CWCI’s just-released analysis of the Independent Medical Review program’s 2013-2014 results indicate it is working well – despite being flooded with requests from a relatively small group of docs.

Let’s stipulate that the IMR process is not foolproof. There’s no question errors have been made and it is likely some patients’ care has been adversely affected. More on that below…

Here are the key data points:

• 94.1% of all medical service requests are approved.
• 36% of requests were from the Los Angeles area but only 24% were WC claims.

Of the requests that are NOT approved;

• 45% are for drugs (29% for opioids, 12% for compounds).
• 10% for DME.
• 9% for PT.
• 1 out of 17 medical service requests are modified (the treating doc agrees with the reviewer to do something different) or denied.
• Review encompassed 260,889 medical services requested for 76,718 patients.
• 75% of reviewers’ guideline summaries cited the CA Medical Treatment Utilization Schedule; 80% of those cited either MTUS alone or MTUS and non-MTUS guidelines (there’s a lot of additional info in the report on pp 19-21 re guideline usage).

Okay, that’s the data, big-picture stuff. What’s perhaps even more revealing is what some docs wanted to do to patients. For example:

• One wanted to administer Propofol to a patient getting a steroid injection because the patient gets “anxious.” Recall Propofol killed Michael Jackson, and is by no means appropriate for an ESI.
• Another wanted to fuse “every vertebra from the pelvis to the middle back in a 76-year-old patient,” despite no documentation of a lesion, neural compromise or “other clinical finding supporting the procedure.”
• I’ve also heard from a credible source (not in the report) that aspirin was denied to a patient because that patient was already on blood thinners…

What’s abundantly clear is the UR/IMR process has undoubtedly prevented medical catastrophes: opioid addiction, failed back surgeries, adverse drug reactions.

As noted above, we can also stipulate that the process is by no means perfect, however, the reasons for those errors are by no means clear. It certainly appears that the huge volume of IMR requests (the top 1% of docs accounted for 44% of all requests; 10 physicians alone accounted for one out of every seven requests!) overwhelmed the system initially, although of late requests are being processed on a much more timely basis.

The exhaustive, 24-page review concluded with this statement:

"The Workers’ Compensation Insurance Rating Bureau of California recently announced a significant decrease in medical benefit development coupled with a significant increase in expenses related to the delivery of medical benefits. IMR is likely to be associated with both trends."

What does this mean for you?

Evidence-based medical guidelines backed up by a tight UR process prevents a lot of crappy medical care. It can also be cumbersome and is by no means perfect.

Joe Paduda is owner of Health Strategy Associates, a Connecticut-based employer consulting firm, and co-owner of CompPharma, a consortium of pharmacy benefit managers. This column was reprinted with his permission from his Managed Care Matters blog.