One of the ironies of the California workers' comp system is the lack of education treating and evaluating doctors have.

The AMA Guidelines, 5th Edition became the touchstone of disability evaluations in 2005. But QMEs were not required to be schooled in use of those guidelines.

Many QMEs have by now delved deeply into the Guides, taking various seminars. But some QMEs still have a tenuous grip on the Guides.

And what about treating doctors? Have they mastered state-mandated treatment rules?

California adopted the ACOEM Guidelines as treatment standards and later adopted the MTUS, the Medical Treatment Utilization Schedule. Proffered treatments are required to be supported by the MTUS (found at Title 8, California Code of Regulations 9792.20 to 9792.2). Treatments not addressed by MTUS may be authorized on a rebuttal basis "if such treatment is in accordance with other scientifically and evidence-based, peer reviewed, medical treatment guidelines that are nationally recognized by the medical community" and "a variance from the schedule is reasonably required to cure of relieve the injured worker from the effects of his or her injury" (see 8 CCR 9792.25)

Could it be that few doctors are familiar with the MTUS? Have few workers' comp treating doctors even read the MTUS?

That may well be the case.

So is the argument made by Dr. Robert R. Kutzner, a Los Angeles area based
pain specialist. Writing in comments on proposed MPN regs in a DWC sponsored forum, Kutzner charges that:
"I am consternated that we write more and more laws to enforce the MTUS law when we haven't spent any effort to ensure that those whom are responsible to implement it, KNOW ABOUT IT. This is outrageously shocking and easily substantiated: Just ask any provider, any WC Insurance Adjuster, or just about anyone at the Medical Board outside the Div of WC about the MTUS and they won't know what you're talking about. To prove my point simply look at the video recording of the Med. and Pharm. Brd. joint forum on Prescription Overdose, Feb 2013, where I asked hundreds of attending WC Providers and Insurance Adjusters, to include the Professional Panel, if they knew about the MTUS only to receive a blank look where no one knew what the MTUS was. No one, not Adjusters, not TPA's, not the Providers who are supposed to implement the WC Program know anything about the MTUS. Why should they when they are not even required to read it to participate."

Kutzner defines the problem thusly:
"Providers are not required to know or implement the MTUS. Shockingly most Providers don't know what the MTUS is let alone read it. That's right, Insurance Companies don’t require Providers to even read the MTUS to get on their MPN list.
In addition, Insurance Adjusters are not required to know or implement the MTUS. The State does not require Insurance Companies to even read the MTUS to get approval to offer Workers Compensation Insurance.
Third Party Administrators (TPA’s) are not required to know or implement the MTUS. The State does not require Third Party Administrators (TPA’s) to even read the MTUS to get approval to participate in Workers Compensation."

His solution?

"Doctors that want to be on a Provider Network SHOULD HAVE TO AKNOWLEDGE THAT THEY HAVE AT LEAST READ THE MTUS.
Insurance Carriers and TPA's that want to participate in Workers Compensation SHOULD HAVE TO AKNOWLEDGE THAT THEY HAVE AT LEAST READ THE MTUS. They should also acknowledge that they will ensure that their Providers have also read the MTUS."

Kutzner has identified a very basic problem. California workers' comp has become ever more complicated.

Substantive changes in the law, procedural changes, regulatory changes.

The volume of rules and regulations that apply to stakeholders is massive.

It's likely that many of the physicians and stakeholders either are too distracted or too busy to pay attention to the details. Any the DWC currently has no way to monitor training that those stakeholders receive on the basics.

It's a problem.

Stay tuned,

Julius Young
www.boxerlaw.com
www.workerscompzone.com

Judges and attorneys know it as a frequent scenario.

An injured worker, frustrated with the delays and treatment denials in the system, simply wishes to cash out their case. As part of a buyout they usually take a negotiated amount of money in exchange for releasing the insurer from liability for future medical treatment.

Perhaps the worker has other coverage that can be relied upon to fund treatment.

But maybe not.

