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California comp dispute resolution could slow amid QME shortage


An exodus of qualified medical evaluators could slow down and complicate the resolution of disputed workers compensation claims in California, according to experts.

Qualified medical evaluators are qualified physicians certified by the California Division of Workers’ Compensation Medical Unit to examine injured workers to evaluate disability and write medical-legal reports used to determine an injured worker’s eligibility for workers compensation benefits, according to the division.

In California’s workers comp system, the medical-legal process includes a panel, or list of three qualified medical evaluators, issued to an injured worker when a question arises about whether or not an injury is work-related or if there is a medical dispute that has not been resolved by the treating physician’s report, according to the division.

The number of qualified medical evaluators declined 20% between January 2012 and September 2017, according to a recently released California Workers Compensation Institute study. The study compared data from the list of physicians certified in California as QMEs in 2012 to the certified QME list from September 2017 to analyze changes in the QME population.

“There has been some anecdotal word of mouth that there are access problems with individuals being able to schedule an appointment with QMEs,” said Stacy L. Jones, senior research associate at the Oakland-based California Workers Compensation Institute. “We wanted to get an idea of how many QMEs were actually in the pool and some of the demographic information about where they are located in relation to where injured workers are and what the pool consists of in terms of specialty.”

Getting high-quality medical legal evaluations in a timely and accurate manner has always been a concern in workers comp, according to experts.

“If you look at the average age of the people who do most of the medical legal evaluations, they are a lot of the baby boomers,” said William Zachry, San Francisco-based senior fellow at the Sedgwick Institute. “Baby boomers are retiring or leaving the industry for various reasons as they get older. In California, there has always been a problem with getting good medical legal evaluations in the rural area ... that is one of the challenges that has been problematic for as long as there has been comp in California.”

Despite the drop, available QMEs are taking on more evaluations, said Mr. Zachry.

“The question becomes quality and timeliness: Are the injured workers having to wait a long time to get an evaluation?” he said. “And my understanding is that after the initial kerfuffle with getting it up and running, generally speaking, the panels have been put out with the three positions to be selected pretty quickly.”

Finding out how long the injured workers are waiting is a “piece of the puzzle” that would determine whether there is a problem, he said.

Other experts say that the QME drop will have a definite effect.

“The 20% fall in the number of QMEs in a little over 5 years, per the CWCI report, is alarming and has a significant impact on the ability to find a QME on a panel list who can evaluate a worker within the required timeframe of 60 to 90 days, much less issue a report within 30 days of that evaluation,” Diane Worley, San Francisco-based director of policy implementation at the California Applicants’ Attorneys Association, said in an emailed statement. “It doesn’t matter whether they have 1, 2, or 5 offices, less QMEs means longer wait time for appointments and for reports.”

The division should be actively recruiting QMEs in the specialties of urology, pulmonary, gastrointestinal and oncology as well as increasing the overall numbers. Not doing so would increase frictional costs for employers, according to Ms. Worley.

“Many who have to navigate the current QME system, whether they are on the applicant’s or defense side, say they would gladly go back to the old system where both sides get their own QME without going through this restrictive panel QME selection process,” she said. “Less friction and more timely evaluations and reports.”