Is CA Work Comp Litigation Unconstitutional?

California is again a poster child of a work comp system where procedure trumps substance and the injured worker gets the short end of the stick (with the employer getting a copy of that short end).

The Division of Workers' Compensation (DWC) issued a memorandum system wide last week announcing its decision to issue new qualified medical evaluator (QME) panels in cases where the original request for a panel didn't meet the timelines set in the Sept. 27 Workers' Compensation Appeals Board (WCAB) decision of Messele v. Pitco Foods Inc..

The short-staffed, director-less DWC Medical Unit is reviewing panel requests currently on file and will reject requests that are considered untimely under the Messele decision, the division said in a DWC Newsline published on Thursday.

The DWC also said it will allow requests for new panels in cases where a panel was issued based on a request now considered untimely. The steps to request a new panel vary depending on whether an evaluation has been performed, and are outlined in the division's memo.

If you're not from California this entire process is unfamiliar territory. Basically statutes and regulations are in place that govern specifically when parties to litigation attempt to seek an agreed medical evaluation (AME) and if that fails to request a panel of three doctors (QMEs) from the DWC in which to perform the medical evaluation.

Brad Chalk, president of the California Applicants' Attorneys Association, told WorkCompCentral the division's plans to honor new panel requests when a panel was previously issued could affect thousands of cases and that it takes between three and four months, on average, for a represented claimant to get a QME panel. If a claimant has already gone through the QME process, the new panel request would drag cases out longer and make them more expensive.

The waiting period between when an AME is proposed and when a QME request can be filed is necessary because attorneys race to file the first panel request. The winner is rewarded by getting to select the specialty of the panel. Applicants' attorneys typically want chiropractors or pain management specialists, who are considered more liberal than the specialties requested by defense counsel, which are usually orthopedic specialists.

There are also questions about whether a doctor will be paid for performing an evaluation if the Medical Unit convenes a new panel because the initial request was untimely. Theoretically under existing statutes the physician could not be paid because the medical report that issued via an untimely QME request would be inadmissible, and thus not subject to reimbursement.

What all of this nonsense points to is that workers' compensation is so ridiculously complex as to be completely out of touch with its stated constitutional purpose:

"A complete system of workers' compensation includes adequate provisions for the comfort, health and safety and general welfare of any and all workers and those dependent upon them for support to the extent of relieving from the consequences of any injury or death incurred or sustained by workers in the course of their employment, irrespective of the fault of any party ... and full provision for vesting power, authority and jurisdiction in an administrative body with all the requisite governmental functions to determine any dispute or matter arising under such legislation, to the end that the administration of such legislation shall accomplish substantial justice in all cases expeditiously, inexpensively, and without incumbrance of any character; all of which matters are expressly declared to be the social public policy of this State, binding upon all departments of the state government." (Emphasis added.)

California workers' compensation litigation is so far removed from the stated goal of an expeditious, inexpensive dispute resolution system that it is arguably unconstitutional.

I've been around long enough to have witnessed how we got here - now how do the People of California take back control and bring some common sense to this system?
workers compensation, work comp, injured worker

Express Scripts & Walgreen's - Market Economics Put Fee Schedules to Shame

I commented yesterday that maybe fee schedules aren't all that effective or relevant in the real world of workers' compensation vendor control.

A comment by a pharmacy benefit management (PBM) executive in a WorkCompCentral story this morning caused me to ponder that a little more.

Commenting on the big break up between Express Scripts and Walgreen's, ScripNet CEO Dennis Spooner said to WorkCompCentral reporter Greg Jones that in states where the employer has limited rights to direct care the break up may not make much difference in injured workers' access to pharmacy benefits:

"So if you're on the Express Scripts workers' compensation pharmacy program, you still have the right to go to Walgreens, and Express Scripts can't do anything," he said. "Walgreens will mail a paper bill and it's probably going to be at the full rate in the fee schedule. On generics (in Texas), that's average wholesale price, plus 20%, plus a $4 fill, which is about 50% more than what they would be paying if Walgreens was in the network." (Italics added.)


What caught my eye is that there is such a deep discount in the reimbursement for pharmaceutical benefits - well below fee schedule!


I understand that volume permits certain economies of scale relative to the provision of retail product. What is surprising to me is that the scale of this volume discounting would allow not only for the retail distribution of drugs, but also all of the attendant incidental costs to that drug - manufacturing, distribution,  regulatory load, and of course profit for everyone involved in the distribution chain.

The contract between Express Scripts and Walgreen's covers both work comp and general health and expires January 1 if not renewed or renegotiated.

Walgreens stands to lose $5 billion in annual sales, 7% of its business, by not accepting Express Scripts patients, according to a report by the Chicago Tribune. That probably wipes out its prescription drug profit margin.


This is just the market playing out, and doing what it is supposed to do - wringing efficiencies out of systems to the benefit of the marketplace.


And I assume that part of the Walgreen business model is to get people in to fulfill prescriptions and then sell them other items in the store to recoup sales and profits through other retail sales.

Express Scripts doesn't feel that access to pharmacy benefits for its customers is going to be affected, which is part of the reason why it is using its market clout to muscle Walgreen's:

"If Walgreens chooses to leave our network, we will still have more than 56,000 participating pharmacies, more than enough to meet all client guarantees for access," Express Scripts said in an emailed statement to reporter Jones. "On average, another network pharmacy that provides the same service for a lower cost is located within a half mile of any Walgreens."


Alex Knight, a PBM consultant and vice president of sales for ProCare Rx in Collierville, Tenn., said losing access to the 7,779 drugstores Walgreens operates won't have a significant impact on the ability of Express Scripts customers to fill a prescription.

"In the U.S., there are 65,000 retail pharmacy locations," Knight said. "There are 20,000 McDonalds, and no one says they have a hard time getting a Big Mac."


Market economics at work challenging fee schedules ... indeed.

workers compensation, work comp, injured worker

Fee Schedule, Schmee Schedule

In a meeting yesterday with a prominent and successful medical management company owner who processes and collects his customer's workers' compensation treatment bills, he admitted that he ALWAYS bills out procedures at 40 to 100 percent of fee schedule.

The reason is because regardless of what is billed out, insurance carriers routinely seek a discount in the payment/settlement of the bill, even if the bill is at fee schedule.

In order for his customers to make a profit then, the medical management company must over bill in order to collect at least the regulatory amount. And through clever tactics involving bundling of bills often times some amount in excess of fee schedule can be collected.

