Friday, November 22, 2013

Maybe It's Not Reasonable And Necessary

One of the big debates concerning California reform is whether changes to Utilization Review process to incorporate the subsequent Independent Medial Review is working.

Skeptics have pointed out the surge in IMR requests when the law mandated that all UR denials are subject to IMR regardless of date of injury or service.

When that happened the IMR company, Maximus Federal Services, saw a huge increase in business.

And the blame game started.

Some blamed the applicant attorneys who are alleged to appeal every single UR denial, despite validity and accuracy, because there is no disincentive to do so and/or they are trying to make a statement.

Others blamed the carriers and administrators for using UR too much and forcing IMR in situation when they should just approve the procedure and payment.

Still others blamed the doctors for requesting procedures without adequate documentation or support.

But I hear from representatives of the various groups involved in the controversy that they want the system to work.

Applicant attorneys tell me that it is destructive to their clients to go through the time and effort for an IMR review, stating that they just want necessary and appropriate care for their clients.

Carriers and administrators tell me that they are just following the law, that sometimes some treatment requests have gone through UR and IMR when the economics didn't justify it but that otherwise their concern is to provide reasonable treatment that complies with the Medical Treatment Utilization Schedule.

Doctors likewise say that all they want to do is get their patients the treatment they think is reasonably necessary.

Some UR denials occur because of a lack of documentation. Some are because procedures fall outside the MTUS. Still others don't meet regulatory or legal requirements.

It seems to me, though, that all of this misses the reality that about one quarter of all UR determinations are overturned by IMR, which is a ratio consistent with what is experienced in the general health sector.

What this means is that what is occurring in workers' compensation, though of greater volume that originally predicted, is mirroring the behavior of the general health market which is mostly Medicare and Medicaid.

So I have to wonder whether IMR is really broken? Perhaps it really IS working. Perhaps all of this attention and complaining is for naught and all of us are just a little shell shocked because we're not used to what is going on.

The thought when IMR was introduced was that there in fact would be a period of high volume, and some discontent with the system, but that the noise would quiet once people adjusted and got used to the system.

I know that there is research pending on IMR utilization and results, and likely there will be more research. IMR drivers will be identified, trends will be noted, suggestions will be made - all of this will help us understand how to best utilize the process and/or navigate the process.

So, I'm wondering if there really is anything to be upset about at this point. Perhaps we really don't have enough information. Perhaps we're panicking because this is a new process to which we haven't adjusted.

When we really get down to it, the problem doesn't stem from UR, or IMR, Maximus or the Administration. The problem doesn't reside with any single, individual, or faction within the system.

The problem is that workers' compensation at the level that UR and IMR operate is an adversarial system.

This means that people fight.

When people fight it costs money.

I think that IMR can work if people will work together. We all have differences of opinion as to what is reasonable and what is necessary.

That's why there are guidelines, rules and regulations - to put some sort of framework around the nebulous terms "reasonable and necessary."

This is supposed to reduce the adversity and increase compliance.

I have a strong suspicion that if one really closely inspects what is going on with UR and IMR the underlying cause for such disputes is because someone somewhere along the path of treatment request failed to follow a guideline, rule or regulation.

When the researchers publish their works we'll find out. In the meantime I've decided I'm not going to panic. We need to make clear, precise, and well informed decisions. At this point our collective decision making capabilities are clouded by uninformed emotion.

1 comment:

  1. The blame game started when the Legislature took Workers' Comp out of civil litigation, and tried to turn it onto a benefit delivery system, without looking at the underlying motivations of what causes litigation and mistrust. And mind you, this was enacted at a time where there was employer loyalty and people stayed in one job for their entire career.

    So it must follow that what actually interfered in this loyalty bond is the interference of third parties, all trying to carve out their piece of the pie, without understanding the underlying principles.

    And now you're advocating more uninformed but (to give them the benefit of the doubt) well-meaning individuals (have you ever read Frank Neuhauser's 1999 report to CHSWC), to waste more employer money, pontificating on what's gone wrong, and how a little more tweaking can fix it.

    I've heard tell that the modern day statistician is akin to yesterday's Torquemada, he can torture any set of facts to make it say what he wants.

    Instead of trying to obtain a Utopian result where costs never rise, and everyone is magically cured, lets stop,, trying to show what went wrong because its as futile as King Canute and the tide, let's just accept that the desire to "get ahead of the mark"is embedded in the psyche, that it's not personal, provide the benefits and take the money that's being wasted on research and statistics and pay more people to actually handle the claims.