Monday, June 29, 2015

Change The Ride

I flew home anxious from the Summer California Applicants' Attorneys Association conference in Las Vegas Saturday; there were some tasty aftermarket parts to install on The Sewing Machine!

TSM is a 2011 Honda CBR250R. I bought it from a friend about 18 months ago with only 281 miles on it for a paltry $2,900. How could I go wrong?

All motorcycle owners modify and customize their machines. It's inherent in the gear-head mentality. It can't be helped - motorcyclists have an affliction called Compulsive Modification Disorder.

So I rode the heck out of it, resisting the CMD (though barely) until it was time to replace the tires at about 3,500 miles. I wanted to get a feel for the bike, understand its characteristics, and also understand what mission it would be fit for me.

Honda designed the CBR250R as a sporty beginner's bike, but in truth it has much more sport in it than beginner, particularly if you've been owning and riding bikes as long as me.

What I discovered was probably the PERFECT Malibu canyon carving bike. With only 24 rated horsepower this bike isn't passing anyone unless it's a really tight corner, but with only 320 soaking wet pounds to throw around there aren't too many bikes that can stay with it in the corners, except for bicycles - and they can't keep speed up hill!

The weekend before I had already installed some excellent Bridgestone Battleax BT 090 radial tires to replace the trashed stock IRC rubber. Waiting for me in the garage upon return from CAAA were a set of Woodcrafter Racing clip on handlebars (1.5 inches lower than stock) and rearset foot pegs from Yoshimura Racing that put the foot controls 40mm rearward and 30mm higher than stock.

Then I went riding on Sunday afternoon.


I had a different bike. Wow. An already competent canyon carver turned into a cornering cue ball. The confidence of the sticky tires in combination with the new riding position put more smiles per miles on my face than ever; and this bike had already attained status as one of my all time favorites in 45 years of riding.

Just a couple of minor, and inexpensive, tweaks, and the entire character of the bike, and the grin on my face, changed in huge proportions. I'm glad I waited to find out what I had, what I needed, and what was available before throwing solutions onto something that I didn't understand.

Which brings me to the CAAA convention.
The Sewing Machine when it was "new".

There was, unfortunately, a recurring theme with everyone that I talked to there - and that included attorneys (both sides), doctors and vendors: Injured workers' medical care continues to be delayed and/or denied for no logical reason.

Remember the statistics from the Workers' Compensation Insurance Rating Bureau's annual meeting just a few weeks ago? Dave Bellusci, the Bureau's Chief Actuarial, showed us that California leads the nation, by a long shot, in delayed care. And that delayed care equated to costs that were oodles above the rest of the nation directly and indirectly.

That unfortunate statistic was born out by the anecdotal evidence I encountered at CAAA; whomever I talked to had the same basic story - there is a real problem getting doctors to treat workers' compensation patients.

Eventually some treatment occurs at some level, but the amount of delay and procedural interference in getting to a treatment status is causing a huge increase in compensable consequences (and some consequences that aren't compensable, at least in the eyes of the insurance industry).

One story that seemed to represent that common theme was of an injured worker that had been receiving consistent medical care for years. Same medication, same procedures, same everything. All had been authorized, all had been paid for, all was dependably provided.

The treating physician then retires. A new physician, not as adept at comp as the original treating doctor, takes over the case and prescribes the same treatment as before, albeit not as skillfully, negating some documentation or some other minor defect.

The request goes to Utilization Review and gets denied.

During the time period of the UR procedure applicant's attorney notes the defect in the treatment request, and asks the doctor to correct it. He does, it gets submitted, and that passes UR.

On the day that UR approves the second request (remember, this is for the same procedure as the first), a denial is issued from UR for that first defective request.

Now comes the galling part - the claims adjuster assigns the matter out to defense counsel to contest the treatment request.


So now, not only does the injured worker NOT get the treatment that he has been receiving as authorized treatment during the entire pendancy of his claim, but his attorney has to go to court to get the treatment authorized.

Folks - that's just plain wrong. If that adjuster were under my supervision, he'd be no longer. That's what I call in my rough manner, A-hole Adjusting. There's no reason for that behavior, and there's no excuse.

