"...perhaps UR is getting called to the mat on their more vacuous opinions, that can't stand up to the medical guidelines." Alan Gurvey
Published on 918/17 by WorkCompCentral , Author Greg Jones
After increasing for each of the last two years, the California Workers’ Compensation Institute is projecting the number of independent medical review determinations will drop this year.
Maximus Federal Services, the contractor responsible for IMR decisions, issued 86,066 decisions in the first half of 2017, CWCI said in a Spotlight Report published Thursday. At that pace, Maximus is expected to issue 172,132 determinations for the entire year.
The projection for 2017 would be 2.2% decrease from the 176,002 determination letters issued in 2016. Maximus issued 165,525 IMR determination letters in 2015 and 143,983 in 2014, the first full year in which IMR applied to all dates of injury.
For the first six months of 2013, IMR was available only to challenge utilization review denials of treatment requests for those injured on or after Jan. 1, 2013. In July 2013, IMR was applicable for all dates of injuries.
While CWCI is reporting signs of a first decline, IMR volume remains nearly three times greater than the 50,000 to 60,000 decisions supporters of IMR and SB 863 expected each year.
Aside from the apparent decrease in IMR volume, there was little change among the other metrics CWCI uses to monitor decisions. IMR continues to uphold about 9 in 10 underlying UR decisions.
Providers in Los Angeles and the Bay Area generate a disproportionate amount of IMR determinations. And a small group of providers account for the lion’s share of disputes.
CWCI reports that 111 individual providers — the top 1% — were responsible for 45% of all IMR decisions issued between July 2016 and June 2017. The top 10% of providers — 1,114 — generated 85% of all IMR decisions over the same period.
In its last IMR report, published in March, CWCI said the top 1% included 125 providers responsible for 44% of IMR decisions in 2016. There were 1,248 providers in the top 10% who were responsible for 85% of IMR decisions last year.
CWCI’s latest report identifies a new entry on the list of the 10 individual providers responsible for the largest number of IMR decisions.
A physical medicine and genetics specialist in Northern California jumped from No. 21 in 2016 to No. 8 among the list of providers who accounted for the largest number of IMR decisions through the first six months of the year.
CWCI does not identify the providers by name in its report.
The 1,516 treatment decisions for this provider accounted for 1% of all treatment decisions issued between January and June. According to CWCI, 93.7% of the IMR decisions associated with this provider upheld the UR decision.
The No. 1 provider, responsible for 2.8% of total medical service decisions — in which 99% of the time the UR decision was upheld — ranked No. 3 in 2016. Last year’s top doctor in terms of IMR decisions has dropped to No. 3.
Overall, CWCI said these 10 providers were responsible for 20,249 medical service decisions, or 13% of all IMR decisions in the first half of the year.
CWCI also reports that Los Angeles and the Bay Area continue to generate more IMR decisions than would be expected based on the percentage of medical services provided in these regions.
About 20% of medical services in California’s comp system are provided in the Los Angeles area, but the region accounted for 32.7% of IMR decisions. The Bay Area, where 16.3% of all medical services are provided, accounted for 21.9% of IMR decisions.
On the flip side, the Central Valley accounted for 17.4% of IMR decisions but 26.3% of medical services. The Inland Empire and Orange County accounted for 15% of IMR decisions and 17.6% of medical services.
Rena David, treasurer, chief financial officer and senior vice present of research and operations for CWCI, said the way the organization calculated the percentage of services performed in a region has changed since the last report. She said CWCI excluded “other” medical services from the equation and also took pharmaceutical use into account.
The result was that the percentage of services provided in the Central Valley increased to 26.3% in the latest report, from 18.5% in the report released in March. But David, who co-authored the latest Spotlight Report with Robby Bullis, a senior research associate at CWCI, said the takeaway is the same.
“I think the main message here is that there appear to be proportionally fewer IMRs than what one would expect, given the services provided in the valleys,” she said.
CWCI’s data also shows that IMR outcomes have been pretty consistent over the years.
CWCI said 91.3% of UR decisions were upheld in IMR decisions issued during the first six months of the year. The uphold rate in 2016 was 91.2%, which was up from 88.4% in 2015 but the same as the uphold rate in 2014.