Add to this that it may take years to collect that receivable and the issue of cash flow plays prominently in the overall gaming of the system - by both carrier and provider.

The absurdity of this game is pervasive in workers' compensation, regardless of whether it is California, Texas, Florida, New York, Illinois ... Alaska.

So I'm trying to understand the utility of a fee schedule when it seems to be so universally ignored?

I had opined in an earlier post that a proposal to create a copy service fee schedule would benefit both payers and the copy services, but now I'm starting to wonder whether that is in fact a correct analysis.

Will a schedule just end up being ignored like it is with medical billing, and the problem of unpaid bills clogging the system with lien controversies just going to return, except with an even greater degree of technicality due to some "schedule"?

And while we're at it, how about educating the people that are responsible for outputting medical bills and collecting them - I'm talking about the line workers who are actually responsible for generating the paperwork?

As an example, our customer service representatives routinely take calls from clerical staff at medical collection agencies seeking to use the California EAMS system through the DWC Direct filing system. These line workers display a complete ignorance of the legal requirements in filing certain documents, such as liens or Declarations of Readiness (DOR).

In fact in a call just the other day the customer told our representative that they don't serve DORs on anyone, they just file them - that is how they were instructed to process this paperwork!

The customer was completely ignorant of Regulation section 10250 that mandates that DORs are to be served on all parties and lien claimants on a case!

Or the customer who told our representative that she was instructed to file a lien at the moment a billing goes out to the carrier - again completely ignorant of the requirement that there is a waiting period and completely ignorant of the fact that she is lying, under penalty of perjury, on the face of the lien claim form that she complied with Regulation 10770.5 time periods.

We take calls like this on a daily basis.

Everyone tries to save a penny in this system but expends a buck doing so....
workers compensation, work comp, injured worker

What the Occupy Movement Has to do with Work Comp

Does the current "Occupy Wall Street [insert local protest location here]" have any relevance to workers' compensation?

I ask this because the movement, which has no real leadership, and seems to encompass a myriad of issues without any stated goals, does seem to have one common theme - growing unrest of the American population with the way things are.

Indeed, the Occupy movement in this regard is no different than the "Tea Party" movement that sprang up a couple of years ago. Though the Tea Party appeal is to conservative voters, and Occupy seems to be associated more with liberals, Occupy seems quite willing to accept into its ranks anyone who are not part of the 1%.

The 1% of course are the top people in the US that control 40% of the nation's wealth and are a focus of Occupy's protestors who see them as the perpetuation of pockets of affluence amidst great swaths of deprivation.

Is that what the Occupy movement is really about?

Or is it, as some commentators state, about "corporate greed"?

That doesn't seem accurate to me either, because if one were truly objecting to corporate greed then one would just buy a share in a company or two then attend shareholder meetings and voice objection in a more direct manner.

What is accurate is that the Occupy movement spawned out of the sorry state of our economic affairs that was precipitated by the stewards of our economy losing sight of the big picture for the sake of short term goals.

And every Tom, Dick and Harry had a part of it too by succumbing to the intoxication of easy debt and the story line that a home is a cash register.

So the "corporate greed" that is the subject of Occupy stems from the feeling that the financial industry owed the American public a greater responsibility to keep us safe from ourselves and not provide the devil's temptations? I guess that's what these people are saying.

Workers' compensation, when all the "benefits" and legal trappings are removed, is just a financial industry product. The industry and systems exist on the magic of financial theatrics, providing a mechanism of cash flow through investments to spread the risk of the occasional work injury among millions of workers and their employers.

In the context of financial risk management, workers' compensation has as the root of its existence the creation and maintenance of a societal value: that the economy depends upon the existence of healthy individuals to do work.

Are we, as individuals in the workers' compensation industry, part of the problem that is the essence of Occupy? Are we failing to provide society value?

When workers' compensation is mentioned to the small business owner, heck even the big company risk manager, signals of disgust are typically relayed through facial expressions. After 100 years, employers fail to see the value in work comp.

Likewise, mention workers' compensation to the average worker, if they even know that there is such a thing as work comp, and it becomes a topic of disdain.

Here is what Occupy is all about - the failure of our society to return value to the common man.

Ask yourself when you sit at your desk to review a case file, or to propose an employer's base rate, or take the pulse of an injured worker, whether you are returning value to society.

The nature of our existence is to ensure that the wheels of commerce continue to turn as smoothly as possible. When there is friction we aren't doing our jobs, and we aren't returning value to society - and that makes employers and employees mad.

workers compensation, work comp, injured worker

CA Copy Service Fee Schedule a Smart Move

Readers from states other than California always marvel at the odd customs, practices and laws governing workers' compensation in the Golden State.

So I'm sure there's some chuckling outside of the state's borders when reading about the latest debate - a fee schedule for photocopy services.

I don't know about the practice of obtaining medical and employment records in litigation outside of California because I've never practiced law outside of the state, but the ability to get prior records of an injured worker that is litigating in the work comp system is a critical piece of the puzzle.

It all comes down to "substantial evidence" - whether the proffered evidence can be deemed sufficiently reliable in the face of other information to support an award of benefits, or the denial of benefits.

In California practice, the general strategy of the applicant side upon case intake is to question the injured worker about the injury, prior medical, prior cases, employment history, etc. then set about to procure records that would support the story. Hopefully the applicant is an accurate, truthful historian, and the records bear this out so there is no dispute later on down the road. This makes for smooth litigation.

On the defense side the practice is to review the case file upon intake in detail, noting any historical points of interest and then procuring the records to see if there are any anomalies or, if the record is solid, to know that credibility in history is not an issue.

In either case, the methodology for procuring records by the applicant side versus the defense side is different, in part because of the laws that govern discovery, in part because of contractual relationships, and in part because of custom. Applicant record procurement, governed by practices dictated by the Code of Civil Procedure and the Evidence Code, follow a more rigid, detailed procurement process due to records authentication requirements as a consequence of the timing of record procurement. The defense record procurement process is more relaxed, typically because records may be obtained prior to the initiation of litigation and thus through signed authorization rather than via subpoena.

The question raised by the new Administrative Director of the Division of Workers' Compensation (AD), Rosa Moran, is what is reasonable for copy service fees. The goal is to come up with a fee schedule to reduce disputes regarding the payment for these services. This is geared towards applicant record procurement because defense record procurement is done via contracted services whereas applicant record procurement is paid for after the fact.

