The Freedom Nurse

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There are a lot of paths that people take before landing in workers’ compensation as a profession. Most paths are unexpected and mostly underwhelming. Not so for Cynthia Ortiz, Captain in the U.S. Army and Utilization Review Nurse for Risico Total Managed Care. Her journey to workers’ compensation has been nothing short of heroic and in the purest form of service via an accomplished military career in the U.S. Army Reserves.

Captain Cynthia Ortiz’s military service career began when she was seventeen years old, a junior in high school. Motivated by the love of her country and the military’s promise to support young recruits with higher education opportunities and funding, she made the courageous decision to enlist. Thirty years and five deployments later, she stands at the door of retirement of her military career gazing back on her years of service with immeasurable pride and gratitude.

Her ability to fulfill her commitment to the U.S. military, and thrive over the years has been made possible by the support of her biological family and her work family. Cynthia is married to her high school sweetheart of twenty-eight years and has a fifteen-year-old son, a twenty-five-year-old daughter, and a four-year-old granddaughter. She has been employed by Risico Total Managed Care for nearly twelve years and has been deployed twice during her tenure at the Utilization Review Organization (URO) – once for nine months to Central America and once for three years domestically as part of Homeland Security.

“The support of my family at home, and my family at work, has been greatly influential in my ability to give my very best to the country I love and the individual soldiers that I’ve served over the years. The value they’ve placed on what I do has allowed me to realize one of the most fulfilling experiences of my life in service to the troops,” says Cynthia.

Cynthia wears many hats in the Army Reserves. Her career started as a paramedic, a Staff Sargent for twenty years, and currently serves as a surgical nurse, an Officer of the U.S. Army (Captain) for the past ten years. Cynthia has held leadership positions ranging from Commander, providing medical readiness training, establishing and setting up field hospitals, as well as offering counseling to the troops.

Cynthia recalls, “As a child, I always felt a strong sense of fulfillment when nursing and caring for people, as well as animals.”

Her innate love of animals initially drew her to consider becoming a veterinarian. However, the educational path to obtain a four-year Doctor of Veterinary Medicine (DVM) was longer than what Cynthia was comfortable with.

Having grown up in a family surrounded by professionals in the medical and nursing fields, she witnessed first-hand the level of fulfillment that can come from nursing ill, or injured individuals, back to health. It was this first-hand exposure that inspired Cynthia to pursue a profession in nursing.

Her introduction to workers’ compensation and utilization review came by way of her husband, who works in the physical therapy field. She knew quickly that workers’ compensation would provide opportunities for her to do what she’s passionate about by helping make the journey to recovery smoother and easier for injured workers.

Kind, caring, benevolent, compassionate. These are just a few words that are used to describe Captain Cynthia Ortiz by individuals who know her best. With these personality traits, it should surprise no one that she not only enjoys serving her country, but is passionate about the humanitarian efforts that the Army coordinates and deploys abroad.

Cynthia’s most recent deployment placed her in the heart of Central America. Her group was tasked with providing medical care and screenings to remotely located communities, throughout Honduras, Guatemala, Columbia, El Salvador, Panama, and Costa Rica, where routine care was not readily available. They administered care for minor medical procedures and provided important medications to local nationals, civilians, and local military personnel assigned to support Cynthia’s group.

“The humanitarian services that the U.S. Army Reserves provides beyond our borders is my favorite aspect of serving this great country. Most times, the troops providing the service to the locals get as much, if not more, out of the experience. There are moments that I will fondly remember for the rest of my life.” states Cynthia.

One such moment that Cynthia shared was during her time in Central America. Her group was assigned to visit and deliver medical care and supplies to a community so remotely located making ground transportation impossible. Army choppers were used to transport Army personnel and the supplies needed to deliver the aide.

Upon wrapping up and preparing to depart for the evening, Cynthia and her colleagues learned that choppers were being held back due to the extreme rainy weather. The troops were forced to scramble and were able to set up for the night in a local clinic.

“Within ten to fifteen minutes of learning that we were stranded, local families began to bring us blankets, mattresses, and other items to make our stay comfortable. They didn’t have much, but each family joyfully gave of the little they had to feed us – 1 egg, a little bit of sausage,” recalled Cynthia. With tears swelling up in her eyes she continued, “They did not hesitate to share of little they had. And, they did it willingly and happily. I will never forget that experience.”

Cynthia confesses that retiring from a military career that spans three decades is going to be challenging. She will miss the troops, the service, and the sense of fulfillment that it brought. Her family, on the other hand, will be glad to know that she will no longer be called away for extended periods of time for potentially dangerous assignments.

Amy Skinner, Director of Nursing for Risico Total Managed Care, states, “Our whole team is so very proud of Cynthia. She is as dedicated to her job in utilization review as she is with her role in the Army. I’m very humbled by the sacrifices she has made for our country, especially in the time of the pandemic. Thank you, Cynthia!”

It would not be an overstatement to say that Cynthia is a real-life hero – a freedom nurse.

As an organization, we are immensely proud of her accomplishments. We are humbled and honored that an individual with her character, compassion, and commitment to service tirelessly advocates for injured workers on the front lines of workers’ compensation.

This Fourth of July, Risico celebrates Captain Cynthia Ortiz and every other workers’ compensation professional who serves, or has served, in the U.S. Armed Forces. Thank you for your service and thank you for inspiring us all.

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ACOEM Publishes COVID-19 EBM Practice Guideline

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Academics have been fervently working to uncover trustworthy scientific evidence on which to base COVID-19 treatment protocols and business response recommendations. ReedGroup’s MDGuidelines, publishers of the evidence-based occupational medicine practice guidelines independently researched and developed by the American College of Occupational and Environmental Medicine (ACOEM), announced this week its publication of the very first evidence-based medicine (EBM) practice guidelines for Coronavirus (COVID-19) for occupational health. MDGuidelines has made the guideline available free of charge.

The announcement comes at a critical time as state jurisdictions fight to mitigate the pandemic’s effects on their respective economies and workforces. The ACOEM guidelines are adopted, in whole or in part, as the presumptively correct standards for treating occupational-related injuries and illnesses in two of the nation’s hardest-hit markets, California and New York.

Dr. Avrom Gart, Risico Total Managed Care’s Medical Director states, “The new ACOEM guideline on Coronavirus (COVID-19) is important to Occupational Medicine because it establishes a starting point in writing for medical providers to consider. There is too much opinion in the public domain about what could work, or should work, but nothing that provides a transparent base of evidence. At the end of the day, individuals diagnosed with COVID-19 will have to consult and listen to their doctor for the best course of care.”

A Guideline for All Stakeholders

The guideline’s intended audience includes, occupational and other physicians, health care professionals, insurers, employers, attorneys, non-occupational specialists, and all other stakeholders in worker health and workers’ compensation systems. Guidance provided in the guideline for these groups includes information pertinent to contagiousness, incubation, clinical presentation, mortality rates and more.

Employers throughout the country may be particularly interested in the employer considerations section of the guideline. The guidance provided here includes recommendations related to employee contact, general principles and recommended planning for businesses.

