Thursday, September 26, 2013

Don't Blame; Wear the Shoes

The blame game is on with the California Independent Medical Review process.

August saw 15,731 IMR applications. The trend appears to be about the same number of requests for September.

But the company that secured a two-year no-bid contract to provide IMR services, Maximus Federal Services, allegedly is still working to clear requests from July when the company received about 3,000, according to the Division of Workers' Compensation.

Maximus wouldn't talk to WorkCompCentral reporter Greg Jones, instead deferring all questions to the DWC.

DWC has simply said that they think the numbers have peaked and that things will settle down, calling the back log of requests of up to two months a "slight delay."

California Applicants’ Attorneys Association consultant, Mark Gerlach, told Jones that the problems begin with Utilization Review - inadequate instruction, direction and control over the UR process that is causing an excess number of IMR requests.

Gerlach believes there are too many UR decisions made on faulty or incomplete information because UR is not required to review complete medical records pertaining to a treatment request and physicians aren't tasked or willing to provide more information with their work loads. He proposes that UR reviewers undertake more effort to communicate directly with physicians making the treatment requests.

“Physicians will often say if they get a chance to talk to the UR reviewer, they can work things out. But in case after case, when you look at the UR decision, it says, ‘I attempted to call the physician twice, was not able to get through, and therefore, I’m denying the treatment,'” Gerlach claims.

That may be, but I think the issue is deeper - too much UR in the first place.

It was excess UR that caused the IMR process to be conceived and delivered via SB 863. The complaint from the negotiators of that bill was that too many medical treatment decisions were taking up judicial resources.

Now too many medical treatment decisions are taking up administrative resources.

And the common denominator is UR, because an IMR can not occur without a UR decision denying treatment in the first place.

I don't know who is making all of the IMR requests. IMR can be requested by the injured worker, his or her representative or the treating physician. I'm not sure it matters - IMR doesn't begin unless there is a UR denial.

And each IMR request costs the carrier (and ultimately the employer) $560 for a "standard review."

If what Gerlach says is true, that so many UR denials are based on failure to communicate, then there is a breakdown in the process as one file gets pushed off a desk to make way for the next file. The time burdens, the work load, the human factor, can not deal with the volume for whatever reason.

Workers' compensation has many areas of study and analysis. We look at lots of numbers to try and figure out what is happening, whether it is frequency and severity of injury, to volume of certain medical procedures or prescriptions - numbers are a big part of the workers' compensation analysis.

But one thing that we aren't very good at, and I think it's just because nobody has done it, is to follow the life cycle of a treatment request (or any other micro-process within the system).

This is called systems analysis - the study of sets of interacting entities to identify a better course of action and make a better decision than might otherwise have been made."

The truth is that we as an industry don't really know how this entire machine that has been constructed to process industrial injury claims really works. We have rules and procedures, laws and regulations, but the fact is that we don't have any real, foundational understanding as to how all of this impacts the momentum of a case.

When computers were first coming into the scene, Apple and Microsoft, and other top software vendors, spent tons of time and money actually sitting down with users to observe exactly how they interacted with the machines. Visual and auditory cues were observed, ergonomic tests were devised, users were interviewed, all in the attempt to completely understand the process by which someone interacts with a system to get the proposed work done, one step at a time.

This analysis allowed designers and engineers to skip redundant steps and build in better functionality and reliability.

Work comp is a Byzantine mess that has been compiled over the years to address concerns and desires of various special interest constituents without adequately studying how such changes would affect the actual life cycle of a claim file.

Assumptions were made based on anecdotal evidence often charged with emotional pleas that were not necessarily based on real, tested, validated data.

We can speculate, we can blame, but until we "walk a mile in [their] shoes" we really won't have any idea what to do.

1 comment:

  1. Legislators will never do this, and we have too many self-appointed experts who talk to perhaps 900 people in a small geographic area who think they don't need to do this.
    If you really want to have changes that adjusters and attorneys can use, then the State is going to have to post the proposed legislation on an open page, where everyone in the industry can go in and write their opinion BEFORE the law is legislated everyone plays catch-up.