Like it or not, the trend in California is toward increasing usage of medical provider networks (known as MPNs).

That trend is confirmed in the findings of research by the California Workers Compensation Institute, which issued a November 29 bulletin documenting network usage from 2004 to 2010.

Network utilization rates for all "first year medical services" increased from 51.1% in 2004 to 75.3% in 2009. In accident year 2009 networks had an 81% share during the first 30 days and a 71.4% during the first year after the first 30 days. "First year medical services" was defined to include evaluation and management, anesthesiology, surgery, medicine, lab and pathology, radiology, physical medicine, chiropractic, special services, othotics/prosthetics, pharmacy, med-legal reports and other miscellaneous categories.

The trends were similar when CWCI looked at the percent of first-year workers' comp physician-based outpatient service payments to network providers for all services. By accident year 2009 the percent for the first year was 65.5% (i.e. 74.5% for services during the first 30 days post-accident and 61% for services post 30 days).

The CWCI broke out results in several categories. Take surgery for example.
Network usage for surgery climbed from 56% in accident year 2004 to 75% in accident year 2009.

But increased usage of medical networks has not kept medical treatment costs from outstripping other system costs. Along with medical cost containment expenses, treatment costs have escalated sharply.

And since indemnity costs have been relatively stable, this raises the question: if indemnity benefits can only be raised by systemic cost reductions (a position apparently being taken by the Brown Administration), then how can medical costs be tamed while ensuring worker access to prompt and adequate medical care?

One would think that any "grand bargain" type of comprehensive reform that does not look at this issue is doomed to failure.

Former Insurance Commissioner Poizner noted during several rate hearings that insurers had achieved only limited success with cost reduction tools at hand, i.e. medical networks and UR. At the time, he refused to endorse
requests for a substantial increase in the workers' comp advisory premium rate.

This is the conundrum with faces employers and labor, insurers and applicant attorneys, doctors and hospitals. How can we deliver quality medical care at a reasonable price to California's injured workers and still have money left over to adequately compensate injured workers who have had their earning capacity diminished?

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

A récent Los Angeles Times article on prescription drug abuse is worth noting.

The article, "Drug Deaths Now Outnumber Traffic Fatalities in the U.S.", by Lisa Giron, Scott Glover and Doug Smith, is likely to add further weight to concerns about the expanded use of opioids in the workers' comp system.

The authors charge that:
"Public health experts have used the comparison to draw attention to the nation's growing prescription drug problem, which they characterize as an epidemic. This is the first time that drugs have accounted for more fatalities than traffic accidents since the government started tracking drug-induced deaths in 1979."

"Fueling the surge in deaths are prescription pain and anxiety drugs that are potent, highly addictive and especially dangerous when combined with one another or with other drugs or alcohol. Among the most commonly abused are OxyContin, Vicodin, Xanax and Soma. One relative newcomer to the scene is Fentanyl, a painkiller that comes in the form of patches and lollipops and is 100 times more powerful than morphine."

"Such drugs now cause more deaths than heroin and cocaine combined."
A link to the full article is at the bottom of this post.

Expanded use of opioids followed a paradigm change in the way pain was treated. Within the past several decades more aggressive pain treatment protocols have become popular.

Some pain meds that are often used for end stage cancer are used in the workers' comp system for orthopedic injuries.

After writing a post about this some months ago I received a handful of e-mails from injured workers concerned that I was criticizing them and the treatment that they say works for them. In response, I noted that I was not implying that their pain was not real or that the meds weren't indicated for their particular situation. Nor was I implying that they were abusing.

On the other hand, I noted that in the past I had had clients who overdosed and a client who was found to have been diverting narcotics for sale. So on an anecdotal level, I had some familiarity with concerns being raised by other journalists and researchers.

These issues are not confined to California. Florida's workers' compensation system has developed a reputation as a "pill mill".

Have medical treatment guidelines and limits on physical therapy actually encouraged doctors to default to a pharmaceutical approach faster? Are pain management doctors being chosen as primary treaters earlier in the process before other approaches are sorted out? What role do MPNs or attempts to escape from MPNs (especially in the Southlland) play in this?

Should California adopt a new algorithm that must be followed where doctors want to start workers on opioids? Should other controls be put in place? Should we make the process easier for doctors to get authorization for a detox program? Does in-office dispensing by physicians have a role in all of this, and how to control the "bad actors" without penalizing careful prescribers?

It's a complicated problem and at the moment I see little consensus on practical solutions. Although there is already research data from CWCI and CHSWC analysis data on medical treatment, moving forward with new regs or bill language to make some changes will not be easy.

Here is the L.A. Times article:
http://www.latimes.com/news/local/la-me ... full.story

Stay tuned.