And remarkably, at least from our reporting, copy services are quite in favor of a fee schedule because this will reduce disputes on payment, thus reducing collection costs and improving cash flow.

The key is that applicants must be able to procure their own sets of records because otherwise mistrust in what the defense actually provides in the discovery phase of litigation will ruin any potential cost savings.

Applicant fears are not without substance. From my prior practice years, though rare, there were occasions where the records my defense client obtained were in fact different than the records obtained by the applicant attorney, even though ostensibly both sets of records came from the same entity.

So in order for regulation of photocopy services in California work comp litigation to work, several elements must be preserved:

1. Injured workers (applicants) must be able to procure records independently of the defense, regardless if the defense may already have those records.
2. The regulations/fee schedule must be sensitive to the differences in the cost components of procuring records by applicants versus defense.
3. The fee schedule needs to be based on an actual cost review with a reasonable profit component. There are several methods this can be accomplished and the AD should explore all alternatives to establish the most reliable methodology to get the best data.

The Commission on Health and Safety and Workers' Compensation (CHSWC), estimated in its 2010 Lien Report that copy service disputes account for about 17% of liens. The commission also said the amount in dispute in copy service liens ranges between about $600 and $750. 

Establishing a fee schedule for copy services should, in theory, lead to a significant reduction in lien filings and litigation at the board level.
workers compensation, work comp, injured worker

Dispute Resolution and Needless Disability

On my way back from Dallas Friday evening, I finally had the chance to read Robert Aurbach's piece in the July/August AMA Guides Newsletter, "Dispute Resolution as a Creator of Needless Disability."

For those of you who are not familiar with Aurbach (resume here), he is in my opinion one of the leading thinkers in the area of workers' compensation systems and an adroit author and editor of numerous publications of and concerning workers' compensation, in addition to having drafted laws for various systems and is internationally renowned for his work in disability management systems.

The importance of Aurbach's opinion is that he has a international experience in workers' compensation, providing him with a very unique perspective that transcends systems that operate in the United States.

One element that Aurbach see across that board in all workers' compensation systems is that there is an imbalance in the outcomes produced by litigation of workers' compensation claims, because the motivations for all involved in litigated workers' compensation claims is a negative outcome: disability.

Aurbach attempts to link physical science to the injured workers' mental state when that worker is told that he is "disabled". The brain alters the organization of its neural networks based on experience, a phenomenon known as brain plasticity or neuroplasticity, according to the article.

Thus, "When injured persons feel pain and a physician tells them that they have a permanent
condition, the feeling of pain can become associated over time with the diagnosis, the emotional response to the diagnosis, and factors associated with the diagnosis."

This acquired behavior is reinforced in the workers' compensation litigation process, says Aurbach.

"The worker is confronted by an overwhelming array of new and poorly understood stimuli, and the physical sensations, reminder of diagnosis, emotions associated with the situation, and any situation invoking the victim’s role may get associated in a new neural network through repetition and duration. Each of these stimuli acquires the power to independently trigger an experience of the other emotions, sensations, and ideas, and the creation of a disabling pattern is complete. The injured person has adapted to the role of the victim. As repetitions of this cycle continue to build while the claim for benefits awaits resolution, the worker sinks deeper into the role of the victim, and the neural network of associations can become stronger, and the role becomes harder to break."

Aurbach does not discount the impact of psychosocial issues impacting the injured workers' "disabled " state, but is cognizant that the workers' compensation process may be the tipping point - that one last set of circumstances that provides the missing link for a person to experience the neural association of disability.

Auerbach then goes through in detail the litigation process. The description is not jurisdictionally specific, but there are many elements that are common across the litigation process regardless of jurisdiction because of the underlying anglo-legal customs that are pervasive in modern dispute resolution systems. Each part of the process contributes to the injured workers' "disability", or "enables" the disability model.

Ultimately, the injured workers' identity is intertwined with his/her diagnosis:

"The focus on the connection between injury at work and disability, the worker’s personal identification with a diagnosis, and the process of multiple evaluations of impairment repeatedly sends the message of disability, limitation, and inability to resume a normal life to the worker. Like the classic case of the child, told by a teacher that he or she is stupid, who conforms to the message in their performance at school, it is not surprising when workers acquire a disabled lifestyle and develop what is for them a genuine inability to return to productivity and normalcy."

In short Aurbach provides an excellent and thorough explanation of how and why workers' compensation systems as they presently exist contribute to the "disabled" status of those injured at work, rather than provide relief when it is needed most.

Anytime any legislator proposes workers' compensation "reform" they should first be required to read Aurbach's work.

workers compensation, work comp, injured worker

Non-subscription: Model for the Information Age

As I type this I'm on a Southwest flight to Dallas. I was practicing the delivery of my presentation to the PartnerSource Non-subscription conference but got interrupted by distracting thought.

That seems to happen a lot to me...

In any case, you likely know that Texas is the only state in the country for which workers' compensation is voluntary. Employers that opt not to enlist in the workers' compensation system of that state are known to "go bare", and are more officially called "non-subscribers."

There may be a few small businesses that "go bare" but for the most part, non-subscription is the purview of large employers which have the resources to develop alternative risk management systems.

These large employers have operations in many states usually, and so the attendees at the PartnerSource conference are generally familiar with workers' compensation.

And for the most part, these risk managers love their non-subscription programs because they deliver superior results than the compulsory workers' compensation systems they manage in the rest of the United States.

Superior cost savings, faster return to work, and happier more productive employees are cited as non-subscription benefits over the risk of civil liability exposure. Ironically, I believe that non-subscription in Texas also makes that state's workers' compensation system more effective as well, because it has to compete with non-subscription so there is motivation for the system to work better and deliver good results, for employers, employees, and carriers.

I may be wrong because I don't have the data in front of me at 35,000 feet (no wi-fi, and if there was my staff would probably kill me!), but if my memory serves correct Texas is one of the very few states where carriers consistently post combined ratios below 100%, providing the insurance industry there underwriting profits in addition to the more typical carrier profit line of investments.

The attendees at the PartnerSource conference want to know how to get non-subscription to other states where they operate. They are passionate about non-subscription, the control it gives them over the entire worker benefit delivery system, and the competitive enhancement their businesses experience because of the lower costs and higher productivity they experience.

I don't know if this is where the trend is going in work injury protection, but there is certainly increased scrutiny of workers' compensation's joint promises of employer protection from civil liability and expedient delivery of worker medical treatment and income protection.

