Malpractice reform in utilization review is again on the line, this time because the California Supreme Court has scheduled hearings King v. CompPartners on Tuesday.

Dr. Robert Weinmann

The case resolves about the rights of an injured worker when UR denies access to treatment ordered by a California licensed physician and when, as a result of this medically wrong UR decision, an injured worker is not only denied treatment but also suffers harm as a result of the combined negligence of UR and the insurance carrier that benefits financially by being absolved of its obligation to pay for care.

The current issue revolves about the decision of an insurance company to stop paying for Kirk King's Klonopin. The insurance company's decision was made on the basis of a utilization reviewer's wrongful judgement that could in due course prove harmful to physicians engaged in UR.

Our information is that the UR doctor made an incorrect and harmful decision that was happily adopted by the insurance company. This quick step could end up with a two-step revision of UR, namely, requiring that UR physicians be licensed in the states where their decisions are used and that they carry malpractice insurance in those states.

This publication favors both steps. 

The California Workers' Compensation Institute (CWCI) has argued that UR is not medical practice, a clearly absurd position to treating physicians and to the patients who are harmed. This fatuous argument was supported twice by Gov. Arnold Schwarzenegger and once by Gov. Jerry Brown, who vetoed bills that would have implemented state licensing for UR and independent medical review doctors.

Brown's reasoning was more tortured than Schwarzenegger's: He said that requiring UR doctors to be licensed "would be an abrupt change and inconsistent with the manner in which utilization review is conducted by health care service plans under the Knox-Keene Act and by those regulated by the California Department of Insurance."

That is just the point: UR and IMR decisions that deny indicated and necessary care are harmful intrusions into medical care, and should be squashed. These denials require the abandonment of the duty of care owed to injured workers.

CWCI's reading of the law is frivolous, legalizes abandonment of sick and injured workers, and deserves to be repealed along with enabling law created by SB 863, which added insult to injury by adding IMR to the utilization review process.

In a nutshell, in the unfortunate case of Kirk King, the insurance carrier stopped payment for prescribed medication based on the UR doctor's report. The result was that the patient suffered epileptic seizures.

The opinion of this publication is that the injured worker was abandoned, and that the UR system and the insurance company were at fault and opened the door to the malpractice litigation now in progress. The harm that befell Kirk King is proof that the UR system practiced unsound and negligent medicine. 

The Supreme Court should find that UR doctors owe a duty of care to injured workers and that in the King case, UR and the insurer were negligent. Such a decision will restore equity between treatment and utilization review. 

Dr. Robert Weinmann writes the Politics of Healthcare blog, from which this entry was taken, with permission.