ACOEM’s guideline also dives into disability considerations qualifying its findings by stating that while disability will be better defined with studies to come over time, there are major concerns based on preliminary data and information from analogous diseases. In other words, we are still learning about COVID-19’s disability and recovery expectations which will need much attention.

The guideline points out that there are no quality data on disability for patients without hospitalization and estimates recovery from post-infection fatigue to take about two to three weeks for mild cases. For patients with mild to moderate pneumonia treated with oxygen supplementation, recovery is estimated to take four to eight weeks after hospitalization or clinical recovery.

The prognoses for severe pneumonia and acute respiratory distress syndrome (ARDS) are much worse. Approximately 50% of survivors may be projected to not return to work within a year of survival of the acute infection, based on prior experience from diseases that have similar symptoms as ARDS.

Hydroxychloroquine for Treatment of COVID-19

A debate around the use of hydroxychloroquine for the treatment of COVID-19 has developed in the media. Outlets have published concerns about the drug’s potentially dangerous side effects, including sudden death. The drug’s prominence in the public domain came after President Trump expressed confidence in the drug as a promising treatment option for COVID-19.

ACOEM’s new COVID-19 guidelines lists hydroxychloroquine as a “Recommended” treatment of COVID-19 for “select patients”. The recommendation’s Strength of Evidence is listed as Level C, describing the limited evidence-base with at least one randomized study of moderate quality.

The rationale for ACOEM’s recommendation of the drug for select patients is due to the quality evidence available for the efficacy of chloroquines (especially hydroxychloroquine) for the treatment of COVID-19. ACOEM qualifies that the medications are low cost, and adverse effects are minor for short courses of treatment at commonly used doses. Based on the available limited evidence, earlier treatment appears to be important for efficacy versus administering with treatment in an ICU after viral replication has ceased, according to the guideline.

Patients who may be good candidates include those who are moderately to severely affected with COVID-19. However, ACOEM found that there is no quality evidence supporting the drug’s efficacy when used after ARDS is established.

Patients with multiple comorbidities, such as diabetes, cardiovascular disease, COPD may also benefit from the use of hydroxychloroquine when administered early and the effects of COVID-19 are milder but worsening.

This along with other treatment considerations are included in the guideline. ACOEM’s recommendations, or non-recommendation, of specific treatment protocols are substantiated by the studies considered and the scoring of those studies. These elements provide the transparency required by a trustworthy EBM development process.

The Development of the COVID-19 Guideline

ACOEM’s EBM Practice Guidelines are developed in compliance with the Institute of Medicine’s (IOM) Standards for Developing Trustworthy Clinical Practice Guidelines and Appraisal of Guidelines for Research and Evaluation (AGREE). Pursuant to these standards, the development of the guidelines includes the use of various teams and panels throughout the process.

A critical part of each guidelines’ development process is the designation of the Evidence-based Practice Panel. Pertinent to COVID-19, the panel members represent expertise in occupational medicine, internal medicine, pulmonary medicine, and infectious disease. ACOEM’s complete development methodology is available on its website.

MDGuidelines’ ability to produce high-quality EBM guidelines so quickly is a monumental undertaking. Generally speaking, a trustworthy, high-quality EBM guideline can take up to two years to develop and to publish comprehensive content updates according to emerging research.

Provided that MDGuidelines and ACOEM can remain agile with updates to this guideline, this trustworthy EBM Coronavirus (COVID-19) guideline, and its subsequent updated versions, will be an immensely useful tool for users around the globe involved in health and business recovery efforts.

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The Modernization of Agriculture’s Guest Worker Program

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During their 40th Annual Forum in Monterey, California, the Agricultural Personnel Management Association (APMA) took a deep dive into the Farm Workforce Modernization Act of 2019 (H.R. 5038). The bill is aimed at modernizing the H-2A temporary agricultural employment of foreign workers, or guest worker program. The conversation on 5038 is meaningful as thirty-three (33) years have passed since the House of Representatives passed a bill that aims to resolve agriculture’s unique labor challenges (Regelbrugge, C. (APMA 2020). All About the Workforce.).

H-2A is designed to allow U.S. employers, who meet specific regulatory requirements, to bring foreign nationals to the United States to supplement their workforce and fill temporary agricultural jobs. During a 3-hour panel discussion, San Diego-based grower West Coast Tomatoes and Nipomo-based Castañeda & Sons, Inc. Farm Labor Contractor (FLC) shared best practices necessary to stay compliant with H-2A requirements (i.e., provisioning housing, food, and transportation for guest workers) and optimizing recruitment efforts for high-quality, experienced temporary workers from Mexico. Their comments made it clear that without access to temporary labor via the H-2A program, it would be nearly impossible for their operations to exist.

Agriculture’s Contribution to California’s State Economy

California produces nearly half of the nation’s fresh fruits and vegetables. The State’s near $50 billion industry (2018), easily assigns California as the country’s top agriculture producer and exporter, with almost double the cash receipts for all commodities compared to the second largest agriculture state – Iowa (USDA ERS, Feb. 2020). Notably, California’s agricultural exports reached nearly $21 billion in 2017 (CDFA Agricultural Statistics Review 2017-2018).

The cash receipts quantified by USDA ERS do not include the impact agriculture has on other business verticals such as shipping and warehousing, that are larger parts of the State’s economy. In all, agriculture’s contribution to California’s state economy is material with roughly 77,100 farms and ranches located throughout the Golden State.

California’s ongoing labor shortage, however, presents a formidable challenge for growers within the State, and around the country, to meet the demands of produce retailers. Experts consider the program designed to help agriculture employers supplement their workforces with temporary labor to be materially antiquated and in need of modernization.

Surveying California Farmers

A survey of 1,071 farmers and ranchers, conducted by the California Farm Bureau Federation (CFBF) in conjunction with the University of California-Davis in 2019, found that 56% of the survey’s respondents reported being unable to employ an adequate number of workers at some point during the previous five years. Of the farmers reporting the labor shortages, at least 70% stated the issue was more pronounced during the two (2) years preceding the survey, 2017 and 2018 (CFBF, Apr. 2019).

CFBF’s survey also discovered that in spite of increased wages (86% of respondents reporting raising wages) and the use of labor-saving technology and mechanization (56% reported their use), the labor shortage and issues with decreased production persist.

Data Source: https://www.cfbf.com/wp-content/uploads/2019/06/LaborScarcity.pdf released April 30, 2019

One of the survey’s respondents stated, “We have had to decrease our strawberry and pole tomato plantings because of lack of labor. We have reduced strawberries from 80 to 17 in 2018; we had to walk away from half the field because we did not have enough employees to harvest the whole field. This year we only planted 9 acres of strawberries. Tomatoes have been reduced from 80-100 acres to 25 acres. We have had to increase our winter squash planting to 90 acres in 2018 because this crop does not require much labor to grow or harvest compared to strawberries and tomatoes. We need 125 people but have only been able to retain 40-45 employees.”

When survey respondents were asked if they had enrolled in the H-2A visa program to help supplement their workforce during the past five (5) years and bring in guest workers, the vast majority said NO with only 6% stating YES.

One farmer stated, “H-2A visas aren’t practical for small growers in our area. We really need immigration reform that is practical for all growers, including portability options.”