The law generally lags society by a wide margin. In our context for instance, the change from an agrarian society to industrialization started during the Civil War, but workers' compensation in its modern form didn't really get going until after 1917 when compulsory work comp was ruled constitutional by the US Supreme Court.

Even then it took another 40 years for all the states to provide workers' compensation, Mississippi being the final state in 1949.

That's about when computers started creeping into society. Big, huge, monolithic machines of tubes and wire miraculously performing mathematical computations that fascinated the world quickly became smaller, faster, lighter at an ever quickening pace.

I still remember my first notebook computer - a 386 with maybe 2 megabytes of random access memory and maybe 20 megabytes of disc storage running DOS on a monochrome screen with than damned blinking green cursor, and weighing about 10 pounds. That was 1984.

I'm typing this post on a MacBook Air with 256 GIGABYTES of solid state storage, 4 GIGABYTES of RAM, with an amazingly clear full color display on the most modern operating system architecture yet, weighing less than 3 pounds, all at a cost that is far less than the inflation adjusted cost of that first notebook. I forgot any DOS commands about 20 years ago…

And I'm not even going to get into all the other information devices we now take for granted like smart phones, tablets, and other portable systems.

We have migrated as a society at large from industrialization to informationalization in the span of about 40 years. And our economy has reflected this social shift as well - the United States may not produce much steel any more, but it is still the leader in making ideas by a wide margin.

The point is that it took about 80 years for society's laws to catch up to the change from agriculture to industrialization. I think we are seeing a more rapid pace of change in our laws catching up to the social move towards the Information Age, but I truly believe that this is an unstoppable trend.

Change won't happen overnight, but change IS going to happen. I am convinced of that.

Non-subscription is a part of that change. You can participate and prepare for that change and help sculpt the model, or you can go down with the sinking ship.

There's an old military saying: Lead, follow or get out of the way.

Whatever path, it's your choice.
workers compensation, work comp, injured worker

Georgia Showing Politics Steers Science

This morning's story about the Georgia State Workers' Compensation Board studying whether to seek legislative authority to adopt treatment guidelines got me thinking - why is it that different states have different guides?

I learned in school as a child that basically all human beings are biologically the same.

There should be no difference in one's biology if a person is from California, New York or Georgia.

So why is it that the states that do adopt treatment guides all do something different?

For example, California adopted the guides from American College of Occupational and Environmental Medicine (ACOEM) as a part of its 2004 reform, but also has guidelines that supersede ACOEM.


Texas, as a part of its last reform adopted guides, but the state couldn't decide what it wanted so it adopted both ACOEM and those from Work Loss Data Institute (WLDI).


Florida just has its own guides and did not adopt a national standard.


Do doctors receive medical training differently in California than in Texas, or Florida, or Georgia?


Or do the politics of a state determine whether a person's biology is treated differently than another state?


Watching the debate unfold in Georgia, me thinks it's the politics.


John Poole, legislative consultant to the Georgia Self Insurers Association told our reporter that guides are being considered to control medical costs in the workers' compensation system.


Donald J. Palmisano Jr., executive director of the Medical Association of Georgia, wonders why this would be  necessary in light of Georgia's utilization review process.


Jason Perkins, a member of the executive committee of the Georgia Trial Lawyers Association, said discussions about the treatment guidelines have centered on increasing medical costs.


Phil LeFevre, senior account executive for the Work Loss Data Institute, said the board is concerned with both costs and outcomes for workers. He said the state board has not decided whether to write its own guidelines or adopt WLDI or ACOEM.


And of course both WLDI or ACOEM stand to gain market share in the guidelines business so there is motivation to push for a guideline standard.


The first objective of any work comp guideline adoption program should be to ensure that injured workers receive quality medical care that results in the return of a worker to productive status.


And each treatment case will be different because though everyone's biology is standard, no one's life experience is standard, so what is effective for one person is not effective for another without some additional accounting for an injured workers' coping tolerances.


We have seen increasing evidence lately that accounting for psychosocial factors is nearly more important than accounting for biological factors in terms of controlling costs - because when you really get down to it, controlling costs is the primary reason treatment guides are adopted or implemented, NOT to ensure the delivery of quality care.


I don't believe that controlling costs and delivering quality care are mutually exclusive though. Indeed they are complimentary if the design has as a primary focus the delivery of VALUE, which means not focusing on procedure costs but looking at the totality of all variables consequentially related to a work injury.

Back to my original question - why does each state have something different? I believe, as I have opined in the past, medical treatment in workers' compensation is more political than scientific.
workers compensation, work comp, injured worker

"Reform" Should Not be Defined by Financial Outcomes

In a webinar presentation yesterday, advocacy groups representing California employers indicated that they are looking for a new "reform" or overhaul of the state's workers' compensation system.


There seems to be consensus from the group in yesterday's presentation that permanent disability indemnity benefits need to be increased.


But the group is unwilling to concede to increases without taking something away from some other cost driver.


Sensible enough given that workers' compensation operates within a defined set of financial parameters - there is only so much money to go around so increasing one thing will require decreasing another.


Jason Schmelzer, chief lobbyist for the California Coalition on Workers' Compensation (CCWC), said in the webinar that business agrees it is necessary to adjust permanent disability (PD) benefits, but there are a lot of questions about how it should be done citing that fact that PD is not defined specifically in either statute or regulation creating the problem of court opinions interfering with the reforms.

"The Almaraz/Guzman and Ogilvie decisions are a testament to the creativity of the Appeals Board," he said. "Most observers think the reforms were pretty clear, but the reflection looking back on the system is when we do the next reform, we need to make it iron-clad."


I disagree with Schmelzer - history is replete with "reforms" being interpreted by the courts and escaping the "intent" of the reformists - there is no possible way to make any law "iron-clad". Laws get written, then cases with specific facts applying those laws are argued by attorneys who are trained to advocate for their clients, be they injured workers or employers/carriers so whatever "reform" is instituted will be challenged and case law will be made. That is how our system works.


I agree with Schmelzer on an important point. He told the webinar audience, "There is no reason for as much to be going in front of the Workers' Compensation Appeals Board as there is. We need to bring down the tension level."


The problem with the thinking of these advocacy groups in my opinion is that they are intent on repeating history - expecting different results with the same inputs. In other words, rather than tackling the underlying raison d'êtree, "reform" is being defined by changing the surface level. 


The discussion needs to be about the culture of workers' compensation. The question needs to be about what the ultimate outcome should be.

