Monday, April 29, 2013

QME Backlog ... Again?

One of the peculiar laws in the California workers' compensation system (and there are many) is the Qualified Medical Examiner (QME) process.

The QME system was devised, as are so many things in comp, to eliminate a pervasive problem - but has itself become a pervasive problem, because, like we see so often, those who make the laws are not involved in actually executing the laws.

In the old days before the QME process attorneys shopped for doctors willing to write a report that was consistent with how that attorney felt the case should be managed. Applicant attorneys had their favorite doctors, and defense attorneys had their favorite doctors.

Then there would be lengthy litigation fighting about which doctor was more correct.

The QME process was supposed to eliminate doctor shopping and the lengthy litigation.

Doctor shopping was sort of eliminated, but the process quickly devolved as DWC strained to keep up with requests for QME panels. Seems the volume of medical-legal disputes was underestimated.

Former Division of Workers' Compensation (DWC) Administrative Director (AD) Rosa Moran had an almost singular focus during her short tenure - to eliminate the back log of requests for QME panels in litigated cases.

Moran did a good job. When she took the job the time to get a QME assignment was 10 months. When she left the job she had gotten that time down to about 4 weeks.

Now, DWC is behind again.

Division spokeswoman Erika Monterroza told WorkCompCentral the Medical Unit was issuing panels within 30 days until July 2012, but is now about five months behind in processing requests.

Anecdotal observations by attorneys put the actual time more like 7 to 10 months.

In one of likely many situations, the wait to get a QME panel was so long, the parties settled the case without an independent medical because neither the worker nor the employer wanted to wait any longer for a panel to issue.

This is a case, again, where the system is in the way of itself, depriving injured workers of the Constitutionally guaranteed right to expeditious resolution of their claims and injuring employers with excessive experience modification factors on their premium renewal because claims remain open for extended periods of time.

It seems to me that this is a process that should be completely automated, with a self service feature that does not require teams of individuals to pour through thousands of applications trying to match physician requests with available QMEs.

The process is not supposed to be subjective - which is the main criteria for building any computer system. The business rules are well known. The process is not complex.

It simply is a matter of paperwork overload - the very thing that computer systems are excellent at eliminating.

The employer-financed funding for DWC this year, I believe, is about $340 million. It seems to me that a small bit of that funding could be budgeted to write the programs necessary to automate the QME process.

But can the The State be trusted to spend wisely on computer systems? DWC doesn't have a good track record.

The Administration spent about $60 million (at last count) bringing online in 2008 its Electronic Adjudication Management System (EAMS) - a system that was to give the DWC valuable information about the case load in the District Offices and the ability to better manage these claims.

I have been critical of EAMS in the past (still am), EAMS has been the subject of unflattering investigative reporting by the Los Angeles Times, and the system continues to frustrate the user population who have otherwise grown adept at maneuvering around its foibles and idiosyncrasies.

Still, there are functions in EAMS involving much more complicated processes than constructing a panel of QMEs that work well and are much more efficient than the old manual activities that were replaced with automation.

We bank over the Internet. We shop over the Internet. We engage in complex communications involving multiple sets of people over diverse geographic zones in efficient and time saving manner - all via networked computers ... but we can't get a panel of three doctors from which 2 are eliminated so that the last one does the evaluation?

I know I'm naive about how government procurement functions, and how much effort is necessary to really do something that benefits the public - seems to me however that someone in Oakland should be able to take a team from the state's information technologies agency and whip up some code to get this job done.

I'm kind of simple like that though - remember, I'm just a dude with a computer on the Internet writing opinion into a networked blog that anyone with a computer and Internet connection can read and comment on, share, search or save. [Note heavy sarcasm here.]

Like those who write our laws, I don't have any actual experience in getting the job done.


  1. Hi! Thanks for the real talk in regard to the state of workers' compensation. I'm new to the field (going on a little more than 3 months now), and I appreciate the candidness of your analyses.

    Shortly after reading this post, I read your post on SB 1062 in OK.

    It got me thinking very critically about the role of technology in the potential revaluation of workers' comp. Obviously (as per your example in this article) technology needs to be well developed to work.

    However, I wonder if a suite of well-developed software that disallows the fiscal impact of intermediaries by more directly connecting the actual people involved in a workers' care would be a means to that end.

    My burgeoning knowledge is directly related to electronic billing at this point. I can see places where technology has the potential to simplify the complexity of the legislation, but your articles have made me realize that billing technology alone may not be a one-bullet solution.

    I'm curious to know, based on your experience, if you have any opinions in regard to where else technology could be utilized to actually make workers' compensation work for everyone involved?

    Or is workers' comp simply destined toward decreased use until extinction?

  2. I've heard that one obstacle is that the 3 doctors who come up on the panel need to be manually screened to make sure they are not in the same group. But that isn't a difficult algorithm to fix.

    They are within 100 miles of some of the best business software consultants in the world and can fix this easily and cheaply. Wanna bet they go back to the usual screwups? Or continue doing it as if it's 1955?

    1. Agreed James - shouldn't be a difficult thing to program.

      Becca - welcome to the wacky world of comp! You're in for a lot more that doesn't make sense. We all just learn to live and play within the rules (most of us at least).