The complexity and scope of H-2A can be daunting for many growers, particularly smaller operations. During the APMA’s H-2A panel discussion, Ruben Lugo, US DOL Wage and Hour Division-Western Region, Ag Enforcement Coordinator, suggested that growers consider assigning a dedicated person to administer their H-2A program in order to maximize adherence to the programs requirements and take full advantage of the program’s benefits. Human capital is often stretched thin within smaller farming operations making it impractical as the CFBF study reflects.

If H-2A is to become a viable option for all growers, small and large, the program’s modernization and simplification will be increasingly important.

The Farm Workforce Modernization Act

Congressman Jimmy Panetta (California’s District 20), a member of the House Agriculture Committee, delivered an energetic overview of H.R. 5038 and update of ongoing bipartisan discussions at APMA. The bill is a bipartisan effort spearheaded by U.S. Representatives Jimmy Panetta (D-CA-20), Zoe Lofgren (D-CA-19), Dan Newhouse (R-WA-04), Mike Simpson (R-ID-02), Doug LaMalfa (R-CA-01), and Mario Diaz-Balart (R-FL-25). H.R. 5038 passed the U.S. House of Representatives with a 260-165 votes on December 11, 2019.

Contained in a bill summary published by the House of Representatives are three (3) main elements to the Farm Workforce Modernization Act: (Title I) Earned Status for Certified Agricultural Workers (CAW), (Title II) Improving the H-2A Program, and (Title III) Mandatory E-Verify for the Agricultural Sector.

According the House’s summary, the bill is a response to President Trump’s call for merit-based immigration reform and meets the “desperate need” of America’s farmers and ranchers for a legal, reliable workforce. H.R. 5038 does this by requiring a significant commitment for past and future work from current agricultural workers as part of a stringent employment-based program. Provided specific criteria are met, workers may be eligible to receive a renewable five (5) year visa and potentially Lawful Permanent Resident (LPR) status.

An element of significant importance to smaller farming operations is Title II, proposed improvements to the H-2A program. Under H.R. 5038, the amount of time and cost spent on the program by growers would decrease, making a temporary legal workforce more accessible. The bill also modernizes and applies caps to “out-of-control wage growth” in the Adverse Effect Wage Rate (AEWR).

In addition to decreased time and cost, the bill promises to streamline the processing of H-2A applications and pilot a portable H-2A visa program to allow employers and farmworkers to respond more dynamically to labor needs. This element of the bill focuses on making the H-2A program more responsive and user-friendly for employers.

The third element of the bill is widely considered the compromise by employers. It establishes a mandatory, nationwide E-Verify system for all agricultural employment deployed using a structured phase-in and guaranteed due process for authorized workers who are incorrectly rejected by the system.

According the Congressman Panetta, the legislation was put together over a period of nine (9) months with input from agricultural stakeholders and labor organizations and was introduced with the support of 26 Democrats and 23 Republicans.

Congressman Panetta also explained to an audience of growers, FLCs, and other agriculture stakeholders in Monterey, CA during the APMA conference that the push for mechanization and immigration reform will ease the pressure being experienced by farmers due to the labor shortage in agriculture.

In a press release published on Congressman Panetta’s website, Congressman Mike Simpson stated, “I am thrilled to see the Farm Workforce Modernization Act pass the House with a strong bipartisan vote. Idaho farmers and ranchers have been asking me for years to address their labor needs and this bill takes an important step towards solving this issue…It isn’t a perfect solution but compromise rarely is. The bill balances strong immigration enforcement with common sense reforms that allow our farmers to access a legal workforce without granting any special pathways. I hope the Senate can move similar legislation so we can sign a solution into law.”

Agriculture’s Labor Shortage Effect on Workers’ Compensation

Similar to the Grand Bargain of workers’ compensation, the H-2A program is designed to provide reciprocal benefits for employers and employees. To the employer, H-2A offers a path to access supplemental legal temporary workers. To the employee, H-2A ensures material protections such as fair pay, housing, meals, and insurance coverage such as workers’ compensation.

With this in mind, the ongoing labor shortage in agriculture has prompted some employers to hire workers who are less qualified, inexperienced, untrained and unfamiliar with the rigors of the agriculture work environment, in an effort to fill the available positions as they scramble to meet production demands.

The byproduct of hiring less experienced and less qualified employees is the prospect of added risk to the grower and their workers’ compensation insurers. These employees can be more prone to work-related injuries, which may fuel workers compensation incident frequency and overall loss activity.

Exacerbating the issue, the average age for workers in agriculture, like in many of other industries, is getting older. In 2006, the average age of farm workers was 36 years old. In 2017, the average age for farm workers was 42 years old. By 2020, a quarter (25%) of the workforce in the U.S. will be 55 years or older (Siegel, J. (APMA 2020). The Aging Workforce: The Fastest Growing Employee Population.).

With agriculture, food, and related industries contributing $1.053 trillion to U.S. gross domestic product (GDP) (USDA ERS 2017), the stakes are very high to come up with a viable solution to address the industry’s seemingly perennial labor shortage.

“When it comes to Agriculture, things get done. They get done in a bipartisan way,” proclaimed Congressman Panetta during his speech at APMA. “Bipartisanship is still alive in agriculture,” he continued as he expressed a sense of optimism when asked if he felt whether Republicans in the Senate would pass the bill.

Time will tell if the U.S. Senate will prioritize production over politics as they prepare to deliberate to pass the Farm Workforce Modernization Act, or choose to develop similar legislation. Stay tuned.

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Let the People Choose

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I’m continuously inspired by the journeys that leaders in workers’ compensation take on their path to the industry. Such rich, diverse, and in some cases heartbreaking backgrounds serve as the ideal bedrock for a system that serves people who have been injured on the job left feeling vulnerable, mourning, and in dire need of empathy.

On September 24, the Comp Laude® Awards and Gala featured eight industry leaders as part of the People’s Choice Awards, which is quickly becoming the signature event of the conference. This group of individuals represented the legal, medical management, client services, and marketing business verticals in workers’ comp. One presenter, a past injured worker himself.

All excellent orators. All inspiringly passionate. All perfectly human.   

Knitted Together in Purpose 

The idea of eight various stories delivered by eight various individuals at eight various tempos and styles is enough to make the most patient listener uneasy. This is, in my opinion, where the People’s Choice Awards has staked its claim as Comp Laude’s premier event.

People’s Choice Awards emcee, Greg McKenna is irreplaceable; he is highly skilled at taking each individual presentation, a colorful segment in and of itself, and masterfully knits it together with the others to form a collective body of work – nothing short of a piece of art.   

Each year brings with it a unique collective theme. This year, the stories were arranged in order to mirror the rise and fall of energy – the propellant of change. The theme of “change” is apropos on so many levels within the context of workers’ compensation.

The Psychology of Change 

The various stories merged together through what mental health professionals call the “Change Curve.” The term describes the pattern of energy that routinely commences after a change agent, or incident, is introduced into and disrupts one’s environment (physiological and/or psychological).