Do we want to compensate people for being disabled, or do we want to provide incentive that changes the expectations of people that end up in the system?

Do we want to control medical costs on a piecemeal basis, or do we want to reward physicians for returning value to workers' compensation?

Do we want to continue putting money into investigations of employers committing payroll fraud or who provide unsafe working conditions, or do we want to create a culture of mutually shared responsibility and reward?

Creative employers are working within existing systems and are experiencing extraordinary results because they are not using the same old inputs.

Just yesterday I blogged about Safeway experimenting with biopsychosocial treatment, a fancy way of saying they are dealing with the WHOLE injured worker and not just the "injury", and experiencing positive results beyond their wildest imaginations.

I have blogged in the past about employers paying more for medical care during the early parts of a claim and experiencing greatly reduced litigation rates, disability rates and payroll replacement costs.

These are just examples of piece meal solutions working within an existing "broken" system to obtain superior results for both injured workers and employers.

The lesson is that these people thought outside the box, examined the CULTURE of what was going on and created INCENTIVES to drive the culture. They defined what the expected SOCIAL outcome was first. They did NOT define financial outcomes first. These creative people then instituted changes that would drive the social outcomes and then measured the results on a global basis examining costs beyond the incremental, special costs, of just the workers' compensation program.

So, my simple message to the well meaning advocates of "reform" - step back and think first about what the desired social outcome is first, then think of ways to motivate people towards those outcomes. And while the financial issues should be addressed, they should not define "reform".
workers compensation, work comp, injured worker

Setting Expectations Early Lowers Costs

A recent experiment by a large grocery chain in California demonstrates that setting expectations for claimants that they will return to work quickly and with as little disability as possible positively impacts workers' compensation statistics.


William Zachry, vice president of risk management for Safeway Inc. told  attendees of the Association of Workers' Compensation Professionals 13th annual Workers' Compensation Conference in Sacramento on Friday that the company started an early intervention program to test whether poor coping skills were responsible for increases in workers' compensation costs despite a reduction in the number of injuries.


77 people who went through the pilot program in Northern California were told up front that the expectation was they would return to work without disability. To their surprise, all 77 returned to work with no litigation and even though one subject received back surgery.


Safeway worked with Kaiser Permanente and Dr. Melvin Belsky, the store's corporate workers' compensation medical director, to developed a questionnaire that helped identify workers who might have poor coping skills examining characteristics such as drug dependency, depression and anxiety to determine which injured workers would become chronic pain patients. 


The biggest indicator, according to Belsky, was when the claimed disability was not proportional to the type of injury.


Belksy expected about 10% of the injured workers would become chronic pain claimants accounting for about 75% of medical and indemnity payments. Though the sample is small, it is still significant that none of the test subjects did.


Belsky said a growing body of evidence has found a connection between adult health status and early childhood abuse and household dysfunction. Because people in this group didn't develop necessary skills for dealing with adversity, they need to be treated differently.


Treatment following the biopsychosocial model, that includes a mix of physical therapy, conditioning and cognitive behavioral therapy is sufficient to get these people back on the job, according to Belsky.


Dr. Steven Feinberg, chief medical officer of American Pain Solutions and an adjunct clinical professor at Stanford University School of Medicine, agreed with Belsky, noting that doctors are not taught biopsychosocial treatment skills in medical school.


I might add that our workers' compensation laws are set up to discourage biopsychosocial treatment. We reward on the basis of disability. We pay doctors on a procedure basis. Attorneys are compensated based on how much the injured worker is disabled. Treatment of interdependent psychosocial components risks new "body part" claims.


Safeway has the luxury of self-insurance, so it can engage in experiments such as the one described here. The lesson is that there is an art to claims management that goes well beyond time limits, fee schedules, and AOE/COE.
workers' compensation, work injury

Targeting Photocopy Services for Regulation Requires A Balanced Approach

Division of Workers' Compensation Administrative Director Rosa Moran told attendees of the Association of Workers' Compensation Professionals 13th annual Workers' Compensation Conference on Friday that one of nine committees she has formed will be looking at regulating photocopy services.


"I'm going to start with something small, because we've got to get our house in order," she said. "I randomly picked something that kind of annoys me. I picked copy services."


The copy services that Moran is targeting provide services such as photocopying medical records and legal documents and delivering them to case participants. 


According to the WorkCompCentral story, the committee will first identify what a copy service should do and then determine an appropriate charge.

"They do everything but shine your shoes nowadays," Moran said. "What is the product people are willing to pay for? Do you want to pay for the annotated index? Do you want to pay for the service they do for (Uninsured Employers Fund) cases?"


There are two sides to the photocopy coin, of course.


One aspect of the business involves procuring records at the request of the insurance/employer/defense community. Those are direct, fee for service, businesses where the "customer" usually has a pre-existing contract for services and pretty much knows what it is going to pay for the service or product up front.


The aspect I suspect that Moran has her eyes on involves fulfilling requests for applicant attorneys, and these services are performed on a lien basis. The applicant attorney will take a case, get a medical history and then have the records procured to ensure either that there aren't any time bombs or booby traps in the medical history or to find evidence to support the case.

Regardless, the fees charged for procuring records for applicant attorneys are generally many times higher than the fees charged for getting the same records for defense customers.

The two sides of the service are not apples for apples because the expenses involved in getting paid after fulfilling applicant attorney record requests are significantly higher than when performing work directly for the defense.

Applicant attorney photocopy services generally wait for well over a year before they can collect on their receivable, many times for several years. They are required to file liens to protect their payment interests. Many times carriers dispute the right to reimbursement or negotiate down the fee, requiring copy services to retain representation to make appearances at hearings.

Yet there needs to remain an independent record procurement availability to the applicant bar because otherwise the control over critical information would become lopsided providing the defense with an unfair advantage in the least, or worse, the ability to completely hide potentially damaging evidence.

Any regulation on the fees that photocopy services charge for records sought by applicant attorneys needs to also provide for more prompt and secure payment for those services.

My suspicion is that the photocopy interests would not have an objection to a fee schedule if regulations also ensured that they would be paid timely, at the specified rate, without objection, and without further need for receivables enforcement.
workers compensation

When Negative Legislation has a Silver Lining

Sometimes there are positive unintended consequences to legislation providing in theory win-win situations to constituencies that one would otherwise think to be diametrically opposed.