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

Here is a link to an ear

There's been growing concern in workers' comp about "co-morbidities".

Obesity, high blood pressure, diabetes and other underlying conditions can make it more difficult to treat injuries. There may be more complications after accidents and surgeries.

And prolonged inactivity after an injury may worsen some of these conditions. If you're recovering from surgery, having lots of "procedures", and on lots of meds, there's a good chance you may be feeling like being a couch potato and doing channel surfing.

California workers' comp sometimes covers weight loss programs where doctors can make a convincing case that it is medically necessary to control weight in order to treat the effects of the injury.

In my experience, there's a lot of cynicism about such programs. That may be because losing weight and keeping it off is hard. It's seen by many as an issue of personal responsibility rather than an industrial
responsibility.

And yet we all know that if the population is growing fatter and less fit, workers' comp medical treatment costs will inevitably rise.

Another angle on all this comes into focus with publication of a study yesterday in the journal Health Affairs. The study, by Pablo Monsivais, an assistant professor in the Department of Epidemiology and the School of Public Health at the University of Washington, focuses on the cost of a healthy diet.

It turns out that eating healthy can be expensive. Healthy eating tends to mean spending more at the grocery store:
http://www.sanluisobispo.com/2011/08/03 ... ilege.html

So with many injured workers' having budgets that are stretched very thin, expecting that they will "eat healthy" (even if they knew how to do so) is difficult.

How far does the liability of the comp carrier extend in obesity situations?

In a 2011 panel decision, Navarro vs. Williams Associates and SCIF, the injured worker, a pre-diabetic, weighed over 300 pounds and sought lap band surgery. The worker had sustained an injury to her spine and lower extremities.

The Agreed Medical Examiner recommended bariatric surgery though in deposition he noted that he had no special expertise in such surgery.

Utilization review denied the bariatric surgery, claiming that it was not supported by treatment guidelines. The workers' comp judge denied the surgery and applicant filed for reconsideration.

On reconsideration, the board upheld the denial of the surgery. The panel of Lowe, Caplane and Moresi noted that it is true that the Labor Code may require treatment of a nonindustrial condition when such treatment is necessary to cure or relieve the effects of an industrial injury, citing the 1968 Granado case.

But in Navarro the WCAB was not convinced that the AME had sufficiently connected the dots in his analysis to justify medical necessity. The panel said:

"The health benefits of achieving and maintaining a reasonable weight are not in dispute. However, that losing weight is beneficial is not equivalent to the medical necessity of Lap Band surgery. What Dr. Wertheimer failed to explain-and what is necessary to satisfy applicant's burden of proof-is how weight loss by Lap Band surgery is reasonably required to treat applicant's industrial injury".

Moreover, the WCAB panel noted that
"The AME's testimony nowhere states that weight loss, by any method, is medically necessary. At most, he says that applicant would feel better if she were lighter, that she would be more active, and that her symptoms of both industrial and non-industrial conditions would be lessened."

The moral of the story? Doctors who advocate for weight loss treatments need to put some energy into explaining the how and the why
they recommend such treatments as medically necessary.

Julius Young
www.workerscompzone
www.boxerlaw.com













Monsivais, the author of the study, is associated with the University of Washington Center for Public Health Nutrition:
http://depts.washington.edu/uwcphn/pubs ... vais.shtml

Would revamping California workers' comp physician fee schedules be playing with fire?

That's a question currently being debated in many circles.

Since 2001 the California Division of Workers' Compensation has been considering a change in physician reimbursement methodology. Studies have been performed under contract with the DWC.

In 2011, a bill was introduced to require California to move to another system, the RBVS. That bill, AB 923, carried by Kevin DeLeon of Los Angeles, has not moved from Committee since late June. But whether the bill stalls this year or not, the issue remains on the DWC's plate.

With a new DWC Administrative Director likely to be announced very soon, the issue of physician fee schedules remains in play.

Injured workers and applicant attorneys are very concerned about quality of care and access to care. Of particular concern is access to specialty care.

Would specialists, including surgeons and docs who do diagnostic tests, leave the California comp system in hopes of finding greener pastures if
adoption of RBVS means lower pay?

Generally, the RBVS method (also used by Medicare) would increase reimbursement rates to primary care physicians and shift pay away from specialists.

It's no secret in Sacramento that some of the occupational medical clinics
are fans of such a shift. Occ med chains would benefit from such a transition.

Would the shift lead to a doctor exodus?

That's a question that is being analyzed by one of my blogging compadres, David DePaolo. DePaolo is the publisher of Workcompcentral.com.