Workers who have employer sponsored group health coverage or private coverage administered by companies such as Blue Cross or Blue Shield may find that their treatment is denied under the terms of the policy if the policy excludes payment for workers' comp related conditions.

What about workers who have no insurance or whose insurance will not cover workers' comp? Once they settle their cases, how do they fare?

Some of those workers may be eligible for Medicare, so they are expected under Medicare's rules to "protect Medicare's interest" by using an allocated portion of their settlement (a Medicare Set Aside) to cover medical costs before Medicare will willingly kick in.

Others will use their group or individual medical insurance anyway, despite exclusionary language, hoping that their usage of treatment resources caused by a work injury is not flagged by the insurer. Some will seek treatment at the VA or public clinics or county hospitals. Some may receive "charity care".

If there is any research on how workers who settle cases access treatment resources, I'm not aware of such studies.

Perhaps the Affordable Care Act/Obamacare will affect all of this. But for now it's not clear how many injured workers end up having to pay for treatment "out of pocket" after cases are settled.

But I'm sure there are some who do.

I was thinking about those workers as I noted that the Centers for Medicare and Medicaid Services has now released a study of hospital pricing. The study documents hospital-specific charge data on the 100 most frequently billed discharges from 3,000 U.S. hospitals (a link to the study is noted below).

The study documents that there is a huge range of billed charges from hospitals for the same procedure.

Insurers may get discounts. But if you are an uninsured injured worker without insurance, you may be charged the "rack rate" just as you would be if you walked up to a hotel and booked a room without a discounted reservation.

For example, a joint replacement may on average be billed at $83,538 at California Pacific Medical Center in San Francisco and $110,305 at St. Francis Memorial in San Francisco, just a couple of miles across the city. The same procedure at a local Kaiser was on average billed at less than half the cost.

Where injured workers have settled their cases and later found themselves without coverage, have they done comparison shopping?

Perhaps. I have personally represented several workers who settled their cases and used the funds to seek medical treatment in India or Thailand at a lower cost. Undoubtedly some immigrant workers from Mexico return there to get treatment.

But for workers who need to treat in the USA, obtaining such data has been hard until now.

For those workers who have settled their cases and are without other viable coverage, the CMS data may be helpful in choosing where to have elective treatments performed.

Here is a link to the CMS site where data can be obtained on charging practices of specific hospitals (the site has a search function to search for the hospital of your choice)
https://data.cms.gov/Medicare/Inpatient-Prospective-Payment-System-IPPS-Provider/97k6-zzx3

Here is another link to the CMS study:
http://www.cms.gov/Research-Statistics- ... index.html

Here is a link to a New York Times analysis of the study:
http://www.nytimes.com/2013/05/08/busin ... shows.html

Stay tuned.

Julius Young
www.workerscompzone.com
www.boxerlaw.com that

They call that a knee.

You can decide for yourself. But brace yourself. It's not a pretty picture.

I'm talking about the photo of Reggie Williams' knee.

The former football star is featured in a Sports Illustrated article about AB 1309, the bill which would limit the ability of professional athletes (including those in the minor leagues) to file California workers' comp claims.

Here's a link to the article:
http://sportsillustrated.cnn.com/nfl/ne ... index.html

As the author notes:
"It's possible that AB 1309 could be passed in a weaker form. For instance, the sides could grandfather in some current claimants so they maintain their existing benefits, or phase out their benefits gradually instead of abruptly terminating their cases. The ultimate irony remains that if the bill passes as currently written, Williams and other athletes would have to turn to government assistance in covering their medical costs. In that case, taxpayers would be the ones fitting the medical bills."

Read More: http://sportsillustrated.cnn.com/nfl/ne ... z2Slwmwg7e

Stay tuned. I'll continue to cover the controversy generated by AB 1309.

Julius Young
www.boxerlaw.com
www.workerscompzone.com

Here's a project for Christine Baker and Kathy Zalewski:

Clean up the unconscionable backlog of panel QME requests. The QME panel backlog as of mid 2012 had been whittled down to around 30 days under the leadership of former DWC Administrative Director Rosa Moran.