As an example, California Gov. Jerry Brown last week signed a bill to eliminate the profit motive for prescribing compound drugs, an important legislative victory for the employer community. 


But pharmacists say the governor's signature on the bill also demonstrates the state's approval of compound drugs in the workers' compensation system.

AB 378 (Solorio, D-Santa Ana) addresses pharmacy goods, including compound drugs, medical foods, co-packs and durable medical equipment, as well as physician-dispensed over-the-counter medications. The bill adds these pharmacy products to the list of goods for which physician self-referral is prohibited.

The law provides that compound medications must be billed at the ingredient level and reimbursed at the Medi-Cal rate for each ingredient as identified by its national drug code (NDC). Ingredients that do not have an NDC are not reimbursable under the new law. If a physician dispenses a compounded medication, the bill limits reimbursement to 300% of documented paid costs, not to exceed $20.

The employer/carrier community felt that there was a loophole in the pharmaceutical control laws based on evidence such as a report by the California Workers' Compensation Institute in August 2010 which found that compound medications, convenience packs and medical foods accounted for 2.3% of drug costs in the first quarter of 2006, but climbed to 12% of prescription drug costs in the first quarter of 2009. During this same time period, CWCI said the average payment for compound drugs increased from $468 to $591.


Jason Schmelzer, chief lobbyist for the California Coalition on Workers' Compensation, told WorkCompCentral that, "the spike in compounds was clearly related to financial incentives for physicians and facilitated by certain companies that figured out and helped them take advantage of the system." The new law was intended to curb those abuses.


Bruce Curnick, vice president of Landmark Medical Management, told WorkCompCentral that the bill will clean up some abuses of the system, but it largely leaves compounding unaffected and that while the legislation caps reimbursement for medications dispensed by a physician, those limitations will apply only to doctors who do the compounding in their offices because of the definitions of "administer" and "dispense" as found in the California Business and Professions Code.


There is concern with the reimbursement rate being set too low. Jon Roth, chief executive officer of the California Pharmacists Association, said he can appreciate the comment that the bill appears to legitimize the use of compound drugs but felt the Medi-Cal reimbursement rate is too low.


But AB 378 provides that the administrative director of the Division of Workers' Compensation has the authority to make regulatory changes to prevent a reduction when the methodology for determining reimbursement rates in Medi-Cal changes from the average wholesale price to the average acquisition cost. This may help out the pharmacy sector from rates that make it difficult to provide medications in the work comp system.

I'm an optimist by nature, but occasionally even I am surprised when an interest group sees a positive benefit from a legal change that would otherwise be deemed negative. The world continues to surprise me!
workers compensation

FL Judges Shown Politics Controls Judiciary

In most states the workers' compensation adjudication system begins with an administrative process and the judges are administrative law judges (ALJ) that have limited judicial powers and are bound by judicial canons of ethics and conduct.

In most states ALJs are hired by the state agency and are not the subject of executive appointment.

Florida is unique in that its ALJs are appointed by the Governor. This makes the workers' compensation adjudication process in Florida subject to politicization.

Apparently that is what is going on in Florida.

Veteran Judge of Compensation Claims (JCC) Paul T. Terlizzese is losing his job because the Statewide Nominating Commission for Judges of Compensation Claims in August failed to reach a majority vote on Terlizzese.


Terlizzese, of Melbourne, was appointed by former Gov. Jeb Bush as one of the state's 32 judges of compensation claims (JCCs) on Nov. 1, 1999. His term expires on Oct. 22.


From what was reported in WorkCompCentral this morning on the matter, Terlizzese had his enemies but he had never been counseled for unethical behavior or bias.


But there was a group of lawyers that had filed complaints against Terlizzese claiming that he demonstrated bias against injured workers.


Those six complaints were investigated by David Langham, deputy chief judge of the Office of Judges of Compensation Claims who found no evidence of that Terlizzese had violated the Florida Code of Judicial Conduct.


A few days before the nominating commission met last April, the Workers' Compensation Section of the Florida Bar released the results of its 2011 survey of judges and gave Terlizzese low marks.

On a scale of one to five, he got a rating of 2.5 for courteousness to counsel, witnesses and parties; a score of 2.3 for patience and willingness to listen, and a score of 2.6 for impartiality. The three ratings were the lowest given to the state's 32 JCCs. We don't know who participated in the survey, how many participated, and whether there was a "bias" in the survey (i.e. whether more participated in the survey regarding Terlizzese than other judges).

Florida's JCC decisions are not reviewed, like many states, by an administrative review system, but go straight into the appellate courts, with the First District Court of Appeal have exclusive jurisdiction over workers' compensation appeals.


Terlizzese's record on appeal is good: Langham said Terlizzese has been affirmed at a rate of between 83.5% and 87.3% in appeals of his orders.

Workers' compensation is a product of the political process, which is the reason in part why we never have a "complete" solution to system issues.


But placing ALJs in the political cross hairs threatens the independence of the judiciary.


I don't know Terlizzese, and I don't know his court room demeanor, but the actions of the nominating committee and the Governor's office don't pass my "smell" test. From our story there were only six complaints, one by a politically powerful person (former Rockledge, Fla., Police Chief John Shockey).


In addition, the nominating commission, which is supposed to be composed of 15 members, only had 8 present to vote on Terlizzese because of vacancies on the commission and the fact that a Jewish holiday had begun on the date of the vote.


The complaints against Terlizzese were about bias. It appears to me that the actions against Terlizzese are ironically biased.

workers compensation

Tying Work Comp to Other Systems Can Cause Chaos

Tying workers' compensation systems to other systems, which often seems logical, can cause chaos occasionally.

This is becoming evident in California where a change in how prescription drug reimbursement rates are calculated for the Medi-Cal database may cause billing problems in workers' compensation and might also require regulatory changes for consistency in how medications are reimbursed.


California Labor Code Section 9789.40 requires reimbursement rates for prescription drugs in the workers' compensation system to be 100% of the rate paid by Medi-Cal. 


The Department of Health Care Services (DHCS) maintains the Medi-Cal database, which until Sept. 28 was based on average wholesale price information provided by First DataBank. First DataBank stopped publishing average wholesale price information at the end of September because of several lawsuits in which it was accused of inflating the prices.

DHCS is changing from average wholesale price to average acquisition cost. Average acquisition cost will be based on survey data showing what pharmacies actually pay for drugs, according to the Division of Workers' Compensation (DWC).


There seems to be consensus that average acquisition cost is a better costing methodology, at least by those interviewed by WorkCompCentral in this morning's story.


