The Timing of Pain & IMR

Ezekiel J. Emanuel, an oncologist and former White House adviser, is a vice provost and professor at the University of Pennsylvania. He is a contributing opinion writer for The New York Times on a range of topics including health and health policy.

Earlier this month Emanuel opined that some interesting research on pain revealed that it's not the pain itself that is definitive of the perception of the quantity of pain experienced, but the timing of the pain.

More precisely, "the pain at the end — whether it is getting better or worse — plays a disproportionately large role in determining how we remember an experience."

I think this general statement on the perception of pain is also applicable to workers' compensation and the myriad of processes that have been devised over the years as systems go under constant "reform."

The past couple of days I briefed over the complex nature of workers' compensation and just how much coordination of disparate interests is necessary in order for the system to work.

But we always seem to go back to ground zero - that is the feeling and criticism that workers' compensation doesn't work very well for either the employer or the employee.

Is that always the case? Or is it just that the most recent pain is the pain we remember most?

There has been a lot of pain recently in workers' compensation. Pain that can not be numbed with opioids or narcotics. We've seen struggles with repackaged drugs and over-prescription. There have been issues with vendors seeking reimbursement, claimants being denied care and dying, employers facing tighter insurance markets, physicians facing pay cuts, carriers with poor investment opportunities - all sorts of pain in the work comp system.

Emanuel uses remodeling a house as a metaphor for understanding the pain perception studies reflecting accurately that remodeling, regardless of how well it goes during the process, never ENDS well because there are always some irritating, niggling problems that cast a shadow on the overall experience.

This is workers' compensation - the experience of going through the system is painful because there is always something at the end that imparts some discomfort to those involved.

A wave of states have passed reformation laws this past year - some, like California, were massive undertakings involving untested but optimistic programs.

One of the programs instituted in California is the Independent Medical Review (IMR) system - a program borrowed from Texas but with some interesting twists.

WorkCompCentral reviewed the published reports of the new IMR process, albeit an immature process with only 34 results published to date. 

While there might be some alarm that nearly three out of four treatment requests that were denied by utilization review were also deemed medically unnecessary, what this means to me is that nearly one out of four treatment requests denied by UR were in fact deemed proper at the IMR level.

Reasons cited by reviewers in upholding treatment denials included a lack of documentation to justify a request, requests for treatments not supported by the Medical Treatment Utilization Schedule (MTUS) or any other peer-reviewed evidence-based treatment guideline or requests for treatments that guidelines say should be pursued only after attempting other therapies.

What is encouraging in these denials is that the IMR process is giving clear guidance to the medical community dealing with workers' compensation injuries that there needs to be some documented justification for the request. Speculation, tradition, or the "I'm the doctor" reason, no longer are sufficient.

Obviously one quarter of the requests were properly documented, were properly requested, and UR was found to be wrong.

And the parties didn't have to wait for a year to find out that UR was wrong - this is a huge boon to injured workers seeking treatment and should dramatically increase efficiencies.

Would IMR have helped Charles Romano get the treatment he needed instead of the delays and denials experienced that resulted in his death? Perhaps not, based on the facts in Romano and the apparent disregard for authority demonstrated by the Sedgwick claim examiner in the case.

But perhaps IMR would have helped avoid this disastrous case. We'll unfortunately never know.

IMR in California is contracted out to Maximus Federal Services, which has been providing similar services to the California Department of Health for some time (in addition to many other state and federal programs).

General health is different from workers' compensation - the laws are different, the variety of treatment is different, the operating environment is different, the exposure by the payer is different, and the market is huge (work comp is only 2% of the overall health market).

Nevertheless, comparison to Maximus' work in the general health field is compulsively inviting.

Data on the Department of Managed Health Care’s website shows that between 2007 and 2011, Maximus approved a group health plan’s decision to deny treatment in 44.2% of the 8,529 cases it reviewed. In 36.6% of cases, Maximus overturned the decision to deny a procedure or treatment, and in 19.2% of cases the group health plan agreed to approve the procedure before the IMR process was completed.

The sample of cases above is much, much larger than the 34 cases published in work comp IMRs so one can't draw any definitive conclusions in such a comparison at this time.

But it is important in my mind that Maximus, in the general health setting, overturned a carrier's denial in 1/3 of referred cases, and nearly 1/5 were approved before a Maximus opinion was rendered.

Maybe I'm just a glass-half-full kind of guy, but I find these statistics encouraging because they demonstrate neutrality and independence.

Or, perhaps what the statistics are saying is that there has been significant adjustment in the prescribing practices of physicians.

Because general health is far larger than workers' compensation and the fact that only 8,529 cases were reviewed over a period of 4 years indicates that the vast majority treatment requests don't generate controversy or dispute - if this translates to workers' compensation then the system will become much more efficient.

Our perception of pain is based on the timing of the experience - will IMR reduce our pain? Obviously it's too early to say yes or no in any definitive manner, but the early results are encouraging.