UR – we aren’t ready to have the conversation yet

Greg Jones’ recent articles in WorkCompCentral highlight the inherent problem in the debate in California around UR; there’s little data on which to base any assessment, much less draw conclusions. Moreover, the data that is available is not consistent; there are no common definitions or consensus around what constitutes a “denial”, an initial review, a secondary review, an appeal, a reconsideration,
Here are the key take-aways from Greg’s May 21 piece:
“Jerry Azevedo, a spokesman for the Workers’ Compensation Action Network, said
between the legislative proposal and reform talk, utilization review is an important topic. It would be beneficial to the entire community to have quantifiable data to understand the real frequency at which requests for medical treatment are being denied, he said.without statistics on utilization review it’s really only possible for stakeholders to base their debate on anecdotal evidence[emphasis added], which is not the best course of action.
“In terms of operating a system and in terms of what we want regulators to do, it needs to be based on statistics and what the numbers really are,” Azevedo said.”
The result of this lack of understanding is, at the least, mass confusion. At the worst, legislators and regulators are called on to make decisions affecting workers comp based on anecdotal information, press releases, histrionic statements, and data carefully selected to represent the perspective of the presenting party.
That’s no way to run a system.
Let’s start with a basic question – what, if anything, are the benefits of UR?
Well, the last credible study I could find was published in December 2007 by Alex Swedlow and John Ireland of CWCI. The study, entitled Analysis of California Workers’ Compensation Reforms; Part 1: Medical Utilization & Reimbursement Outcomes Accident Years 2002 – 2006 Claims Experience”, analyzed the impact of California’s work comp reforms.
Here’s the key data:
“In five of the six treatment categories, the average amount paid per claim for that type of treatment during the first 2 years following the injury declined – the only exception being surgery. Among surgery claims, the average amount paid for surgery services at the two-year valuation point was about 5 percent higher in the post-reform period than in the pre-reform period.”
Okay, I know, this was based on data that is now a bit old, and we need more current information and analysis. But CWCI’s research clearly and convincingly demonstrates that the reforms did have a significant, positive impact. Utilization declined across most medical treatment categories, and since then costs have declined dramatically. Really dramatically.
CWCI will be publishing updated research on this issue later this summer.
It is abundantly clear – from Jones’ article and the confusion surrounding the costs, benefits, and outcomes of UR, that we can’t make any decisions based on the information available today. It’s not sketchy, it’s almost non-existent. And, what we do have is contradictory and unhelpful as basic data field definitions are inconsistent.
As luck would have it, my firm (Health Strategy Associates, LLC) has just begun our first annual Survey on Utilization Review in Workers Compensation. We are surveying C level execs as well as desk-level folks (claims adjusters, claims execs) for their opinions concerning and results of UR.
The On-Line Survey should take 20-25 minutes tops, and one lucky recipient will receive an iPad 2 as a token of our appreciation (make sure you include your contact info if you want a shot at the iPad).
We will be publishing the results of the Survey in June, and hope it provides additional insight into the utility of UR across the industry.