Physicians who accept injured workers as patients know that adverse utilization review (UR) decisions can devastate well-planned diagnostic and therapeutic programs. Some major facilities won't tolerate this risk and refuse to accept injured workers.

Dr. Robert Weinmann

Utilization review is required in workers' comp. It works like this: Doctor A interviews and examines Injured Worker B, and decides that certain diagnostic tests and treatment are indicated.

But in workers' comp and in other insurance venues, that decision gets forwarded to a doctor who does not interview or examine the patient. What he does do is review the medical record and decide about authorization for the recommended diagnostic test and/or treatment. Absent this authorization, the treatment program is stopped dead in its tracks. 

Under California law, doctors who do utilization review need to be licensed physicians. However, the law does not say that they must be licensed in California. This oversight has led to a situation where doctors who are not licensed in California reject treatment plans.

The rejections may be appealed but in the vast majority of cases they are upheld. It would be simple enough to correct this oversight by amending the law so that UR has to be done by California-licensed physicians.

California-licensed physicians are subject to discipline by the state Medical Board, which has, as a matter of fact, recommended that all physicians doing UR on California cases be licensed by the state board and be subject to discipline by the state board.

By contrast, non-California licensed physicians are not subject to this state's Medical Board. They are also not subject to discipline by their own state boards, since California cases are out of their jurisdiction. This situation has led to countless appeals, delayed care, further injury to untreated injured workers and an exodus of doctors from industrial medicine. 

Now comes Senate Bill 1303, introduced by Dr. Richard Pan, to make sure that forensic autopsies are conducted by licensed physicians instead of by non-medically trained persons who've been designated or elected as coroners. However, as the bill is currently written, the requirement is for this job to be done by a "medical examiner ...  a licensed physician and surgeon duly qualified as a specialist in pathology." 

No mention is made of licensure in California. At least, not yet. 

In order to avoid travesties akin to what has been happening with UR for the last several years, my recommendation is that medical examiners shall meet the qualifications as already stated in SB 1303, and to these requirements, be added mandatory licensure in California with the same oversight by the Medical Board as is provided for physicians licensed in California. No residence requirement is sought, only medical licensure in California.

Otherwise, in highly disputed forensic cases such as we've described in previous editorials, the door is opened for medical examiners who are not subject to to the state Medical Board.

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