One study published in the Spine Journal says no.

In fact, the opposite may well be the case; compared to Washington State, workers’ comp back patients in California get way too much unnecessary surgery, leading to higher costs and worse outcomes – including more wound infections, life-threatening complications, and device complications.  

The study used a case-mix adjusted of patients undergoing an inpatient lumbar fusion for degenerative disease in 2008 – 09, and produced the following results:

• the rate of lumbar fusions in CA was 47% higher than in WA.
• the complexity of procedures was much higher in CA.
• CA costs were more than 20% higher in CA than WA.
• CA costs were influenced by the (since fixed) double payment for surgical devices and coverage for bone growth enhancers (which have decidedly mixed reviews)

So, we have too many and too complex procedures performed on too many patients at too high a cost, with worse outcomes.

Why?

Well, the limits on lumbar fusion in WA are pretty tight, for very good reason.  In contrast, CA only required a second opinion to approve the procedure.

The financial incentive inherent in CA’s high payments for the procedure may (!) have had something to do with it.

What does this mean for you?

More surgery is often not better care, and in many instances means worse care – and a pretty crappy life for the patient.

 

To date, 94 percent of medical treatment requests are approved after initial/internal UR and elevated physician-based UR.

At most, 4.7 percent of all medical treatment requests are denied.

At most.

Those are the headlines from CWCI’s just released analysis of all completed IMR decisions (see 1/8/14 report), an exhaustive and precise project that involved a manual review of each of those requests and resolution thereof.

CWCI’s summary indicates “IMR agrees with approximately 79 percent of the elevated physician-based UR decisions.”

What does this mean?

There are two main takeaways.  First, there’s no widespread denial of care to injured workers, far from it.  The research clearly demonstrates that while the vast majority of treatment requests are approved, the vast majority of the IMR decisions uphold the UR determination to deny or modify treatment. (Update)

Which leads to takeaway two.  Do not assume this means the IMR process – or UR itself is unnecessary or superfluous.  While a cursory review of the results would lead an uniformed reader to draw that conclusion, the report provides insight into the potential downside of ending UR.  The authors reviewed a study conducted by the Washington state work comp fund, known as L&I. Back in 2000, L&I stopped requiring UR for MRIs, as almost all were approved. A few years later, they looked at the volume of MRIs conducted had jumped dramatically.

Here’s what they concluded:

What does this mean for you?

We know now that the IMR process is not a “medical treatment denial scheme” perpetrated by carriers looking to deny care.

Far from it. 

Two articles in WorkCompCentral yesterday grabbed my attention.

One discussed an 8.7% rate increase recommended by California’s regulators (down from a 9.5% recommended by another group.  Part of the increase was attributable to “overall market deterioration, the causes of which are not clear.”  Greg Jones’ piece went on to paraphrase Dave Bellusci, EVP and Chief Actuary for California’s rating bureau, who reportedly said it was “too early to say what is driving the higher medical loss severity and growing claim frequency.”

Another piece cited the latest research by CWCI and Axiomedics’ Dr Laura Gardner. The lede of the story was this:

“Claims featuring multiple opioid prescriptions are linked to higher rates of indemnity claims, more expensive medical benefits payments, a greater probability of attorney involvement and lower claim closure rates.”

I don’t want to leap to conclusions here, as correlation does not equal causation, however the juxtaposition of the two stories was striking, especially when one recalls that the prevalence of opioids in workers comp has increased dramatically over the last decade.

What does this mean for you?

What is the impact of opioids on your medical and claims costs?

WCRI’s latest CompScope reports are out – there’s a megaton of info in the 16 state reports (I certainly have NOT read them all), but here’s what I’ve gleaned from an initial review of the reports on several large states.

Reforms often have unintended consequences – primarily increasing, rather than decreasing, medical costs.  Providers and their helpers find ways around the regs or actually use them to generate more profit, and there are a plethora of examples:

• CA physician dispensing of drugs not on Medi-Cal fee schedule – when the drug fee schedule change drastically reduced payments for drugs, the loophole the dispensing profiteers drove thru was this; if the drug was not listed by Medi-Cal, then it was paid under the old AWP-based fee schedule.  Voila, a huge opportunity for selling repackaged drugs thru dispensing docs;
• CA cost of compounded drugs went up after fee schedule was imposed, something predicted by several experts, yet ignored by the politicians searching for a quick and easy fix.  They got their quick and easy, but didn’t get a fix.
• FL outpatient facility costs went up after the change to fee schedule from 75% of billed charges to 60%.  Anyone could have predicted this; all hospitals have to do is increase their billed charges, which, shockingly, they did.

Reform changes that appear to have the most real impact on costs are typically adopting an RBRVS or MS-DRG based fee schedule and adopting binding UR and strong clinical guidelines.  Ideally, both. This addresses the price and utilization issues at the same time, making it harder (not impossible, but harder) for providers seeking to game the system to succeed.

What does this mean for you?

Good reform can be effective. Bad reform is often very counter-productive – and there’s a lot of bad reform.

Back surgery is far too common, far too risky, and far too costly – it’s also far from proven effective for most conditions.

That’s why Minnesota’s decision to educate workers’ comp claimants contemplating back surgery is a great example of legislators and regulators getting it right.  The legislature passed SB1234 which among other things called for a two-year pilot program:

“for employees with back injuries who are considering back fusion surgery. The purpose of the program is to ensure that injured workers understand their treatment options and receive treatment for their work injuries according to accepted medical standards. The services provided by the patient advocate shall be paid for from the special compensation fund.”

The program’s Patient Advocate helps claimants determine if lumbar fusion surgery is appropriate, educates them about the risks (only half get better after surgery, about a third have a “poor” result), complications, likelihood of repeat surgery (about 25% get another surgery), and poor outcomes (less than half return to work).

This makes so much sense on so many levels. The research indicates PT and anti-inflammatories deliver better outcomes than surgery for degenerative disk disease, probably the most common cause of low-back pain.  That’s not to say surgery isn’t the right treatment for some; a government research project indicates patients getting surgery for herniated disks have better outcomes in all categories except one – return to work.

Leaving aside that rather big caveat, this is exactly what the workers’ comp system needs – more science, better educated claimants, and a clear and understandable discussion of potential risks and benefits prior to aggressive treatment.

I’d be remiss if I didn’t note the State of Washington dealt with lumbar fusion some years ago, requiring conservative care before contemplating surgery and banning multiple level lumbar fusion for patients with no prior lumbar surgery.

Hat tip to WorkCompCentral for the head’s up.

What does this mean for you?

See, legislators and regulators can – and do – get it right.