Is this Medical Care?

 

    If you are injured or become disabled as a result of your work, you are funneled into a medical care system which limits you to the workers compensation insurance company's hand-picked medical provider network. It is also true that insurance companies have the legal right to kick any doctor off the medical provider network if they recommend too much treatment or treatment that is too expensive. As a result, many of the doctors in our community have chosen not to treat injured workers or have been kicked off workers comp networks because they actually try to provide treatment rather than towing the employer line. Despite the complete control of medical treatment by the employer, injured workers often find that more time and effort is spent and wasted on denying treatment recommended by these same hand-picked doctors.

    It will come as no surprise then that workers' compensation insurance carriers' own expenses consume more than 35% of the money paid out in the workers' compensation system and the fastest-rising costs are those to review and overrule treatment from the insurers' own hand-picked doctors. In contrast, the permanent disability compensation payout to those injured on the job is a small percentage (10.8%) of the payout of the workers' compensation insurers. These numbers were compiled by advocates for injured workers using insurance industry figures from the Workers Compensation Insurance Ratings Bureau (WCIRB). The data shows that out of total workers' compensation payout, insurer expenses consume 35.7%, all medical care combined receives 38.3%, temporary disability payments 12.5%, and permanent disability compensation just 10.8%. The Schwarznegger Rating Schedule slashed permanent disability compensation by 50% to 70%.

    These numbers reflect a different reality than the constant drumbeat of employer and insurance carrier complaints would seem to imply-- that benefits paid to injured workers are simply too high to be borne by employers. The reality is that insurance payments to injured workers are far less than payments to others in the system, and the expenses and profits to insurance carriers.

    The extent of the problems in the workers comp medical treatment program was driven home this week when State Compensation Insurance fund (SCIF) issued a notice to the doctors in their Medical Provider Network (MPN) that they must sign an agreement which states, among other things, how and when they can recommend home care for an injured worker and the extent of the specifications they are allowed to prescribe without seeking authorization before making the recommendation. Furthermore, they must agree that they will limit prescribing opioid medications regardless of the patient's needs without prior agreement from the insurance adjuster or by order of the Judge. If the doctor does not agree to submit his proposed prescriptions to SCIF for pre-authorization he or she will be kicked off the MPN.

    The California Society of Industrial Medicine & Surgery (CSIMS) has contacted SCIF to advise them that their "heavy handed attempt at contract medicine" dangerously restricts the ability of SCIF MPN physicians to comply with California law— the Intractable pain Treatment Act and Health and Safety Code Section called the Pain Patient's Bill of Rights. Furthermore, they point out that SCIF has ignored the California Medical Board's Guidelines for Prescribing controlled Substances for Pain all of which would compel MPN physicians to violate the tenets of these guidelines on a routine basis and, in so doing, risk loss of their medical license and exposure to malpractice liability. Needless to say all this does not contribute to quality care for those subjected to MPN physicians. CSIMS further notes that the agreement prohibits physicians from even prescribing some medications, regardless of medical necessity yet SCIF provides no medical evidence to justify the requirement which is in itself a Labor Code violation.

    Now, certainly I would agree that there should be caution used in prescribing strong opioids or any other strong medications; however, I would not agree that an insurance adjuster should be the arbiter of what my doctor should or should not prescribe. How is that different from practicing medicine without a license? It would seem that SCIF is boldly making an effort at putting in writing their intention to prevent doctors from recommending treatment before it becomes an actual prescription to be sent to Utilization Review. This practice would surely reduce the escalating costs of reviewing or denying care since that care would not even be recommended in the first place. But, honestly, doesn't this miss the point of a medical delivery system? Remember that injured workers already contend with the draconian limits placed on physical therapy treatments, occupational therapy and chiropractic care. It would seem that soon there will be little a doctor can offer to the poor working person who is relegated to this system. Those who have other options—private health insurance, Medi-Cal, Medicare-- will seek to have their needs met elsewhere, pushing off the legitimate obligation of the employer and its carrier to provide the care for work-related injuries on to the rest of us as taxpayers and as part of the private health insurance pool. Those who have no other options simply go untreated and often fall into a lifetime of pain and disability leaving themselves, their families and society without the productivity they may have attained.

    The system of workers compensation was designed at the dawn of the industrial revolution to provide adequate and well-defined benefits to people who are injured or become sick on the job. The idea was to provide these benefits without having to prove negligence. This would save employers from diverting their resources to expensive litigation and would allow injured workers and their dependents to receive disability payments and treatment in a timely and efficient manner in an effort to get them back to work and on with their lives as soon as possible. In exchange for receiving benefits without proving negligence, people injured on the job have given up their civil right to sue their employer even when they are negligent—unfortunately a still too common occurrence. As time goes on it seems that we have come very far from the original ideal. Our current system is focused on insurer profits and employer costs with California workers receiving second and third rate medical care and among the lowest disability benefits in the country.