Yet I heard tale after tale of similar stories while at the CAAA conference, from attorneys, from doctors, from other vendors.

There seem to be several underlying reasons for this malevolent behavior.

First off, UR seems to be cook book programmed. I don't know whether this is true, but from the evidence I have to assume that there are computer algorithms out there that dictate what the UR decision is without any human intervention, and if any element is missing from that algorithm then denial occurs.

Second, and related, claims has increasingly been taken out of human decision making. The logic has been ascribed to computers that can not connect endpoints if a dot is missing.

Third, the old guard medical providers aren't adapting well. The old saying, "you can't teach an old dog new tricks" has some truth to it. They just can't adjust to this new paradigm of medical treatment review and authorization.

Fourth, the new medical professional is of the Millennial Age - they don't have the patience for this BS. If it's not a push button system then it isn't going to be in the treatment arsenal. And they're certainly not going to put up with multiple levels of review without compensation for the effort.

The doctors that are left, and who are doing it right, still won't see a patient if the claim is older than six months. I had one doctor specifically tell me that - the reason: she doesn't get paid to review volumes of medical records to figure out what is going on. So she just doesn't take on any patients with dates of injury more than six months prior to appointment.

Oh, and there has to be prior approval on procedure and cost before committing to that patient.

So as a consequence there really is a medical access problem! There are doctors. But the patients can't get to them. And when the patients actually do get to a physician the delays in treatment approval are ridiculously lengthy.

Here's what's going on - injured workers, bottom line, aren't getting the medical treatment they should, and as a consequence the vast majority of EMPLOYER'S costs (those that participate in the the insured market) are going up.

SB 863 was a radical reform. SB 899 was a radical reform. Both occurred just a few years from each other. Both were supposed to reel in costs while providing better benefits to injured workers. Both have not succeeded in that mission, in my humble, albeit anecdotal view point (with some quantitative support from the industry).

Instead of waiting for the tires to wear down, and to understand the character of what we have and our mission, we changed everything. And now we're finding out that there are attributes that aren't so savory.

You might argue that my sampling is a small cross-section of claims that is overrepresented because I was talking to litigators. But the truth is that if the injured worker were treated quickly, efficiently, and without unnecessary interference from procedure and process, then most of those litigators would not be telling me these tales.

The system pushes claimants to attorneys, who still can't help their clients. The cards are stacked, and in the wrong direction.

All of us, every single one of us, will ultimately act in accordance with what is in our own best interests. If the law provides a system where an insurance company can save money on a claim then that is what the carrier is going to do. If the system promotes excessive disability to determine compensation, then that's what will happen.

The next modification to TSM is some front suspension tuning. I now understand that how and where I ride my bike overtaxes the forks; they are both underdamped, and under-sprung.

California workers' compensation is both OVER-damped, and OVER-sprung. But I don't think we need more radical solutions.

We've ridden the machine now for nearly 3 years. We know what needs to be done.

But it will take everyone to set aside their own, personal, self-interests.

1 comment:

  1. Yep. 🏈 "A-hole Adjusting" sonderkommando just following orders...."PROFITS BEFORE LIVES.

    It keeps the #WorkComp Gravy Train rolling....those denials include many unclean hands and bank accounts, huh? Everybody knows. Even CAAA members contribute to the harm to injured workers by their liens by incompetent counsel hanging on in hopes of making a few dollars when someone else settles the case. Judges won't even allow an in pro per injured worker to hire hourly legal counsel. The grand bargain is lose/lose for injured workers all the way. How many Injured workers go thru 4-5 Attorneys without care? More than the CAAA is willing to admit. There is no QUALITY CONTROL there either.😩

    "....Eventually some treatment occurs at some level, but the amount of delay and procedural interference in getting to a treatment status is causing a huge increase in compensable consequences (and some consequences that aren't compensable, at least in the eyes of the insurance industry...."😧

    ENT eval next up for #TBI of 1/9/12. Can thank a WCAB Judge for that bright approval of defense chicanery...with more Neuro psych doctor shopping on behalf of Defense, in a clear ADA violation move.😤

    Nice Bike story too! 😎xoxo