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The IMR debate is focusing on the wrong metric

Now that California’s courts have ruled the IMR process is Constitutional, we can hope things will settle down, docs will start learning what is acceptable and what isn’t, and needless friction will decrease.

Unfortunately that isn’t likely.  If history is any indicator, a very few docs will continue to flood the system with thousands of requests for IMR, most of them for drugs and procedures that fall far outside the state’s evidence-based clinical guidelines.

Let’s acknowledge that the system – like any – isn’t perfect.  Let’s also acknowledge that all the data, research, and credible study to date indicates it works quite well.  What’s lost in the data-driven debate is the real problem – we aren’t looking at the right metric.

As CWCI has documented, well over 90% of all work comp medical procedures, tests, drugs, and treatment are approved.  And, when appeals do get to the last stage; the Independent Medical Review:

Data on the IMR outcomes show that 91 percent of all IMR decisions upheld or agreed with the physician-level utilization review opinion, while conversely, 9 percent of medical service requests submitted for IMR after being modified or denied by a UR physician were approved by the independent medical reviewer.

I’d suggest the CA UR and IMR process is approving TOO MUCH care.

Does anyone think that 94%+ of all medical procedures requested or delivered to California’s work comp patients are medically necessary, appropriate, and the best possible care?

Didn’t think so.

There’s no question too much care can be quite harmful.  The rampant overuse of opioids in workers’ comp is but one example of far too much care causing grievous harm.  Add in far too many spinal surgeries with lots of implants, and one can see that these “approved” services are far from optimal care.

What does this mean for you?

Why aren’t we focused on making the UR process tighter with more stringent controls and requirements before potentially dangerous and debilitating treatment is authorized?

2 thoughts on “The IMR debate is focusing on the wrong metric”

  1. I am always amused by the outrage from certain the medical community and plaintiff’s bar over treatment guidelines, UR, and other controls. They are appalled that anyone would question the recommendations of the treating physician.

    Except….the entire medical community has operated for years in a private health insurance marketplace that has treatment guidelines, utilization review, and physician scoring.

    MediCare also has treatment guidelines and controls.

    So please, save the outrage. Workers’ comp is just catching up to what everyone else has been doing for a very long time. Those who are the most outraged are probably those who are more focused on financial gain than following established treatment guidelines and delivering quality care to injured workers.

  2. The small handful of physicians who repeatedly recommend the same IMR dis-approved treatment aren’t learning how to deliver quality care for their patients. Perhaps it is time for the workers’ compensation system to audit those physicians, identify them publicly (like they do with audits of bad payers) and shift the IMR cost burden to the worst non-performing providers. We penalize “bad” payers based on statistical metrics. Why not penalize “bad” doctors based on IMR statistical metrics?

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Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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