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Luna: Removing Friction From California's Workers' Compensation System

  • State: California
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The California workers’ compensation system has been buzzing with activity since the passage of AB 1124 in 2015, requiring the administrative director of the Division of Workers’ Compensation to establish a drug formulary as part of the state’s Medical Treatment Utilization Schedule (MTUS).

Carlos Luna

Carlos Luna

The addition of the formulary, in concert with the impending updates to various treatment guidelines (following the new expedited process set forth in SB 1160), in MTUS will improve the system by increasing the use of evidence-based care administered to patients, thereby reducing the inappropriate prescription of dangerous drugs and inappropriate medical treatment, and reducing system friction by providing a common standard to base medical decisions for injured workers at every step in the care and claim continuum.    

California Code of Regulations and presumptive weight

Perhaps my day-to-day exposure to regulations and legislative text is what drives my “geeking out” on the code. I have actually heard highly influential people say, “No one pays attention to the labor code” or “No one cares about what the regs state.” Comments such as these just don’t make any sense.

Admittedly, regulation text can miss the mark if stakeholder input is not considered. Real-world experience and wisdom must inform the process that is expected to turn the gears of the workers’ compensation industry. Absent sound and constructive input from the marketplace, regulations run the risk of being detached from the day-to-day needs of the system and all of its stakeholders.

In California, the Division of Workers Compensation’s Administrative Rules emphasize the state’s commitment to injured workers and their employers by defining what may well be the most critical of expectations: that the best available evidence be used to guide clinical decision-making. The state’s commitment to injured workers and their employers is again emphasized by the thorough analysis that was conducted to inform their selection of the content source that powers the MTUS’ treatment guidelines and drug formulary.

The outcome of the state’s thorough analysis of multiple treatment guidelines and drug formularies lends great weight to the state’s assignment of the MTUS (and the platform that provides the foundation for the MTUS, the ACOEM Practice Guidelines and Drug Formulary) as being the “go-to” source when treating ill or injured workers in the California market: 

§ 9792.21 Medical Treatment Utilization Schedule

(c) The recommended guidelines set forth in the MTUS are presumptively correct on the issue of extent and scope of medical treatment. The MTUS constitutes the standard for the provision of medical care in accordance with Labor Code section 4600 for all injured workers diagnosed with industrial conditions because it provides a framework for the most effective treatment of work-related illness or injury to achieve functional improvement, return-to-work and disability prevention. The MTUS shall be the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers.

Assigning this weight to the MTUS prioritizes the use of its treatment guidelines and drug formulary above all other sources. In doing so, MTUS becomes California’s primary language of communication for all workers’ compensation system stakeholders. Understanding that on occasion secondary sources may be needed to form a comprehensive foundation for evidence-base care, California’s Division of Workers’ Compensation defines a very clear path (through its Medical Evidence Search Sequence) for introducing standards not found in the MTUS.

This path should only be taken after the MTUS is considered. 

More than claims and UR tools

California’s endeavor to establish the tools contained in MTUS as the “primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers” is based in the realization that in order to meaningfully improve the friction in the workers’ compensation system, MTUS must be the guiding source for treatment from day one.

The treating physician’s initial interaction with the injured worker is paramount to accomplishing favorable health outcomes. The dialog between doctor and patient not only sets appropriate (or inappropriate) medical expectations, it ultimately shapes the trajectory of the claim — smooth going or friction-filled. This is the point where evidence based care is most effective and necessary.

Retrospective efforts to get a runaway claim train back on track are perceived as detrimental to employee benefits by employee advocacy groups. Deviating from or challenging a doctor’s orders, even when informed by the highest grade of evidence-based medicine, can be an invitation for friction. Disparate standards of care introduced outside of the established path (Medical Evidence Search Sequence) further widens the gap among stakeholders and adds friction to the process.

Opponents of sound patient-centric medicine

Sound patient-centric medicine will always have opponents — opponents by commission and opponents by omission.

Misaligned interests are present in numerous verticals of the industry. Opponents by commission are identifiable by their persistent off-center messaging in the marketplace. Their message intends to de-emphasize what the State has created as a standard; they work to obfuscate what is otherwise a clear path to scientifically based standards for optimal care. Their interest is driven by personal gain, forgetting that a conflict-free, good working system that produces optimal health outcomes benefits everyone.      

In some cases, opponents do not see themselves on the opposing side of sound medicine. Opponents by omission are parties that remain neutral when confusion is intentionally sown into the marketplace by the aforementioned. I often ask, are opponents of sound patient-centric medicine unaware, or are they indifferent to the friction they invite by their lack of action?

California’s success in removing friction from its workers’ compensation system hinges on all of the state’s stakeholders committing to work from the same standards and speaking the same language. Anything short of this type of cooperation is both counter-productive and an affront toward the collective effort to produce improved health outcomes for California’s injured workers.

Carlos Luna is director of government affairs for ReedGroup, which publishes the American College of Occupational and Environmental Medicine treatment guidelines and drug formulary.

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