But DHCS is also changing its fiscal intermediary from Hewlett-Packard to Affiliated Computer Services, and as a result, Medi-Cal pricing information has not been updated since Sept. 28, and new data will not be available until the end of October, according to the DWC.


Consequently those affected will need to review every pharmacy bill from Sept. 30 until the updated file is available, creating considerable duplicate work loads and, of course, unintended system costs.


Another interesting twist that may not have been contemplated was pointed out by Steve Cattolica, vice president of government affairs for the California Society of Industrial Medicine and Surgery (CSIMS).


Cattolica questioned in the WorkCompCentral story whether average acquisition cost accounts for the differences paid by bulk purchasers, compared to those who buy in smaller amounts which may result in reimbursement rates that are inadequate for some smaller operators. 


The Medi-Cal transition will be completed in March or February, according to DWC. In the meantime, the Medi-Cal database will continue to be based on average wholesale prices.
workers compensation

Illinois Networks - A Chance to Provide Value

Efforts to give Illinois employers the right to direct the care of injured workers through preferred provider programs (PPPs), that state's version of medical networks, is moving forward through the regulatory process with hearings set later this month to debate proposed regulations.


House Bill 1698, the workers’ compensation reform measure passed by Illinois lawmakers this year and signed by Gov. Pat Quinn, allows the state's employers to use PPPs, subject to two basic requirements: The PPP must be approved by the Illinois Department of Insurance (DOI), and the Illinois Workers’ Compensation Commission must approve a notification form to be provided to an employee at the time of injury, advising the employee of the PPP, and that he or she has the right to opt out of the program.


The bill also calls for compressing the state’s 29 geozips (an area in which all ZIP codes share the same first three digits)  into four regions for non-hospital medical fees and provides for 14 geographic areas for hospitals. The bill also included provisions for a 30% reduction in the medical fee schedule, which took effect on Sept. 1.


Anjali Julka, communications manager for the DOI, told WorkCompCentral that since HB 1698 became effective on June 28, the department has held a series of meetings with workers' compensation stakeholders concerning the provider networks.


Julka told WorkCompCentral that the DOI is modifying its current regulations (50 Illinois Administrative Code Section 2051) relating to preferred provider programs to address the workers' compensation PPP requirements contained in HB 1698. 


DOI has thus far received five applications for PPPs and it is hoped that they will begin operations in early 2012.


Jay Shattuck, executive director of the Employment Law Council of the Illinois Chamber of Commerce, told WorkCompCentral that injured workers will benefit by being directed to health care providers who specialize in treating workers’ compensation cases, while employers will benefit from improved return-to-work rates and lower overall treatment costs.


The key to PPP success in Illinois will be whether the focus of the regulations and the employers that establish networks is on value returned rather than just cost cutting.


Illinois employers need to make sure they learn the lessons from other states that have implemented networks to understand what works and doesn't work.


Specifically what works is ensuring that physicians are paid fairly and reasonably, but also held accountable to established treatment standards and protocol where outcomes are measured and assessed, to ensure the highest quality care in the first 6 months of a claim and high return to work rates.


What doesn't work is early cost containment strategies focused on procedure expenses separate and apart from the overall medical picture.


Illinois is in an enviable position to learn from early adopter states and may be able to show the rest of the nation how to do medical networks right. We'll see over the next few years whether people can actually learn from others past experiences.

CA's Brown Message - Reform in Total, or Don't

California Governor Jerry Brown has always been known to be relatively unpredictable and not one to tow the party line.

And so it is with workers' compensation.

Presented with a host of bills for signature, the Democratic governor vetoed those that many would have thought a liberal would sign.

His veto message to AB 947, that would have have allowed up to 240 weeks of temporary disability benefits for injured workers who are still recovering from surgery when the current 104-week cap is exhausted, may be indicative of some near future for California workers' compensation:


"It is vital that injured workers receive adequate compensation to provide for their needs when they are unable to work due to work-related injuries. Workers' compensation reforms, however, need to be addressed on a broad and balanced scale -- ensuring workers receive adequate and timely benefits and treatment, while also ensuring that the costs of the system are sustainable."


With respect to AB 211, which would have made $6,000 supplemental job displacement vouchers available to injured workers when the treating physician determines the injury is permanent and stationary and there will be some degree of permanent disability, Brown said, "I am however, reluctant to enact piecemeal changes to the workers' compensation system in the absence of more comprehensive reform that addresses both the cost and benefits under the system."


It was a bit curious that Brown vetoed AB 584, which would have limited utilization review to physicians licensed in California.


Brown said in his veto message that limiting utilization review to California-licensed physicians would be an abrupt change and incompatible with how utilization review is conducted by health care service plans.

"I am not convinced that establishing a separate standard for workers' compensation utilization review makes sense," Brown wrote.

Even AB 1155, which would have interposed additional language in the apportionment statute for the purpose of preventing discrimination on the basis of “immutable characteristics” such as race, gender, sexual orientation etc. was vetoed by the Governor.

Brown did sign Assembly Bill 378 which will bring compound drugs under the state's pharmacy fee schedule and Senate Bill 684, which will require insurers to provide written disclosure to California employers if the carrier includes in the employer's policy a provision that requires disputes to be arbitrated or resolved in courts outside of California.


Brown's executive theme appears to be that workers' compensation in California should be treated in its totality, and that provisions catering to special interests won't be allowed in isolation. 


In other words, only tit for a tat will be considered under the Brown Administration.
WorkCompCentral

The State Fund's Unfortunate Move is the Right Decision

The California State Compensation Insurance Fund yesterday announced it plans to lay off 25% of its workforce next year -- between 1,500 and 1,800 workers. A business move that can not be unexpected due to both the workers' compensation insurance market in the state and the general economy.


At the height of the workers' compensation insurance "crisis" the State Fund saw its market share grow to a high of 53% in 2005. The latest numbers available from the California Department of Insurance has the State Fund at 16% of the market.


In addition to recovered capacity in the California market, the shrinking economy withdrew a large portion of the State Fund's premium base.


According to data published on Sept. 20 by the Workers' Compensation Insurance Rating Bureau written premium in California dropped 58% to $9.8 billion in 2010 from $23.5 billion in 2004.


State Fund's loss expense ratio last year was 166.2%, according to the carrier's 2010 annual report. State Fund reported loss adjustment expenses of $1.888 billion and earned premiums of $1.136 billion last year. 