The Change Curve is frequently used in the context of mourning segmented by three major phases:  Endings (Stage 1), Transitions (Stage 2), and New Beginnings (Stage 3). In this context, the end is actually the beginning. The journey in moving past, or moving forward, ends once a new beginning comes to fruition. Experts have validated that major life events can trigger a mourning-like process in an individual:  Loss of job, physical injury, divorce, etc. Enter workers’ compensation.

Dr. Geralyn Datz, Mississippi-based Licensed Clinical Health Psychologist, offered the following insight respective to grief within the context of workers’ compensation, “When a worker is injured there is an absolute grieving process, over the injury itself initially, because no one wants to be hurt. Many times, this resolves.

For those who progress to chronic injury or illness, there is another grieving process that has to do with the loss of identity that can occur in work injury. To go from working to not, able versus not, and have shifts in roles at home and with friends, is a major challenge for most people. This is a real process that deserves understanding and time.

To the extent that we can support the injured worker and help them get the rehabilitation and other supports needed to transform the injury from a loss to an opportunity – an opportunity to overcome a life challenge, to develop new skills, and adapt to a new normal – is the way that we will help them treat their injury as a new beginning instead of an end.”

The Presenters

Together with the horizontal axis, labeled Time, and the vertical axis, labeled Emotional State/Action (a.k.a., Energy) in the diagram below, the People’s Choice Awards presentations were strategically positioned to personify each milestone that comprises the Change Curve:

  • H. George Kagan, The Admiral and I – Time
  • Nina Boski, Clear and Connected – Energy
  • Laura Thomas, Three C’s of Workers’ Comp – Shock/Denial
  • Diann Cohen, Obstacles vs. Accomplishments – Acceptance
  • Amy Holcomb, Opioids: The Cascading Effect on My Family – Low Mood/Depression
  • Paul Gold, Adversity & Inspiration – Experimental
  • Yvonne Guibert, A Ft. Lauderdale Summer – Decision
  • Doug Clark, There is Good in Everyone – Engagement

This variation of the Kubler-Ross Change Curve charts the phases of emotional state and action against time, in three stages. Source: https://newsfeed.mosswarner.com/change-management-communications/

Each presenter was polished, knowledgeable, and made it tough for the voting audience to select the 2019 People’s Choice Awards’ recipient. I’m not able to recap every presentation for practical reasons. Instead, I will share the moments that stood out to me as a member of the voting audience:

The Admiral and I

H. George Kagan is a Defense Attorney in the state of Florida. He is soft-spoken, humble, and speaks with profound wisdom. He is a very likeable fellow that can carry a conversation with just about anyone about nearly anything in life.

Mr. Kagan took the audience through an engaging sequence of events that included his involvement in a workers’ compensation claim that ultimately ended with the injured worker succumbing to his injuries and passing away. Years later, the injured worker’s father, a Navy Admiral, invited Mr. Kagan to visit with him and his wife on the West Coast.

What started as a chance meeting, initiated by the Admiral, between parties on seemingly opposite sides of the workers’ compensation process (Mr. Kagan a Defense Lawyer and the Admiral being the parent of the injured worker) has evolved into a friendship, founded on mutual respect and appreciation for doing what is right, between two very accomplished individuals.

H. George Kagan, P.A.
Photo Courtesy of William M. Zachry (Used by Permission)

Opioids: The Cascading Effect on My Family

Amy Holcomb oversees utilization review for a prominent workers’ compensation company. She has a delicate presence about her that instinctively draws the audience in for a closer listen.

“This is the first time that I have ever shared this story,” started Ms. Holcomb. “115177 is my son’s name in the Federal prison system,” she continues.

Immediately, the room was still and silent, and seemingly without oxygen as gasps from the audience became audible. I recall my heart rate elevating at the thought of what she would say next. Ms. Holcomb invited the audience, as one would a close trusted advisor, in to a difficult and intimate experience involving her son’s struggle with opioid addiction and the collateral damage sustained by her family unit.

Her son’s experience was not uncommon – diagnosed with a soft tissue sprain/strain and was given a polypharmacy prescription for hydrocodone and soma. Her family immediately spiraled down the slippery slope that most workers’ compensation professionals only read about. Yet, here she was. One of our own sharing her personal heartbreaking story of how prescription narcotics punished her family with an impact that may be felt for generations to come.

After time, homeless and desperate for a fix, Ms. Holcomb’s son turned on his own family. Becoming verbally and physically abusive, he burglarized the very place he once called home while victimizing the people who advocated most for his recovery, his family.

Ms. Holcomb’s courageous recount of the events was difficult to listen to without becoming personally vested. After all, prescription opioid/addiction-speak has become so commonplace in our line of work that at times the real-world implications are taken for granted.

Ms. Holcomb’s final declarations to the audience were delivered with gut-punch power, “You have the power to help stop this. You have the power to save a family.”    

Amy L. Holcomb
Photo Courtesy of William M. Zachry (Used by Permission)

A Ft. Lauderdale Summer

Yvonne Guibert is a marketing consultant that has worked with numerous national workers’ compensation brands. She has consistently supported WorkCompCentral and has been a very visible supporter of the Comp Laude® Awards. A seasoned public speaker, Ms. Guibert’s presentation delivery was eloquent and powerful.  

She placed the audience in a time capsule and ushered them through an exciting childhood experience with her father. It was a time of innocence and adventure with the rock in her life, a real-life super hero.

Ms. Guibert’s childhood was made memorable by water skiing outings as a toddler in her father’s arms to zip-lining on a back-yard course made just for her. The stories were enough to make every thrill-seeking adventurer in the room jealous and every hardened heart melt at the picture of a tough, outdoorsman loving on his adorable baby girl.

Much like the plot of a best-selling novel, her stories of warm family outings were contrast by a dark and hurtful backdrop. Ms. Guibert’s time on the water and in the loving arms of her father was only half of the story. She was a victim of verbal and physical abuse at the hands of a step-parent. The depths of the pain and struggle that she had to endure were as impacting as the highs of the joy she felt when visiting her father’s Ft. Lauderdale home in summer time.

Admittedly, Ms. Guibert’s story broke my heart. My emotions betrayed me as tears streamed down my face in rebellion. I wasn’t alone. The room filled with sniffles as young and old, men and women, people from all walks of life felt the pain that young Yvonne felt.

A seasoned story teller, Ms. Guibert did not end her story on a low note. She proudly declared that better times have come upon her. She is no longer a victim of the her past, rather a victor basking in her future. She has continued on her own adventure. Her goal now is “to find herself as she once was at 10 years old. She was a total bad a**.”

Yvonne Guibert
Photo Courtesy of William M. Zachry (Used by Permission)

Without a doubt, we live in era where trust is not easily given. Love and compassion seemingly elude society on large scale. The People’s Choice Awards, and Comp Laude in general, is a much-needed reminder that the workers’ compensation system is filled with extraordinary people who have, in their own right, endured unfathomable storms in life.

Broken, robbed, and victimized at times, our people continue to rise to the challenge of caring for those who may in fact find themselves broken, feeling robbed and possibly victimized – injured workers.

If the People’s Choice Awards Class of 2019 presenters are any indication of the workers’ compensation community at large, I can’t help but feel that our injured workers are in good hands. The future is indeed bright.