“This consistently high uphold rate shows that the vast majority of disputed modifications and denials made by UR physicians are found to be appropriate,” the report says.
The approximately 90% uphold rate applies across most medical service categories. For example, 92.2% of pharmaceutical denials — the largest category of disputes, accounting for 46.6% of requests this year — were upheld by IMR. For physical therapy, the second-largest category, accounting for 10.1% of disputed services this year, the uphold rate was 94.1%.
But for two categories, evaluation and management services, and psychological services, the uphold rate has been closer to 80%.
In 2014, 78.7% of UR denials for evaluation and management services were upheld. That dropped to 68.2% in 2015 before climbing back to 79% last year and 80.4% this year.
Independent medical review upheld 85% of UR denials for psyche services in 2014. That dropped to 79.6% in 2015, rose to 83.3% in 2016 and dropped slightly to 82.4% this year.
David said most of the IMR disputes over E&M services were primarily consultations, rather than codes for routine office visits with the primary treating physician. She said she didn’t know why the uphold rate was different than other categories.
Alan Gurvey, managing partner of applicants’ law firm Rowen, Gurvey & Win, said he has no definitive explanation for any disparity in IMR rates among different medical categories. But he said he has felt an “overwhelming backlash” to psychological claims from the defense side in recent years. He said it appears to have started with provisions in SB 863 that eliminated compensability for sleep or sexual disorders not caused by a catastrophic injury.
"I say all this because, as I said, I have no info on this disparity of IMR overturns between physical treatment requests and psyche treatment requests, but there seems to be a wave of negative opinions on psyche claims, notwithstanding the medical reality, and since UR can deny, I think, easier without dealing with medical realities, and IMR may be more hard pressed to give bogus opinions — although they do it very easily as well — perhaps UR is getting called to the mat on their more vacuous opinions, that can't stand up to the medical guidelines,” Gurvey said.
Steve Cattolica, director of government relations for the California Society of Industrial Medicine and Surgery, said he’s also at a loss to explain why the E&M uphold rate would be lower.
When it comes to psychological services, however, he said it’s possible that the rate is lower because of a lack of guidance in the Medical Treatment Utilization Schedule for psychological conditions.
“I don’t believe there are any guidelines specific to psychiatry or psychology except for those related to stress as found in the chronic pain guidelines,” he said. “This leaves the MTUS without any guidance for those who treat mental health disorders not related to stress from pain.”
Rene T. Folse, of counsel for defense firm Floyd, Skeren & Kelly, also said the disparity might be the result of less evidence-based guidance when it comes to psychology and psychotherapy.
Folse, who is also a licensed psychologist in California, said some psych services aren’t well-defined in the treatment guidelines. There is plenty of data to prepare evidence-based guidelines covering Prozac or Xanax, he said, but there is little in the way of guidance for psychotherapy.
Psychotherapy is not common treatment on industrial injury claims, he said. Claim files may indicate a patient was or is taking an antidepressant or a selective serotonin reuptake inhibitor, but there is little psychotherapy or treating of patients with behavioral intervention rather than medication.
“If you get to UR, good luck figuring out what is evidence-based treatment under mental health,” he said.
The evidence for evidence-based guidelines is largely based on results from randomized control trials. Those studies are expensive and, in some cases, are paid for by drug companies, Folse said.
The American Psychological Association, on the other hand, doesn’t have the money to finance controlled studies of psychotherapy.
As a result, the recommendations that end up in treatment guidelines tend to be “pill-based” because those are the only treatments that have been proven to work, according to Folse.
He said there are alternative and complementary procedures — “some effective, some junk” — that have been “circumvented by this huge push toward evidence-based medicine using Big Pharma money to prove the efficacy of medications.”
This creates a particularly acute problem when it comes to narcotic painkillers, Folse said.
“If you don’t do opiates, the alternative is complementary medicine, but complementary medicine is not approved by the guidelines not because it doesn’t work, but because nobody has proven it works,” he said. “Now you’re between a rock and a hard place. How do you get out of the opiate dilemma with drug companies in charge of research?”
The Spotlight Report can be purchased from CWCI’s store and downloaded by members and subscribers.