Thanks to the reporting of Greg Jones in Workcompcentral.com, we now know that the DWC has admitted that the backlog has grown by a factor of 5 times in less than one year!

Since mid 2012 the backlog has grown to 5 months according to a statement quoted by Jones from DWC spokeswoman Erika Monterroza.

Jones' article notes that Monterroza responded to an e-mail inquiry as follows:
"The subsequent delay in issuance of panels occurred after overtime and
student assistant work was no longer available".

Monterroza also noted that
"The current backlog for represented cases is back to November 2012".

In plain English, this means that the DWC is just now dealing with requests for QME panels in represented cases that were made around Thanksgiving.

That's pathetic.

It's shameful.

In a normal private sector organization heads would roll or an emergency action plan would be put into place to rectify the problem.

But so far there is little indication that this is on the radar for leadership at the DIR and DWC.

It's not just workers and applicant attorneys who are disturbed by the delays. Insurers have reserves that are tied up as claims can't be resolved.
Self-insureds can't move files.

In some cases treatment costs may increase since workers in denied cases that are later accepted are able to treat out of network during the denial. Periods of temporary disability may be longer because a QME eval is delayed. The longer those claims are open the more likely that compensable consequence injuries are raised.

Some employers and insurers will simply not use AMEs. For example, a Safeway adjuster told me last week that their claims people have been told not to agree to AMEs.

But with the wait for panels getting steadily longer, those files are going to be lingering longer.

This is a project for CHSWC:

Do a study on why the DWC seems to have trouble issuing panels in a timely fashion.

And while you're at it, take a look at whether the division is adequately staffing the unit that will determine whether IMR requests are ripe for determination by Maximus.

Recently, Dr. Rupali Das of the Medical Unit was noted as saying that the DWC plans to publish some IMR decisions. It would appear that the DWC is taking on more projects at a time that it is mishandling other fundamental ones.

Stay tuned.

Julius Young
www.workerscompzone.com
www.boxerlaw.com

Workers' comp has been part of a grand bargain for many decades.

Workers generally gave up the right to seek redress by filing tort lawsuits against employers. Instead, workers' comp law provided a structured level of benefits to injured workers in lieu of having to prove fault in a court of law.

Workers' comp became a part of the social safety net, delivering medical treatment and some indemnity benefits to injured workers. As we know in California, that's a multi-billion dollar industry with its own set of stakeholder players who periodically instigate reform attempts in an effort to reallocate costs and their shares.

Then along came other trends.

Carve outs, where some employers and unions could set some of their own procedural rules.

California is now struggling with how it should deal with claims by athletes who file claims here, some of whom have very minimal connections to California.

How that is resolved could have bearing on how California deals with other interstate employees.

And now, in some other states such as Texas and Oklahoma, there are laws that would allow employers to opt out of workers' comp entirely.

Meanwhile, the long term effects of the Affordable Care Act are starting to roil America's health care system. Anyone who is paying even slight attention is likely to notice the steady stream of articles noting the concerns that are developing about how the ACA rollout is going. Perhaps those difficulties are due to the complexity of the law itself, GOP opposition, or problematic execution by the Obama Administration, or all of those reasons.

In any event, some observers are predicting large increases in healthcare costs, delays in implementation, confusion of small businesses and individuals, and a political train wreck.

If the ACA was to fail will there then be momentum for a single payer system ? A system that offers 24 hour care? There are already many advocates for that type of system.

If so, we could be looking at another very basic change in workers' comp in coming years.

The point is that there is nothing inherently sacred about the comp system.

It's always ripe for re-engineering.

We live in a time when the notion of entitlements is coming under scrutiny.
There's more focus on tax reform, immigration reform, public employee pensions, Social Security and Medicare. But you can bet on it that workers' comp will continue to evolve along with other publicly mandated and administered programs.

Here's a link to a provocative article by The Washington Post columnist Robert Samuelson, "The Twilight of Entitlement":
http://www.realclearpolitics.com/articl ... 18152.html

Stay tuned.

Julius Young
www.workerscompzone.com
www.boxerlaw.com