Thank you to everyone involved in organizing the Comp Laude® Awards and Gala, and more specifically the People’s Choice Awards. Thank you to the courageous individuals that are willing to be vulnerable by sharing their intimate stories.

I am equal parts inspired and challenged to do more, to be better. I hope you feel the same.

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California Employers & Work Comp Stakeholders Sound Off

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The nation’s largest workers’ compensation community came together recently in Dana Point, California to attend one of the country’s more prominent trade conferences. To kick off the event, a panel of work comp subject matter experts, representing system stakeholders and employers, was assembled to address issues ranging from California’s chief public official’s appetite to tamper with seemingly sound system reforms to automation and technology’s role in workers’ compensation. The panel was moderated by Kurt Leisure, The Cheesecake Factory Vice President of Risk Services and included:
  • Bruce Wick, California Professional Association of Specialty Contractor Director of Risk Management;
  • Karen Townsend, Sodexo Senior Manager, Health, Safety & Environment;
  • Jeffrey R. Einhorn, Non-Profits’ United Chief Executive Officer; and
  • Karen Fry, Commerce Casino.
The following is a synopsis of the panel’s reaction to key issues raised during the conference’s opening session.

The Governor’s Agenda for Workers’ Compensation

Question:  The California workers’ compensation system has been through multiple reforms over the last decade, do you feel that our new Governor’s administration will “turn back the clock” and undue some of the progress that has been made?

The inauguration of Governor Gavin Newsom brought with it important questions about the future of workers’ compensation reforms enacted under Governor Jerry Brown’s administration. The general consensus from the expert panel reflected mostly uncertainty with a modest level of confidence that California’s new Governor will not address any major work comp issues during this session. Panelists explained that for the time being labor advocates are not “clambering” for change; labor representatives perceive California’s system stability as a good thing for injured workers. Notwithstanding, it is expected that applicant attorneys will continue to make their argument opposing certain workers’ compensation statutes fueled by the perception that work comp does not take care of California’s injured workers. Due to an abundance of issues that rank higher on Governor Newsom’s priority list, no major changes are expected in workers’ compensation this session according to the expert panel.

Seeking Areas of Improvement in California’s Work Comp System

Question:  Where do you believe that more work needs to be done and do you think that the California WC system has an influence on whether employers stay, move out, or expand/contract in this State?

With the exception of the loss adjustment expense “mess” in California, the panel mostly focused on the rampant issues in Cumulative Trauma (CT) claims as an area overdue for improvement. The severity of the issue varies by region:  Northern California, the Central Valley, Southern California – and more specifically Los Angeles area. Karen Fry of Commerce Casino provided an impassioned description of their experience with CT. “We’re on fire,” she explained. Commerce Casino is located in Commerce, California just 8 miles southeast of Los Angeles. The casino employs approximately 2,400 individuals in occupations that include table game dealers, housekeeping, food-service, maintenance, and office administration. It is estimated that 78% the casino’s claims are for CT. “It’s a money problem. Attorneys seemingly throw random things against a wall and wait to see what sticks. With Judges ruling in favor of the claims, it is becoming more difficult to determine what is real and what is not,” Fry explained. Commerce Casino has implemented various programs and tools aimed at preventing inappropriate CT claims and to help employees feel valued. Programs include access to onsite clinical services, onsite chiropractic services, an open-door policy, and more. According to The Cheesecake Factory’s Kurt Leisure, a primary challenge with CT claims is determining what is a legitimate claim and what is not. The panel concurred adding that with the cost to settle these claims ranging from $25,000 to $100,000, a sit-down is desperately needed to explore a more “equitable” approach to CT issues. The panel agreed unanimously that California’s severe CT issues warrant immediate reform by the state’s legislature; no other state in the U.S. faces issues of this magnitude pertinent to CT claims. The panel further suggested that in order for a legislative effort to be successful, large prominent employers in Los Angeles will need to raise the issue by clearly communicating how CT impacts their business. Even with all of its issues, the panel of experts agreed that California’s workers’ compensation system is making strides in the right direction. When asked if the complexities in the state’s work comp system has an influence on employers coming or leaving the Golden State, the expert panel mostly agreed. The majority of industries are not adversely influenced by California’s workers’ compensation landscape. The ability to do business and tap into the world’s 5th largest economy (surpassing the United Kingdom) outweighs the challenges in the state’s work comp system. (LA Times 2018) Some restaurant chains, however, have expressed concerns and are “cautious” about doing business in California.

Automation in Workers’ Compensation

Question:  We hear a lot about automation coming into the workers’ compensation system from streamlining billing, telemedicine, wearables, predictive modeling, etc.  In your opinion, where does technology fit in best with respect to the administration of our workers’ compensation benefit delivery system and where do we need to make sure that it does not go too far?

The value of automation and technology, as expressed by the expert panel, is multidimensional. There are gaps in communication where technology fits in very naturally. Technology can be immensely valuable in helping to communicate effectively with injured workers who do not speak the English language. Technology, such as Telemedicine, is making great strides in solving access to medical care issues created by California vast geographic footprint. While some technology has produced undeniable benefits in some areas, there are notable limitations. The panel identified a growing challenge with automation technology developed for the purpose of engaging the injured worker – it is being ignored by workers and therefore rendered ineffective. Consensus among the experts concluded that the successful administration of workers’ compensation benefits to injured workers heavily relies on human intervention. “Injured workers are people,” explained Jeffrey Einhorn of Non-Profits’ United. “They must be reached and have work comp explained to them on a human to human basis. If workers are not the most valued asset, we have a problem,” Einhorn continued. With the erosion of the human element comes a greater risk of the injured worker feeling alienated and lost in the process. The likelihood of litigation increases as the level of support for the injured worker decreases. The business of workers’ compensation at the core is built around people. Automation and technology can simplify certain tasks, create efficiencies and bridge important gaps, but it must never replace human intervention.

Well Done!

The stakeholder and employer panel provided one of the more insightful presentations of the conference. All presenters were engaging, charismatic, and well-informed. Numerous other questions were addressed that are not covered here, but will be included in future blog posts. Organizers of the event, and of this particular panel, should be commended for pulling together a great group of subject matter experts who clearly care about the ongoing improvement of California’s workers’ compensation system. Thank you for a job well-done.
  • Employer & Stakeholder Panel: State of California’s Workers’ Compensation System 
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Turning the Clock Back on California’s Workers’ Compensation System

The California Applicants’ Attorney Association (CAAA) is promoting AB 1107 to California Legislators in hopes of materially modifying utilization review exemptions for medical treatment. CAAA has gone on the record stating that they are “dealing with a system that is broken and has failed to deliver the necessary medical care to workers who suffer job-related injuries, whether by lack of accountability or blatant discrimination”.

Is AB 1107 a step in the right direction in promoting prompt, adequate medical treatment for injured workers in the State of California?

In concept, AB 1107 seems like a reasonable idea:  Remove layers of potentially unnecessary validation for the medical necessity of medical treatment and expedite the delivery of said treatment to the injured worker. The bill’s overly simplistic approach, however, sets the California workers’ compensation industry up for trip to the past – more than a decade in the past.

