it is more liberal than general health managed care because there is much flexibility in the rules regarding choice of care and outcomes control.

I'm a fan of managed care. I am a Kaiser Permanente member and our health plan is through Kaiser. The service is fantastic - I actually get into the exam room when scheduled, my records are on computer for instant reference and notation, pharmaceuticals and other prescriptions are handled instantly and seamlessly, and I get status on virtually everything as soon as it happens on the Kaiser website. I have the opportunity to see another physician if I don't like what my doc has to say or do.

I must admit though that it is rare for me to go to the doctor because I take care of myself - I ride my bicycle every day, I eat organic foods from the local farmer's market, my weight is under control, with the assistance of statins my generically high cholesterol is managed, and I try not to drink alcohol too much (I like good wine; hey, a man's got to have some vices!). I probably don't sleep enough though (got a blog to write every morning...).

Not all managed care is created equal though and not all patients are as interactive with their health issues as I am. I will also admit that I may not be a managed care fan if I were going through a medical supply entity that wasn't as organized, sophisticated and well run as Kaiser. It was only 20 years ago that "Kaiser" meant the worst care possible...

And of course there are failure points - that happens in any service supply business. In the medical world a failure in a service point has significantly higher negative impact on a patient's perception of service than in other worlds, perhaps because the service affects the patient in a most personal, and life threatening manner.

Not all UR is the same, just as not all managed care is the same.

So really the debate about UR is not whether it should or shouldn't be a part of the workers' compensation system. UR serves a good and useful purpose and should still be a part of the system.

The debate about UR in California is really about the meteoric rise in the cost of the service and the problem is that we don't know why (frequency or severity or both) the cost of the service has risen so dramatically in just the last five years.

Everyone has their theories - profiteering, conflicts of interest, increases in unsubstantiated treatment requests, etc. - but everyone is just guessing.

Someone will figure out how to study the efficacy and cost/benefits of UR. Until then, the debate on UR has no foundation and should not be a part of the reform discussion.


  1. David:

    I agree with you completely. Medical cost containment necessarily requires two components, control of the cost of services and the frequency of services. In WC we have a great deal of experience with cost containment focused strictly on the unit price and ignoring the frequency end. As a result, medical expenses tripled from 1992 -2002.
    The final answer may be in the frequency that UR is conducted and an intelligent approach to managing that portion of treatment. Where medical providers follow evidence based treatment guidelines, UR is less of an issue and can be saved for significant exposures and not every request for 3 PT visits (the sume total of which is likley to cost less than the UR review).
    I am aware tha some claims shops are now providing a menu of treatment that can be authorized directly by the adjuster where the treatment fits into specific patterns. for much early treatment, this step could result in significant expense for UR.
    Some employers (especially large self insured/self administered ones) are forgoing UR for most treatment where Kaiser is the provider. In part this is because Kaiser is not profit driven where treatment is for work related injuries is concerned and the likelyhood of getting a recommendation for treatment that is not consistent with the MTUS is negligable. Physicians are not directly or indirectly incented or encouraged to provide more treatment and the focus is on RTW.
    If some additional data could be developed with would give us an idea of what treatments are more effectively controlled by UR, we may be able to tailer our programs to maximize effectiveness with the injured worker being the beneficiary.

    In my opinion one of the reasons for the increasing medical costs in WC is the increasing ability of treating physicians to provide the necessary information to UR companies so that treatment requests will get authorized. I beleive our initial experience with UR reflected a much higher denial rate in part because physicians in the past had simply requested authorization and the proceeded regardless of whether the treatment was allowed. There was almost no requirement for a physician to document why treatment was appropriate. As a result reports were too conclusory and did not provide justification for the requested treatrment. Once physicians became tuned into the treatment guidelines, they have improved their ability to request treatment that is consistent with the guidelines and therefore more likely to be approved,

    [FYI in the interests of full disclosure, my wife works at Kaiser as Acting Director of Sales and Account Management for Kaiser on the Job and some the of information provided comes from discussions with her.]

  2. This link shows the amount of work required for an MD's staff to file a request to UR for additional treatment for an injured worker. The workflow shows that the staff time required is a minium of 50 minutes for each UR request with that time increasing if UR does not respond or if UR requests additional information.

    There is no additional reimbursement offered to an MD for managing this cumbersome process.

    It is understandable that workers' comp insurances want to monitor an injured workers' treatment, but the current time-intensive process is not reasonable.

    Often even when UR authorizes treatment, the bill review will deny payment as "not authorized" because UR does not communicate with bill review.