It really shouldn’t be that difficult, should it? After all, over the past three years, the governor and the legislature have made a strong commitment to the concept of “evidence-based medicine,” even as the Division of Workers’ Compensation and the Commission on Health and Safety and Workers’ Compensation digest the various professional guidelines to be included in the medical treatment utilization schedule. Treatment approvals consistent with the injured worker’s diagnosis should be almost, if not fully, automatic, right?
As we develop and adopt these best medical practices – or at least so the theory goes – payers (employers and insurers) will be able to quickly respond to requests for authorization for treatment, the injured worker will be well on his or her way to a speedy recovery, and the costs in the workers’ compensation system will drop.
Why then is there such a hassle in getting even routine medical services approved? Well, the problem is multifaceted, as one would have to expect from California’s attorney-laden workers’ compensation system.
First, there is the problem of providers still looking at injured workers as profit centers rather than patients.
Next come the claims administrators with some payers who have the annoying tendency of believing utilization review means denying everything once and then, if the doctor and the patient are really serious about this, thinking about approving something 30 days later.
Finally, there are the workers’ compensation judges who view the Labor Code, DWC regulations, and the ACOEM Guidelines, those nationally recognized peer-reviewed, evidence-based treatment guidelines, as inconvenient obstacles along the way of them doing what they want to do anyway. After all, they’re judges and they’re simply that much smarter than the rest of us, right?
While the DWC, the Commission on Health and Safety and Workers’ Compensation, and other entities ruminate over what constitutes the best medical practices for workers’ compensation, even a cursory review of the Internet shows dozens of websites that will give you all you need to know about evidence-based medicine. In fact, many of these best practices are available for download onto a PDA, so requests for utilization can come even from the comfort of the country club as the provider awaits his or her tee time. Isn’t technology wonderful?
For all those who still feel that SB 899 was carved in stone tablets, take heed. The delays and frustration arising from utilization review cannot be blamed solely on providers and judges who refuse to believe that the rules have in fact changed.
When common sense falls victim to economic incentives or mechanical application of guidelines without regard to the needs of the injured worker, the ability to control medical costs will diminish. Utilization review is not a game of hide the ball; it is the linchpin upon which all other reforms are based.
The ability to deliver quality medical care on a timely basis is literally only a download away. But to accomplish this will take more than having providers and judges toe the line.
The intent of SB 899 is not being met by those who pay the bills and think that if you say “No” long enough that providers and their pesky injured workers will simply go away. Such behavior only empowers those whose goal is to unwind SB 899, whether in the legislature or in the courts.
The goal of the system is to make it work for employers and workers, not simply to make it cheap. The sooner this lesson is learned, the better off we’ll all be.