Removing Utilization Review

According to California’s Division of Workers’ Compensation (DWC), Utilization Review (UR) is the process used by employers or claims administrators to review treatment to determine if it is medically necessary. UR is used to decide whether or not to approve medical treatment recommended by a physician which must be based on the medical treatment guidelines.

UR has been under the microscope in California for a number of years. UR over-use is frequently debated on the California workers’ compensation education conference circuit and is often credited to be a material driver of spending waste in the state. However, it is important to realize that inappropriate medical treatment administered by a physician (within an MPN, or otherwise) such as a spinal fusion, would be costlier and may cause more harm to the injured worker than good.

The public’s interest in the program seemingly peaked with the publication of the King v. CompPartners, Inc. case in August 2018. California’s Supreme Court ruled that workers’ compensation law provides the exclusive remedy for an employee who alleges injuries caused by a utilization reviewer’s denial of medical treatment.

Editorials published following the case verdict have argued that the workers’ compensation system may not be working as legislature intended. Consequently, I made a prediction in a blog published in September 2018 that there would be an effort “to unravel the UR and IMR processes”. This is precisely the aim of AB 1107 and its proponents.

Unintended Consequences of AB 1107

If the fundamental purpose of UR is to decide whether or not to approve medical treatment, which must be based on California’s adopted evidence- based medical treatment guidelines and drug formulary, the byproduct of eliminating this process is effectively removing the use of evidence-based medicine in determining medical necessity for requested treatments.

A study by the California Workers’ Compensation Institute (CWCI) captures the impact of removing UR on the use magnetic resonance imaging (MRI) in Washington State. Washington’s Department of Labor and Industries (L&I) measured the effect of eliminating UR on MRI use in 2003. Their assessment found an increase of 54% in spinal MRI scans and a 72% jump in lower extremity MRI scans. According to L&I, reviewers were unable to identify any other factors than the removal of UR that accounted for the material increases in MRIs.

Bypassing UR is equal to bypassing the use of evidence-based medicine, a cornerstone of California’s workers’ compensation approval process. Evidence-based medicine was adopted to control over-utilization of medical services, set parameters for effective care, and to reduce treatment costs.

By the Numbers

The validation of the use of evidence-based medicine through UR has proven to be effective in California. The most recent study by the CWCI on Independent Medical Reviews (IMR) volume and outcomes states that UR decisions have been upheld 90.7% of the time.

This means that IMR physician reviewers agreed with UR physician reviewers 90.7% of the time on the modification or denial of the treating provider’s medical request. It is important to emphasize that the treatment request modifications, denials and subsequent independent reviews were conducted by physicians. IMR decisions incorporate the review of medical records and other information provided to support the request, as well as a review of recommendations from California’s evidence-based medical treatment utilization schedule (MTUS).

CWCI’s data also identifies that the majority of disputed medical services that go through IMR originate from a small number of physicians. Specifically, the top 10% of physicians identified in the IMR decision letters issued for the study period (1,190 doctors) accounted for 86% of the disputed service requests, while the top 1% (119 providers) accounted for 44% of the disputed services.

DWC Administrative Director George Parisotto addressed an audience at the California Self Insurers Association’s 2019 annual education conference and stated that according to DWC data, 85% of workers’ compensation claims that request IMR are represented by an attorney. This brings into question whether the high volume of IMRs is attorney driven.

An assessment of California’s workers’ compensation reforms (including IMR) conducted by the Department of Industrial Relations (DIR) reported that the average medical costs per claim (excluding medical cost containment expenses) decreased by about 8% between 2011 and 2015 while benefits for workers for permanent disability increased approximately 30%. The report also found that more than $41 million in Return to Work supplemental payments had been disbursed to eligible workers whose benefits are disproportionately low in comparison to their earnings losses.

“A focus on evidence-based medicine has had wide-ranging impact, reducing costs and unnecessary treatment and creating an efficient Independent Medical Review (IMR) to resolve disputes.” (California DIR)

By the numbers, medical disputes in California are not widespread. When disputes arise, the dispute resolution process (i.e., UR and IMR) is effective in protecting injured workers from inappropriate medical treatment and employers from unnecessary expense.

The workers’ compensation system in California is far from perfect. However, methods to expedite the delivery of care to injured workers already exist. Examples range from 30-day Pass-through / 30-day Exemption Items per SB 1160, Expedited Review, and Prior Authorization Lists. IMR processing timeframes have also improved to 9-days (average age from receipt of complete medical records) as of November 2018 (Parisotto, George. CSIA Conference Presentation. 09 April 2019).

The solution is not to repeal more than a decade of progress by passing over-reaching legislation. The solution is aligning with partners that value scientific evidence, improved health outcomes, collaboration with all stakeholders involved in the care and claim continuum, and whose practices are founded in transparency.

The vehicle to deliver prompt and appropriate medical treatment to injured workers is fueled by evidence-based medicine. If the California workers’ compensation community continues to work with the DWC to ensure the use of it in the clinic, the solutions that AB 1107 seeks to produce will come to fruition.

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Complacency or Complexity: California UROs Crawl to Accreditation

Another deadline has come and gone for the California workers’ compensation community. “A utilization review process that modifies or denies requests for authorization of medical treatment,” according to newly modified Labor Code section 4610(g)(4), “shall be accredited on or before July 1, 2018” by an independent, nonprofit organization that establishes and monitors UR performance criteria, such as URAC. As of mid-June, it was reported (Subscription Required) that nearly half of UROs had still yet to be certified. Is the sluggish crawl to compliance due to a complacent system culture or an extremely complex process?

The California Formulary Implementation Experience

There is additional context, another July 1st implementation, to consider in determining the cause of the surprisingly low percentage of compliance for UR accreditation – the California drug formulary experience.

California Assembly Bill 1124, passed in 2015, required that the Administrative Director of the Division of Workers’ Compensation (DWC) to establish an evidence-based drug formulary on or before July 1, 2017.

A RAND Corporation document titled “California Workers’ Compensation Drug Formulary:  Design, Implementation, and Impact Analysis Project Overview” was published on the DWC website on February 10th, 2016. The document listed necessary study questions, RAND’s approach to selecting a drug formulary model and critical implementation policies that the DWC would need to develop in advance of the July 1st implementation deadline.

  

Trade publications reported that major system stakeholders submitted public comments for the DWC during the period that ended on May 1st, 2017 recommending the implementation deadline be delayed to January 1st, 2018.  A good portion of comments focused on whether enough time was allowed to implement the closed drug formulary by certain stakeholder groups.  The California DWC subsequently announced the formulary implementation would be delayed and addressed this, and other perceived technical, issues raised by stakeholders.

As is the case with the URO accreditation, stakeholders who took the January 1st, 2018 formulary deadline seriously were ready to hit the ground running prior to the date. They worked hard to establish necessary communication and training throughout their networks ensuring everyone was speaking the same drug formulary language and buttoned up required programming in their systems. Those that did not take the deadline seriously crossed the threshold without being prepared; and experienced a bumpy road on new claims where exempt medications were put through the prospective review process unnecessarily. This ultimately downgraded the injured worker’s experience with the handling of their claim.     

The Long Costly Road to Accreditation

The accreditation process is no easy feat. UROs seeking accreditation must be willing to invest a material amount of time and money to completing the process.

As an example, a URO who already operates at a high-quality level will likely spend numerous months preparing for the accrediting body’s audit. UROs who operate at a less than optimal quality level are likely to experience a show-stopping burden to comply with audit standards. The audit consists of verifying documented procedural descriptions, staff interviews to verify that company operations align with the written descriptions provided to auditors.

More specifically, accreditation for URAC’s Workers’ Compensation Utilization Management (WCUM), which satisfies Labor Code section 4610(g)(4), measures up to 81 separate standards (the number fluctuates downward based on relevance to each respective URO). These standards are divided into two sections, CORE Standards and WCUM Standards.

CORE standards audit general business and operational requirements ranging from organizational structure, up-to-date policies and procedures, regulatory compliance, inter-departmental coordination, oversight of delegated functions, sales and marketing, management of business relationships, information management, quality management, staff qualifications and management, clinical staff credentialing and oversight, health care system coordination, and consumer protection and empowerment.

Workers’ Compensation Utilization Management (WCUM) standards audit review criteria, accessibility of review services (on-site and otherwise), standards for initiating review process, initial screening, initial clinical review, peer clinical review, peer-to-peer conversation, time frames for initial UM decision, notice of certification and non-certification decisions, utilization management policy, and information upon which utilization management is conducted. 

In cases where either documentation or practice is not in alignment with the accrediting body’s standards, documentation must be prepared, reviewed, and approved. The implementation of policy into practice must follow. This step can be a culture shock to company systems if not approached properly. Leadership is essential in cases where new processes are introduced to comply with strict accrediting standards managing transitional process friction.

The cost of payroll hours incurred by UROs seeking accreditation is material. Add to this the accrediting body’s fee (leading accreditation bodies can charge fees upwards of $35,000 irrespective URO size) and the fiscal impact can be prohibitive to smaller organizations.

As a firm believer in third-party audits and accreditation (I passionately advocated, in a past life, for evidence-based medicine guidelines to be required to align with National Academies (formerly Institute of Medicine) standards for trustworthy clinical practice guidelines for state adoption in workers’ compensation), I loudly applaud the State of California for passing a statute that requires this quality standard. I can’t help but feel that unless there is appropriate enforcement by way of licensure revocation, fees, or other measures, compliance will remain spotty at best. 

Now what?

I predict the July 1st deadline will have little consequences for non-compliant UROs. Sure, they’ll experience challenges in the credibility of their denials, but ultimately may not see any state-sanctioned penalty for non-compliance. The lack of compliance will be mostly felt by injured workers who will have to contend with the added system friction due to the URO not being accredited. I HOPE I’M WRONG.

Fortunately for insurers, employers and employees, there are at least 56% of licensed UROs in California that have taken the charge for accreditation seriously and have made the investment to comply.

My recommendation to system stakeholders – seek out the accreditation seal. If your URO is accredited, let them know you appreciate their tireless effort in support of quality medical care for California’s injured workers. If the accreditation seal eludes your URO, you can be certain the cost of non-compliance will hit your ledger directly and indirectly.

Employers, heed the warning of this blog and replace your non-compliant vendor with a partner that values the impact that compliance has on your most valuable asset – your people.

The low compliance rate to Labor Code section 4610(g)(4) may, at the end of the day, be a combination of both a complacent system with little to no penalty for non-compliance and an accreditation process whose complexity reaches new heights.

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The Narrative of Workers’ Compensation is Changing

The workers’ compensation system looks much differently today than it did a decade ago, partly due to the opioid epidemic. Tragedies of this scale have a way of spurring unexpected outcomes bringing people together from all walks of life and disciplines. Workers’ compensation stakeholders have, and continue to experience, numerous paradigm shifts among insurers, pharmaceutical benefits management companies, and utilization review organizations. These shifts are all good; they are getting the thinking more in line with a patient-centric approach in each respective vertical.

Changes Among Insurers

Insurers have historically been a natural target of misplaced frustration brought on by system friction in workers’ compensation. They are often painted with a broad brush as callus, cold entities incapable of humanizing the consequences thrust onto someone’s life due to a workplace injury or illness. While this accurately characterizes some players in this vertical, there are others who are successfully changing their culture in how claims are perceived internally and what a successful outcome looks like in today’s workers’ compensation environment. They understand that a win does not always equate to short-term savings.

National Council on Compensation Insurance (NCCI) President Bill Donnell recently had a sit-down with Tracy Ryan, Liberty Mutual’s Chief Claims Officer and outgoing NCCI Board Chair. When presented with the question on how insurers in workers’ compensation can demonstrate their relevance and value, she responded with what some might consider a non-traditional answer from an insurer:  Insurers must share real-life stories of how the workers compensation industry fulfills the “noble mission” of helping injured workers recover from work related injuries.

Is this just marketing speak?

NCCI is now documenting real-life stories as described by Ryan. Their online catalog documents recounts of actual claims from various insurers describing scenarios in which the patient/employee is always the center of the process. Marketing speak or not, this is reflective of an agency’s push to make their focus on patients more apparent in hopes of inspiring a paradigm shift throughout a seemingly antiquated industry.     

The narrative is changing…

Changes Among PBMs

Pharmaceutical benefit management (PBM) companies have the complex job of, well, working themselves out of a job (that’s my personal take). Think about it:  A PBM’s success is most frequently measured by the number of inappropriately prescribed drugs they are able to intercept prior to them reaching unsuspecting injured workers. These unfilled prescriptions have a direct negative impact on a PBM’s bottom line.

CompPharma’s latest data reflects a 9.8% decline in pharmacy costs across 29 payers included in their 2017 survey. According to the PBM consortium, the decrease was the result of continued focus on improved clinical management, the expansion of utilization review and prior authorization, increased clinical involvement in the management of claims, and more structured drug alerts and alert management processes resulting in significant reductions in opioid spending.

Across the country, PBM’s have supported legislation proposing the standardization of evidence-based care by way of treatment guidelines and pharmaceutical drug formularies. This push has led to a notable change in prescribing habits in workers’ compensation playing a prominent role in process and cost efficiencies relating to pharmaceutical spending.

The added legislative and regulatory oversight of pharmaceuticals is prompting a move to non-pharmaceutical options, such as Cognitive Behavior Therapy (CBT) and activity-based treatment, for the treatment of pain. PBM efforts at every level (customer and state levels) are effectively balancing the way prescribers think about the need to use medications based on evidence-based care standards. 

The narrative is changing…

Changes Among UROs

According to California’s Department of Industrial Relations, Division of Workers’ Compensation, “Utilization review (UR) is the process used by employers or claims administrators to review treatment to determine if it is medically necessary. All employers or their workers’ compensation claims administrators are required by law to have a UR program. This program is used to decide whether or not to approve medical treatment recommended by a physician which must be based on the medical treatment guidelines.”

