We are Gawandeans.
That’s the message from the DWC to the workers’ comp community. The Gawandean message was delivered in a presentation to CHSWC on June 4 by Dr. Rupali Das, DWC Executive Medical Director.
The presentation by Das was titled “Providing Better Care to Workers: Independent Medical Review and MTUS” (A link to materials from Das’ presentation is at the bottom of this post).
Dr. Das was clearly trying to explain to the CHSWC commissioners why IMR determinations are so heavily upholding UR denials of treatments. Das cited stats showing that out of 144,644 IMR final determination letters in 2014, 88% upheld the treatment denial, 8% partially overturned the treatment denial, and 8% fully overturned the denial. Slightly less than half of the IMR determinations deal with pharmaceutical issues.
The presentation by Das prominently featured an article by Dr. Atul Gawande in the May 11, 2015 issue of The New Yorker, titled “Overkill”.
Das cites Gawande’s article for the premise that “More is Not Better”.
A look at Gawande’s article is in order. But first, a quick overview of the controversy surrounding medical treatment, UR and IMR.
The DWC’s vision is radically different from that of many doctors and attorneys, who complain that workers are not getting adequate treatment and are suffering under an avalanche of denials.
On the other hand, the California Workers’ Compensation Institute has argued that the volume of treatment denials is a small fraction of treatment requests in the system. CWCI studies have been questioned by CAAA, which noted that CWCI figures probably include so-called first aid injuries and do not adequately reflect the numbers as to workers with more severe lost time injuries. Indeed, at recent meetings, several CHSWC commissioners have asked for information on this point. To my knowledge neither the DWC, CHSWC staff nor CWCI have satisfactorily explored this controversy.
Also it should be said that if there is over treatment it is largely by employer chosen doctors. Why? Employers largely exert choice over which doctors can treat work injuries in California since MPNs have become widely prevalent. But a just-released study by CWCI, “PPO to MPN: Impact of Physician Networks in California Workers’ Comp” by John Ireland, Steve Hayes, and Alex Swedlow, seems to raise some questions about the cost effectiveness of MPNs. For example, cases with at least one opioid prescription have increased after the institution of MPN networks. The CWCI study concludes that under MPNs (analyzing accident year 200 to 2011 claims) there has been a “savings deterioration” and cites various theories on that.
In any event, if 88% of 144,644 treatment determinations by IMR uphold the “no”, that’s 127,286 denials by IMR. That’s a lot of “no”.
Opinion is polarized. Many attorneys, doctors and workers are having a hard time swallowing the cultural change in treatment defended by Dr. Das.
And it’s worth remembering that California has recently seen high profile cases of doctors accused of manipulating the system, including prescribing treatments and procedures for financial motives.
Like Dr. Oz, Atul Gawande has become something of a medical celebrity. So if the DWC is now Gawandean, what does Gawande say?
Das focuses on this quote from the article:
“Doctors are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.”
Gawande, a general and endocrine surgeon, teaches at Harvard Medical School and practices in Boston. Gawande has written about medical over-utilization before, including a profile of how doctors in some particular communities (for example, McAllen, Texas) do much more tests and procedures.
It is interesting to see what informs the thinking of DWC policymakers. Because Gawande’s vision seems to be in vogue at the DWC, I’m going to provide a bullet point summary (in italics) of some of Gawande’s main points:
-studies including an Institute of Medicine study and a recent study of Medicare (which he doesn’t reference in detail) show a huge amount of spending on wasteful treatments and tests
-the “Mother , May I” approach by health insurers to controlling costs has fallen out of favor (note: Gawande does not mention workers’ comp where it appears that the “Mother, May I” approach is still very much alive in California workers’ comp).
-there is an “information asymmetry” between doctors and patients; many patients lack the knowledge and skill to evaluate treatments
-overtesting is a problem because tests often show false positives or conditions that don’t require aggressive intervention. He notes that “Overtesting has also created a new, unanticipated problem: overdiagnosis. This isn’t misdiagnosis—the erroneous diagnosis of a disease. This is the correct diagnosis of a disease that is never going to bother you in your lifetime.”
-Gawande mentions mammography, thyroid ultrasound and prostate PSA testing. In a comment that would probably not be well received by someone with recently diagnosed prostate or breast cancer, Gawande says that “We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted.”
-citing Dartmouth University Medical School professor H. Gilbert Welch, there is a need for less medicine and more health. Some of the treatments have the potential for being more harmful than the treated condition.
-Gawande’s thesis is anecdote heavy.His mother received unnecessary tests when in the ER after she fainted in a grocery store. His friend’s 80 year old father had a stroke after receiving a surgery to make a stroke less likely. He relates the story of an optometrist whose local surgeons recommended back surgery. His employer (Walmart) has a plan which refers certain procedures to regional specialty care centers. The Seattle hospital determined that the optometrist did not require back surgery, and proposed conservative care which worked. Gawande also relates the tale of a patient who was diagnosed with a small thyroid tumor. It was a “turtle”, meaning a slow growing “micro cancer” tumor unlikely to be lethal. But Gawande eventually agreed to remove it, at some risk,, and against his better advice. The patient was adamant due to fear after receiving the micro cancer diagnosis ; she also had little disincentive since she had a health care plan that provided full coverage.
-Gawande touts the model of accountable care organizations under the Affordable Care Act, citing one group that he claims gets better results and savings by allowing primary care doctors more time with patients. Under the ACA, such groups re incentivized to share in 60% of the cost savings achieved.
But if “More is Not Better” is a costly dispute resolution process that generates increasing loss adjustment expenses the best way to resolve the problem?
At last week’s meeting, CHSWC commissioner Doug Bloch asked Dr. Das about what efforts the DWC is making to train doctors who treat comp cases. Das admitted that there is no systematic effort by the DWC to train doctors in use of the MTUS.
CHSWC commissioner Wei returned to the topic, asking for more information on a work path on education of the doctors. Wei mused about incentive or stick-based training
CHSWC commissioner Kessler noted that while more may be too much treatment, not enough treatment may be deadly.
It was clear that the consensus of the CHSWC commissioners is that the DWC needs to come up with more specifics on how to train doctors in medical treatment guidelines if those guidelines are going to be the basis for large scale treatment denials. A motion to that effect carried.
Can the Gawandeans bend the medical utilization curve in California? Can they train doctors to practice in a Gwandean manner? We shall see.
Here is the link to Gawande’s New Yorker article:
A pdf of Dr. Das’ CHSWC handout is here: