IMR - A Civil Rights Violation (California)

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Re: IMR - A Civil Rights Violation (California)

Postby vampireinthenight on Thu Oct 17, 2019 8:41 am

Agree with Barney and jpod. The money is better spent educating employees on how to pre-designate.

But it sounds like Carmetia is more into blowing up not just MPNs but also the MTUS, UR and IMR. Sure great, sounds like a treatment wonderland dream where more and more care yields better and better results. Sometimes. Maybe. But the MTUS is pretty comprehensive and if used properly should lead to predictably good results.

If you are in the business of handing over experimental, unproven or unjustified treatments on a lien basis and got used to a system which required you to simply forward proof of a very squishy standard of "reasonably required to relieve" then it is no surprise you may be dismayed at the application of a MTUS. But as Barney points out, with first-hand knowledge, it was systematically abused to the point where we ended up here. With the weight of history on top of you, reversing the MTUS and reinstating the PTP presumption simultaneously is a pipe dream. Honestly, the picture you paint where your own PTP can give you whatever you want sounds fantastic but it does not comport with hard reality.

I also disagree that a person's doctor "outside of WC" can simply provide whatever he/she wants. Maybe if you pay cash for everything, but not if you have insurance. There are similar utilization reviews in any health insurance. They might seem more flexible, but they are still there.
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Re: IMR - A Civil Rights Violation (California)

Postby Barney5 on Thu Oct 17, 2019 11:57 am

Report on healthcare in California. Depressing.

https://lowninstitute.org/report-califo ... ty-health/
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Re: IMR - A Civil Rights Violation (California)

Postby carmenita on Thu Oct 17, 2019 7:56 pm

I’m an old fashion guy. If I got hurt on the job, I would want my family doctor. Remember those? Remember, you had one doctor that controlled your care?

In comp., you get a person that has the title doctor but cannot make decisions for your care. The MTUS controls your care. An online manual largely based on ACOEM, which is only to be used as a “guide,” one of many in the medical field. Doctors are forced to follow the MTUS, thus, at times, not the best treatment.

On top of that, no one in this system including the Applicant can know the names of the IMR doctors making these final medical decisions. Are you kidding me? And how about King v. CompPartners, Inc.?
So, not only are injured workers mandated to seek treatment from the insurance companies doctors’, a book mostly dictates their medical care, and doctors hired by the insurance company pay the doctors that conduct a review of that “book”, which you cannot sue those doctors for malpractice, and then if you don’t agree with that company “UR” doctor you can file for an “Independent Medical Review” that is so independent -- you cannot even get there identity. What? And what are they reviewing? That same old book. You don’t see a problem here?

That’s what motives me. It’s having a doctor you trust, not the other way around. Again, the workers’ compensation scheme is to ensure that an injured worker receives care instead of lawsuits – that’s it.
My opinion is that the insurance company is there to pay for the applicant’s care. They are third-party players in this system, just like the doctors and attorneys. All third-player interests make money on the system. This system is all reduced to money.

The goal of the system is to offer care to the Applicant. The second goal is reasonable costs to the employer and third-party players. A fee schedule mostly decides the cost of treatment. Who sets that fee schedule, well it's the State of California. Some services depending on the treatment do not have a set fee schedule, and the Courts have addressed those standards of payment per Kunz and Tapia.

That’s your cost containment.

That’s the end of the story. The employer, via its insurance company, has no business forcing anyone to see a designated doctor because they got injured on the job. Moreover, let the man examing you make the decisions about your care rather than a very complex system that is controlled by the employer, and based on a reference book and doctors, you cannot sue or even know the identity of those making the “final” decision about your care. Again, this goes back to the old days, right?

Do I think most Californians would agree, the answer is yes. I believe if put to the ballot, such a measure would pass by a landslide. One’s got to wonder if that penny tax was worth it?