In his recent blog posts, has analyzed the issue. Here's a quote from a recent post, outlining his focus:
" If you will recall, I opined that the medical community had not proffered any valid research reflecting that a change in California to a RBRVS reimbursement schedule would create an access issue for injured workers."

DePaolo continues: "I was taken to task by Carl Brakensiek of the California Society of Industrial Medicine and Surgery (CSIMS), and Robert Weinmann (The Weinmann Report). Mr. Brakensiek offered to supply me with studies that, he said, "indicate there are substantial access problems in RBRVS states with low (below 125%) Medicare conversion factors." I promised to review each report and, if I'm wrong, admit so publicly here and write a letter to the legislature as to my findings; and if I'm right, I would still write to the legislature..."

So DePaolo notes that "I was supplied with several studies which I listed in my post of July 5. In my opinion, to make my promise complete, each of these reports deserves time alone, and comment alone - thus each report will be reviewed in separate blog postings"

Over the past week DePaolo has commented on specific studies that may be relevant to the issue of whether RBVS would cause problems with worker access to physicians.

I'm not ready to endorse all of DePaolo's conclusions, but his analytical effort serves as a good introduction to anyone trying to get up to speed on the issue. So here are links to his commentaries on specific posts:

"2007 Levin/Kent Report Raises Concerns, But Not Access Concerns"
http://daviddepaolo.blogspot.com/2011/0 ... cerns.html

" Levin/Kent 2008 Study Does Not Prove Access Issues"
http://daviddepaolo.blogspot.com/2011/0 ... prove.html

"Association of CA Neurologists 2005 Report - No Better"
http://daviddepaolo.blogspot.com/2011/0 ... -2005.html

"Dembe Report Indicates More Issues to Access than Fees"
http://daviddepaolo.blogspot.com/2011/0 ... es-to.html

"Hawaii Report on Fee Schedules = Best Evidence, Mixed Results"
http://daviddepaolo.blogspot.com/2011/0 ... s-125.html

"Johnson Study - Doctors Won't See Patients"
http://daviddepaolo.blogspot.com/2011/0 ... ients.html

After reviewing the studies, DePaolo remains skeptical that they demonstrate that adoption of RBVS and lower pay will hamper worker access to care.

But a big unknown is how the change would fit with other changes in the healthcare system which may be coming. As the population ages there are shortages of specialists in many places. For example, dermatologists and psychiatrists are in short supply in many places in the state. And if Obamacare survives political and legal challenges, will specialists be busier treating new populations that didn't have insurance?
That's the sort of variable that's not in the studies, but it needs to be considered in any switch to RBVS.

This is a hot-potato issue. I'll be commenting further soon.

And soon I'll be doing my piece on the Top Ten developments in California workers' comp during the first half of 2011.

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

In any large industry, there are temptations to cut corners.

Workers' comp is no exception. Among those who may be tempted are some medical providers.

Today a 181 page indictment was announced in Orange County. Prosecutors have charged Newport Beach radiologist Dr. Sim Carlisle Hoffman with alleged $17 million in workers' comp fraud.

Other alleged co-conspirators charged were a neurologist, Dr. Thomas Michael Heric, of Malibu, and clinic administrative employees Louis Umberto Santillan of Chino Hills and Beverly Jane Mitchell, of Westlake Village. Facilities alleged to be part of the scheme were in Buena Park: Advanced Professional Imaging, Advanced Management Services and Better Sleeping Medical Center.

Among other things, they are charged with billing for tests which were never performed.

According to research by Britney Barnes of the L.A. Times, " In 2001, the state's Medical Board disciplined Hoffman for excessive billing and putting a patient through unnecessary radiology treatments.
Heric was previously convicted of felony federal fraud in 2008 and had his medical license suspended for 60 days."

Concern over provider fraud has led some to suggest that sending injured workers an explanation of benefits paid might deter provider fraud. The concept is that workers might look at the form and spot billings for services that were not provided.

Those explanation of benefits forms have been used in Medicare and in some private health policies.

I'm starting to see such forms sent to my clients by Travelers Insurance.
What isn't clear is whether clients really look at these forms or simply throw them out.

Typically the forms explain what has been bill and what bills have been paid to providers for the worker's treatment.

Several years ago there were efforts by Disney and some other stakeholders, including the Employers Fraud Task Force, to design an explanation of benefits form that would be mandated by law. A bill proposed at the time to require such a form, SB 156, failed to advance.

Whether the explanation of benefits letters will generate some tips to catch provider fraud, or whether they simply generate more expense, isn't clear at this point.

Proponents have also argued that they give the employee some sense of what treatment is costing, injecting a dose of reality into a system where the relationship between costs and benefits often aren't even considered by the worker.

Stay tuned.

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