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Physician subscriptions to California’s drug formulary and treatment guidelines are rising mere days after the California Division of Workers’ Compensation announced that medical providers who treat injured workers in the state would have free access, but doctors continue to object to treatment denials emanating from California’s utilization review process.
The increase comes one year after not one provider treating injured workers signed up to access the state’s mandated comprehensive formulary and treatment guidelines, according to Joe Guerriero, Westminster, Colorado-based senior vice president who manages ReedGroup Ltd.’s medical guidelines and data platform.
“It was extremely rough” getting doctors on board, many whom argued “we shouldn’t have to pay for something that the state is mandating,” Mr. Guerriero said Friday. He had no exact figures for how many have signed up over the last week, but said the Feb. 5 announcement spurred the change.
Known among stakeholders as the medical treatment and utilization schedule, the data portal links ailments suffered by injured workers with evidence-based treatments under the American College of Occupational and Environmental Medicine.
The MTUS went into effect in 2018 and initially cost $675 annually for doctors to access the website, developed and managed by ReedGroup, a disability management and software firm. ReedGroup “never onboarded a doctor at that rate,” said Mr. Guerriero.
ReedGroup and the state then dropped the price to $100 in 2018, which led to about 100 subscribers, according to Mr. Guerriero. A spokesman with the California Department of Industrial Relations said providers who have paid can contact the ReedGroup to discuss a refund.
George Parisotto, the California Division of Workers’ Compensation administrative director, said in a statement that by providing free access, “we are removing barriers that we expect will improve quality of care and reduce friction in the utilization review process.”
Per state law, doctors treating injured workers must follow the guidelines, which in some cases subject prescriptions and requested treatment to utilization reviews, a process doctors told Business Insurance has been highly contested and is fraught with issues.
“The real problem with the guidelines is the (utilization-review) physicians sometimes don’t pay attention to the guidelines,” said Dr. Jacob Rosenberg, chief medical officer for the Walnut Creek, California-based practice IPM Medical Group Inc. and president of The California Society of Industrial Medicine and Surgery.
“I’m treating someone and then here comes this denial … and you see (the utilization-review) missed something,” said Dr. Rosenburg. “Physicians are busy and they get this denial and you have to read it very carefully to see why it was denied, and you asked for something that is very appropriate … you think it’s their job to find anything they can to not to pay for something.”
Also critical of the process is Dr. Robert Weinmann, who runs his own practice in San Jose, California, treating mostly injured workers and blogging about problems with the state system.
He calls the utilization review process “counter-productive because it allows people with no duty to care (to the patient) to overrule doctors who do have a duty of care.”
“The primary treating physician is responsible under the law, and to the CA medical board, to serve that patient,” he said. “The utilization review doctor doesn’t have to be responsible or even be licensed in California.”
Aaron Turner-Phifer, vice president of government relations and policy for the Washington-based nonprofit URAC, which provides certification and accreditation for utilization review doctors nationwide, said the problems implementing the formulary are to be expected.
“The folks providing workers compensation utilization review (in California) have to be accredited by us and I can’t say that there is friction that exists in California that doesn’t exist in other states that are implementing a formulary into their utilization review process,” he said. “You have a change and change always creates friction.”
“There are now guidelines and rules that providers are expected to follow, and anytime you introduce that, that change can disrupt what previously had been normal patient care patterns,” Mr. Turner-Phifer added. “That’s the same in every state.”
Providing free access is a “good start,” but there are other concerns with the formulary, said San Diego-based workers compensation attorney Robert A. McLaughlin of the Law Office of Robert A. McLaughlin and president of the California Applicants’ Attorney Association, which advocates for attorneys that represent injured workers.
“We need to educate the doctors about the formulary and how to use it and the guidelines, and this is a huge advantage,” he said. “I don’t think that doctors intentionally not trying to recommend treatment that is not in the guidelines. I think they need to better understand what the treatment guidelines are (because) there are a lot of utilization requests that really can be streamlined and approved.”
Yet, there is anecdotal evidence that some medications and treatments that fall within the formulary have been denied, he said. One example is when treatment is at first denied, and an alternative is recommended, and then that gets denied also, he added.
“Utilization reviews (are) not necessarily in the most understanding language,” he said.
Mr. Guerriero said he is hopeful that free access will change that.
“We were shocked they wouldn’t pay the $100 but they were pretty adamant about it. (The cost) was a constant theme” as to why doctors did not sign up initially, he said.
Diane Przepiorski, executive director of the Sacramento-based California Orthopaedic Association, said in an email to Business Insurance that the organization has always advocated for free access, but “it’s really a bigger issue than DWC negotiating complimentary access to the MTUS.”
“It seems to come down to many communication problems within the utilization-review system,” she wrote. “There is plenty (of) blame to go around to all parties involved.”
The California Division of Workers’ Compensation has updated its formulary for injured workers to include drugs to treat traumatic brain injury, regulators announced Thursday.