So, I oppose the MPN’s and UR’s. That’s it. No big legal theory here.
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Re: IMR - A Civil Rights Violation (California) (California)

Postby jpod on Fri Oct 18, 2019 3:56 pm

If anything UR and IMR has refuted the claims you make about the MTUS being substandard. The vast majority of IMR appeals are generated by 10-12% of physicians operating in the WC system. The vast majority of treatment plans sail through UR b/c the vast majority of medical providers know how to present sufficient documentation to get their recommendation for treatment approved. Thankfully the Governor signed a Bill to require the DWC to publish the names of the providers who have been wagging the proverbial tail of the WC dog so to speak.

As far as your family doctor goes, again, you can pre-designate your family doctor as long as you do it before you are injured.

But as I said most family doctors don't want to get near WC. The doctors I have talked to don't like it because of the inherent conflict of interest that often arises in WC cases between the doctor and patient. Doctors want to heal patients; they do not strive to leave the patient with residual disability; they want patients who want to get better and return to full function if medically possible and feel frustrated by secondary gain motives that are not present in non-WC cases (the doctor's words not mine).

The original poster tried to argue some sort of property right to work comp benefits exists. The truth is WC is a social bargain that makes employers liable for work place injuries that the employer would otherwise not be liable for in the absence of the WC Act. Unlike tort claims which try to make the plaintiff whole, WC is specifically designed to NOT make the employee whole financially; there are also limits on liability for medical costs. The reason for these limits is to prevent moral hazard, and to limit the hidden tax on consumers embedded in the prices of goods and services. Those goals would be thwarted if your proffered scheme was adopted. Moral hazard and secondary gain situations would flourish.

Also roughly 35-40% of the employees in California are covered under self-insured programs where there is no insurance and no profit motive whatsoever.

Your lament that "All third-player interests make money on the system" is exactly why insurers, doctors, and other third party vendors were kept out of the room while the two principals crafted reforms that made sure a larger portion of costs in the system be directed to benefits paid, not profits for third party vendors.

Allowing the two principals in the system (Labor and employers) to craft reforms without involving the third party vendors was at the heart of SB 899 and 863 reform effort.
Last edited by jpod on Fri Oct 18, 2019 4:29 pm, edited 1 time in total.
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Re: IMR - A Civil Rights Violation (California)

Postby Barney5 on Fri Oct 18, 2019 4:18 pm

I agree with you on IMR.It would be a good start if IMR doctors had to provide their name.Many of the IMR reviewers are not reviewing the records sent. This may stop if they had to provide their name. I see problems with UR but not at the level I see with IMR and failure to review records.
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Re: IMR - A Civil Rights Violation (California)

Postby vampireinthenight on Mon Oct 21, 2019 9:10 am

So you've asked around and you think people would support a law that gives them more free stuff. I guess that is hardly surprising. I could probably get votes to give every child in California a free lollipop. Especially if I limited the voting to children.
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Re: IMR - A Civil Rights Violation (California)

Postby carmenita on Mon Oct 21, 2019 11:08 am

vampireinthenight:

Then start handing out those lollipops. There is nothing free about it. I'm 49 years old and started working at 11 years old. I've been both a worker and an employer. Nobody asked me to "come" to the table and input my opinion on SB 836. Put it to the "people". What you are saying is people can be bought with lollipops? That we as a whole are that stupid?

Maybe some of you are that stupid but we all have opinions and the right to vote via ballot and if put to the ballot I believe it would prevail. Maybe you don't understand how SB 836 got passage??? It wasn't lollipops it was corruption.
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Re: IMR - A Civil Rights Violation (California)

Postby vampireinthenight on Tue Oct 22, 2019 10:25 am

You're missing the point. People will vote for free stuff (ie providing their PTP with a blank check) if it is perceived that way. But your proposal would be opposed and exposed as not free at all (as you point out).

I would continue to tell you that it is doomed to fail but you've clearly made up your mind with your informal polling of friends, so good luck to you. I look forward to reading all of the arguments for and against when it hits my mailbox.
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Re: IMR - A Civil Rights Violation (California)

Postby carmenita on Wed Oct 23, 2019 10:40 pm

Vampireinthenight:

I need to clarify. There is no ongoing discussion of putting it on the ballot as far as I know. I expressed my personal opinion. What I said years back, is I gauged the possibility of getting this on a ballot. There wasn’t an appetite for it at that time.
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