Due to the fact that UR is a payer’s right to review the request for treatment for medical necessity according to the state’s adopted medical treatment guidelines, the process is often seen as a detriment to the injured worker. UR is mistakenly seen as a yet another hurdle in the way of delivering promised medical care to the injured worker. As a result, leaders in workers’ compensation are urging payers to view utilization review through a more critical lens. It can no longer be viewed as a commodity, a service “thrown in” as part of a larger claims product.

“What patients need is careful, thorough UR by physicians with the time and training to foresee and speak to potential consequences of their determinations. And that costs money.” – Joseph Paduda, Principal, Health Strategy Associates; President at CompPharma

Done right, UR is not a mechanism of denial; it is assurance to employer and employee alike that only sound medical care proven to be effective according to leading scientific medical evidence and/or clinical consensus will be used for the restoration of the worker’s health.

Let’s go deeper:

Independent Medical Review (IMR) is the state-sanctioned process mandated specifically allowing injured workers the ability to appeal UR denials. Essentially, IMR holds UROs accountable to using sound scientifically medical evidence and/or clinical consensus when making a determination. If UR is upheld through IMR, it can be concluded that the URO followed the appropriate steps, consulted the appropriate medical evidence, and engaged adequately qualified medical peer reviewers in pursuit of their determination.

With this in mind, envision a scenario where a URO’s Independent Medical Review (IMR) uphold rates are higher than the state average. This statistic is incredibly difficult to accomplish since IMR, by design, is created to poke holes in the UROs assessment allowing the injured worker a fair, unbiased, 3rd party evaluation of the medical necessity of the requested treatment protocol. For a URO to exceed state-averages in IMR uphold rates takes a diligent commitment to quality, intentional focus on fairness, and consistent consideration of the scientific medical evidence via guidelines and/or clinical expertise.

National workers’ compensation thought-leaders have been urging payers, claims administrators, and managed care vendors for years to change their focus putting patients (i.e., injured workers) at the center of the equation (as it should be). We are finally seeing a national push in this direction. Make no mistake, it not a perfect system. There is no such thing. But I personally will celebrate the fact that we are slowly, but surely, moving in the right direction.

The workers’ compensation community is being forced to come together, today more than ever before, to help mend the broken in body and spirit. And from my vantage point, the community is responding as it should.

The narrative is changing…

   

CompPharma data used by permission.

Tragedy has a way of spurring unexpected outcomes bringing people together from all walks of life and disciplines. Here are my observations on the paradigm shifts happening throughout workers’ compensation partly due to the global tragedy that is the opioid epidemic.

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The California King Case: Imperceptible Implications for UROs

Many minds in the workers’ compensation community have been monopolized by California’s King v. CompPartners, Inc. case. On August 23rd, the State’s Supreme Court issued their ruling on the high-profile dispute:  Workers’ compensation law provides the exclusive remedy for an employee who alleges injuries caused by a utilization reviewer’s denial of medical treatment. This column is not as much about the legal details of the case as it is about pondering what comes next for the utilization review (UR) process. Are there imperceptible implications that could usher legislative and/or regulatory changes for Utilization Review Organizations (UROs) across the Golden State?

While the ruling is widely perceived as a win for proponents of California’s workers’ compensation system, the visibility of the King case has inspired numerous editorial pieces seemingly critical of the quality of UR. These write ups undermine the value of medically appropriate UR determinations and their ability to keep injured workers safe from avoidable disability due to iatrogenic conditions.

The details central to the case appear to provide a basis for those who argue that the workers’ compensation system may not be working as legislature intended. This perception will undoubtedly initiate more dialog among system influencers who are unhappy with today’s utilization and Independent Medical Review (IMR) landscape. Their primary objective will be to unravel the UR and IMR processes.

As certain stakeholder lobbies push to reduce the system’s administrative expenses, service vendors face ongoing pressure from employers and insurers to find ways to cut costs for their services that can result in lower quality and less effective products.

Make no mistake, the UR process at its core is designed for the benefit of injured workers and employers alike – the central figures of workcomp’s grand bargain. A high-quality review process ensures the safety of the worker remains top-priority while paving a path to functional restoration in a timely manner. This provides the employer assurance that they only pay for treatment that is proven to be efficacious by the scientific evidence and qualified medical professionals in order to facilitate optimal outcomes.

An argument can be made that while the legal questions around exclusive remedy may have been answered by the King case, the jury is still out regarding the ethical component of UR. Nicely summarized by a recent blog, UROs must take the time to consider the implications of their decisions on an injured worker’s health. It would greatly benefit the workers’ compensation community if all stakeholders involved in the care and claim continuum were to consider the same. In the end, doing what is right by the injured worker is what matters most.

However, if decisions to award business to UR vendors are primarily price-driven, the risk of cutting corners and potentially rendering the UR process inefficient, and ineffective, becomes very real. UROs have a duty to inform and educate clients, as well as the California workers’ compensation community at large, of the risks that accompany a bargain-bin approach to utilization review. The viability of the UR process depends on it. 

A bundled approach to managed care can produce efficiencies. It can also provide covering to conceal price gauging and quality defects in an UR product. How does a payer adequately survey for a high-quality UR service? 

A thorough review of the URO’s process and verifying the program’s accreditation is the only way to qualify the service for quality. UR is a component in workers’ compensation that inevitably requires a high degree of human intervention and clinical analysis. This is due to the complexities of certain medical scenarios that do not always fall within the guardrails of guidelines or best practice standards. These reviews take time to reach a well-informed determination that will usher the injured worker to functional recovery and productivity.     

Ironically, it is not unheard of for misguided payers to dictate a time-limit that their UROs can spend per review expecting the cost for clinical UR reviews and necessary processing to be restrictively low. This pressures UROs to rush decisions, and in some cases bypass necessary clinical analysis, making a decision without looking at the complete picture. Limiting the use of clinical resources required to ensure adequate medical care is being administered to the patient, in an effort to maximize savings, is not an effective strategy for cost and risk mitigation. It does quite the opposite; this practice exposes everyone involved to increased damages. There are no short-cuts to quality and improved outcomes.

The King debate now places California’s UR and IMR systems under increased public scrutiny. The question as to whether the workers’ compensation system is working as intended will only become more prominent in the months to come.

As unfortunate as the health implications suffered by the injured worker in this care are, they are not indicative of the positive day to day outcomes achieved for injured workers’ in California partly due to the UR process. Recently published data by the California Department of Industrial Relations (DIR) and its Division of Workers’ Compensation (DWC) measured that IMR overturned UR denial of treatment just 8.3% of the time in 2017. This affirms that 91.7% UR denials protected injured workers from the potential of extended disability due to inappropriate medical care.

Nonetheless, I expect the UR conversation to be a prominent point of discussion come next year’s legislative session. The additional attention placed on these areas will result in either an improvement in the quality of reviews through increased accountability, or unnecessary hurdles being introduced making it difficult for UROs to provide necessary protections to injured workers.      

Indeed, there will be implications for this segment of the workers’ compensation community that lie beneath the surface of the King case verdict. It will be incumbent upon UROs and their advocates to encourage a paradigm shift among payers respective to the purpose and true value of the utilization review process. In doing so, they will afford themselves a seat at the table to influence prospective legislative and regulatory change.

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