State efforts to impose additional restrictions on workers compensation-related medical treatments raise questions about the role of medical utilization reviews that need to be addressed to keep all sides working together and focused on the key goal of the comp system: healing injured workers.
Medical benefits represent the largest component of workers compensation costs and, given medical inflation trends, containing those costs is a major concern for workers comp payers. Utilization review is one of the main tools that the comp sector has used to curb runaway medical costs, but, as we report on page 24, physicians are increasingly bristling at the oversight.
The reviews, which have been in use for decades, are usually conducted by medical professionals, including other physicians, who review a patient’s medical records and treatment plans to determine whether the prescribed treatment is necessary and appropriate.
State laws and regulations add another dimension to the process by imposing features such as medical treatment utilization schedules and closed-drug formularies that require prior authorization before prescriptions can be filled — features that were often put in place during the opioid crisis.
For doctors confident in their abilities and judgment, the process can be onerous and slow down the treatment of patients, possibly worsening their conditions. A physician on the ground in front of the injured patient, the argument goes, is uniquely positioned to make the best choices for the patient’s ultimate welfare.
Indeed, the expertise of highly trained medical professionals is vital for the safe and efficient treatment of patients, but with about one million physicians in the United States inevitably there is going to be a range of opinions, and escalating costs of medical treatments can’t be ignored.
Comp payers have a responsibility to make sure they are not overpaying for care, but they also need to ensure that their review requirements are reasonable and practicable, especially if they are denying coverage for a treatment or test that a doctor views as important or essential.
To solve the problem, it is imperative that doctors, workers comp insurers and claims managers work together to resolve any differences as to how medical treatments are approved and monitored. Engaging in more collaborative decision-making processes and revising utilization review policies to better reflect the needs of injured workers should be embraced. Maybe regulators need to take note.
Ultimately, the goal of everyone involved should be to create a system that prioritizes the needs of injured workers while also ensuring that resources are being used in the most effective and efficient way possible. This requires the acknowledgment of sometimes dueling perspectives, and an understanding of how every party involved in the process plays a vital role in seeing that injured workers receive timely, high-quality care.