Thursday, June 9, 2011

Limiting UR to In-State Physicians Nonsensical

Pending in the California Senate Committee on Labor and Industrial Relations is a bill introduced by introduced by Assemblyman Paul Fong, D-Cupertino, that would limit workers' compensation treatment utilization review to physicians licensed in the State.

AB 584 would amend Labor Code Section 4610(e) to state that only California-licensed physicians can perform utilization review on treatment requests by California injured workers. The committee voted 4-1 to approve the bill, which still must go to votes before two other committees and the full Senate for a vote before it can reach Gov. Jerry Brown's desk.

The argument in favor of AB 584 is that the review of treatment decisions is the practice of medicine, and thus only physicians with a license in the state in which the practice is being conducted may perform such reviews.

Proponents also argue that the practice of medicine in California is unique because of special education requirements (e.g. 12 hours of chronic pain study), and because of the Medical Treatment Utilization Schedule (MTUS) which, some argue, is so convoluted and difficult to navigate that only physicians from California can perform this service.

In truth, the review of treatment considerations is more akin to checking the applicable guideline (generally ACOEM in California) to see if the protocol for moving to the requested treatment application have been met prior to authorization.

Medical training and the uniqueness of the medical license recognize a particular education, knowledge and skill set inherent in the diagnosis and treatment of medical conditions, and should be based on science as much as possible. 

The human body, so far as we know it, is the same whether that body is in California or in Texas or in Alaska, or some other country for that matter. Publications of treatment guidelines and legal resources (including the interpretation of those resources) are nearly universally available in the Internet Age.

The key word in the practice of utilization review is review. The physician making a prospective or retrospective review need not be actually attending the patient. It is akin to grading a paper - the instructor need not actually see the student take the test.

In other words, where the injured worker is located, or where the physician is located, seems irrelevant to understanding the application of the science and the law to any particular review consideration.

Finally, I note that the bill limits review to physicians licensed in California, not where they are physically located. Perhaps the one argument I might agree with is that it might be easier to check the license status of a physician against the database of the California Medical Board rather than some other state's database - but this doesn't seem to be too persuasive in the age of the Internet.

To me a limitation such as AB 584 just doesn't meet the test of logic.


  1. David:

    If you only knew what kind of crap these providers try to get away with, you might have a better understanding of why this is necessary. Some providers have used very ingenious methods and very shady doctors to counteract the treatment requests of treating physicians. After all it's all about fixing the worker so that he can return to work. When are the providers finally going to keep that promise that they made almost 100n years ago?

  2. Thanks for the comment Ronald.

    Generally the term "provider" in WC jargon refers to physicians and medical vendors, but I think you are referring to the carriers and TPAs.

    I sympathize with those impacted by ill-managed UR and the nefarious practices some of these folks engage in, but the way this proposal is structured won't cure that problem at all.

    What WILL help is actual enforcement of the penalties for bad UR practices - here's the rub: how do you enforce penalties against out of state UR even IF they are licensed in CA?

    AND, what kind of enforcement action is the Medical Board really going to take against a physician that denies a treatment recommendation? There is a lot of latitude that physicians are given relative to medical opinions that does not give rise to actionable enforcement.

    I just don't see this proposed legal amendment providing the protections that its proponents argue.