In 2009, the company had a loss expense ratio of 151.4%, with $1.889 billion in loss-adjustment expenses and earned premiums of $1.248 billion.


Nicole Mahrt, a spokeswoman for the Association of California Insurance Companies, told WorkCompCentral that in 2010 the combined ratio for private insurers in California was 128%, of which about 46% was loss-adjustment expenses.


The State Fund has a disproportionate influence on the statistics reflecting the California workers' compensation market and when the numbers are presented by national rating or industry analysis organizations, such as NCCI or WCRI, the State Fund is routinely asterisked with associated precautionary notes concerning its impact on the numbers.


Indeed, though only operating in one state, the State Fund at $1.136 billion in premium is still one of the largest workers' compensation insurance companies in the nation, and certainly by far the largest state fund.


But while the State Fund is a creature of statute, it receives no funding from the state and it must compete against private insurance, so it must make prudent business decisions and with its loss and expense ratios so high failure to trim expenses would otherwise threaten the entire workers' compensation market.


While it is a shame the State Fund's business move will contribute to the stubborn unemployment rate in California, it is a move that will otherwise benefit the State of California's businesses - at least until the next "crisis".
WorkCompCentral

NY Showing How Much Politics Influences Science

The current debate in New York regarding the development of medical treatment guidelines shows just how much politics is involved in medicine, and just how little science actually steers the debate.

The New York State Workers' Compensation Board (SWCB) began working on the state's first medical treatment guidelines through a 14-member Medical Advisory Committee appointed by SWCB Chairman Robert Beloten.


When he signed a series of workers' compensation reforms into law on March 13, 2007, former Gov. Eliot Spitzer directed the New York State Insurance Department to assemble a task force of doctors to come up with an initial set of guidelines and to explore what other types of injuries should be addressed.

While the Insurance Department task force was finishing work on the proposed carpal tunnel syndrome guides last May, Beloten announced his own initiative on chronic pain and created the Medical Advisory Committee to keep the guides current and on track with "evolving medical knowledge."


The panel includes three doctors nominated by the Business Council, three nominated by the AFL-CIO, three picked by Beloten, and one non-medical representative each from the union and the Business Council.

In addition, the committee is co-chaired by the board's medical director, Dr. Jaime Szeinuk of Mt. Sinai Medical Center, and SWCB Associate Medical Director Elain Sobol-Berger.


Work on the treatment rules for chronic pain and carpal tunnel syndrome has rekindled debate over which injured workers should be covered. The issue is whether the rules are to be applied prospectively only, or whether they should be applied to all injuries and illnesses – no matter when they occurred.


This is particularly an acute issue with chronic pain victims since, by definition, these are long term treatment cases.


The debate is steered by non-medical political interests.


The AFL-CIO, claimant's attorneys, the Medical Society of New York State, and the New York State Chiropractic Association argue that applying the guides to injuries and illnesses occurring before rule adoption will cut off long-term treatment for workers with chronic conditions predating the guidelines.


Both the American Insurance Association and the Business Council argue that limiting the application of the guidelines to new injuries and illnesses would create two classes of injured workers in New York.


One would think that the answer is simple - what does the science say? 


Chiropractic, physical therapy, and other physical medicines have their place in the treatment regiment, but not necessarily over the long term. Chronic pain patients can be treated, and if they're on long term prescriptions for pain medication then there should be adequate guidelines to cope with the cessation of non-beneficial therapy (i.e. opioids or other long-term destructive medications) and transfer of care to other pain treatment protocol.


From my perspective, this is a no-brainer. Just because something has been does not mean it should be in the future.


The old  joke of the patient telling his doctor that it "hurts when I do this", and the doctor responding, "then don't do that" seems particularly applicable in the politics of defining workers' compensation treatment guidelines.
WorkCompCentral

CA Medical Director Position Will be Tough to Fill

The California Division of Workers' Compensation (DWC) Medical Director position has been vacant now for around 3 years, and despite recruitment efforts the DWC has received only one application.

New Administrative Director (AD), Rosa Moran, has her hands full with huge challenges, but one of the biggest challenges is finding qualified people to do the various jobs necessary to run the DWC.

This is particularly acute when the state, despite its independently "user funded" Workers' Compensation Revolving Fund, is on austerity budgeting that doesn't permit flexibility in staffing (i.e. hiring).

Besides cache (and that may be overstated), the DWC Medical Director position is labor intensive and requires extraordinary skill, schooling and knowledge - probably more so than most any other position in state government.

And the government is competing not only against private industry that hires its own medical directors, but against the various other career options physicians have, options that more often than not are less stressful and more lucrative.

In addition, the character of a qualified physician just won't permit that person to assume a nine to five work mentality. That person is going to be consumed with the job and likely will not feel good about doing the job unless they are working it 50 to 60 hours a week.

Navigating the various constituencies within the system while attempting to uphold the promise of expediency in workers' compensation is a highly stressful part of the Medical Director job, adding to the unattractiveness of the position.

Moran, in an interview this past August, realized the rock and hard place position she is in regarding the Medical Director position, telling former Chief Judge of the Oakland District Office Kenneth Peterson:

"Part of the problem with the Medical Director position has been the salary. We are having trouble recruiting candidates because qualified doctors are unwilling to give up lucrative practices. We are looking at the possibility of a part-time position, so a doctor could retain at least a portion of a private practice. There would have to be a way to avoid conflicts of interest, as the Medical Director could not be a QME. We may need to change the position description so we can get a good person on board."

According to salary.com, the median salary for a Medical Director in Oakland (which is where DWC headquarters is located) is nearly $250,000 per year.

The Sacramento Bee website has an interactive tool for comparing state civil service employee salaries as filed with the state Controller's office. The top five salaries are over $1.7 million, the top being $2.3 million, and three of those positions are for college coaches. The top salaries in the Department of Industrial Relations are more than 12 times less financially rewarding than the head coach at UC Berkeley!

Yes, the State of California deems college athletics more important than the health, safety and welfare of its 16 million workers.

And good luck finding a physician to take the Medical Director job at the salary available.

I wish I had an answer for Moran and the state. The Medical Director position is a critical one for the success of the California workers' compensation system, but obviously the system can function, albeit anemically, without one as it has for the last three years.

Honestly though, the Medical Director position will likely remain vacant until the Governor either removes the Executive Order that imposes budgetary restrictions on all of state government or exempts the DWC from it.
WorkCompCentral