Monday, December 16, 2013

Bothcoe, IMR and Medicine

I have a cat named Boscoe, though we add a lisp in the pronunciation of his name because it seems more appropriate to his personality - "Bothcoe."

Bothcoe is a "special needs" kitty. We adopted him as a small kitten, all white, blue eyes, and no whiskers. Seems someone cut them all off.

Special needs because it also seems that he may have been dropped on his head a couple of times in his life prior to our adoption since he never quite seemed to have the same intellectual level of other cats we've owned.

Bothcoe would be a good study in occupational risk management. He's had more than his share of nine lives.

There was the time that he got pinned by the garage door when opened because he was sleeping on top the track.

Or the time he decided to explore the possum trap and did not escape until discovered three days later.

Bothcoe also displayed an affliction towards seizures early on in his life.


Poor Bothcoe - he would always have his seizure at the top of our central stairs, which would cause him to flop uncontrollably down the stairs to the landing mid-flight.

Bothcoe would then experience a period of temporary disability because his brain took a few hours to rev back up to normal Bothcoe operating temperatures, which as I mentioned, was a few scales below normal cat operations.

In order to control his seizures the veterinarian prescribed phenobarbital - 16.2 mg tablets twice per day. This is typically administered in his morning and evening feedings.

Being a cat, you can guess that sometimes medication compliance is difficult. Phenobarbital apparently has a bitter taste, and while Bothcoe doesn't have a particularly discriminating palette, he's not very fond of his food being spiked with his medication.

So we resort to all sorts of incentives like spiking his food with fish oil. Sometimes we just have to shove a pill down his throat.

I get the sense that Independent Medical Review is kind of like Bothcoe - sometimes it has to be shoved down the throat of the system for dispensation.

The message that is coming out of the Division of Workers' Compensation's Medical Unit is that while there are issues with IMR volume and the timing of issuing decisions, the majority do appear to be appropriate when reviewed.

Dr. Rupali Das, executive medical director of the DWC, said, “What appears to be a high rate of denials, or what is a high rate of denials, may in fact be appropriate medical care” when looking at the fact that about 80% of the time the UR decision to deny or modify a treatment is upheld.

Pharmaceuticals represent the most frequent issue disputed in IMR, accounting for about 1,000 decisions, she said. About 300 IMR decisions addressed the appropriateness of durable medical equipment, another 300 addressed surgery requests and another 300 determined whether physical or occupational therapy was necessary. In all of these categories, independent medical review found that the requested procedures were not medically necessary more often than not.

Das said the division is studying the criteria used to make UR and IMR decisions and trying to identify predictors of whether a request will be approved or rejected. She also said the administration is interested in tracking the outcome of injured workers who have gone through the IMR process.

The DWC is currently in the process of updating its Medical Treatment Utilization Schedule, a process Das said could ultimately reduce the number of treatment disputes going to IMR.

To address volume, Das said that the division is working on automating much of the system to eliminate as much of the paper processing as possible.

I think these are all positive developments, if in fact workers' compensation beneficiaries are getting medical treatment that is the most appropriate to their injuries or illness as defined by the current scientific literature.

But the Division must first address the timeliness of IMR decisions. The current back log is unacceptable and there does not appear to be any mechanism in the law or regulations to address this issue.

The other part of the equation - getting the patient to take the medicine - is going to be a longer process. If in fact IMR is upholding "good medicine" then the workers' compensation community will need to adjust in a radical way.

The standard of care in workers' compensation for nearly 100 years has been "anything goes." If a beneficiary wanted some treatment then he or she got it. Sometimes it took a fight, sometimes there was just a cave in after too many bruising episodes in court.

This led to all sorts of ridiculous burdens being placed on work comp: expensive special beds where there is nothing more than a doctor's "prescription", excessive opioid prescriptions, unnecessary surgeries, etc. For so very long if a beneficiary wanted something they got it.

It's a deeply rooted cultural anomaly that is changing and the "anything goes" mentality is adjusting.

IMR is the phenobarbital that is being shoved down the throat of system participants.

For all of the problems the IMR process is experiencing I have no doubt that eventually these will all work out and we will end up with a smooth process. But there is a huge adjustment period. Volume is one issue, acceptance of results is another issue.

We all can agree however that the California work comp system has occasional seizures. It's going to have to take its medication...

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