Physicians who accept injured workers as patients know that adverse Utilization Review (UR) decisions can devastate well planned diagnostic and therapeutic programs for injured workers. Some major facilities won't tolerate this risk and refuse to accept injured workers (this blog published a letter from Stanford saying just that -- see blog)
Utilization Review is required in workers comp. It works like this. Doctor A interviews and examines Injured Worker B and decides that certain diagnostic tests and treatment are indicated. But in workers comp and in other insurance venues that decision gets forwarded to UR doctors who do not interview or examine the patient. Instead, they review the medical record and decide about authorization for the recommended diagnostic test and/or treatment. Absent this authorization the treatment program is stopped dead in its tracks.
Under California law doctors who do utilization review need to be licensed physicians; however, the law does not say they must be licensed in California.This oversight has led to countless situations where doctors not licensed in California reject treatment plans proposed by doctors who are licensed in the state. The rejections may be appealed but in the vast majority of cases the rejections are upheld. It would be simple enough to correct this oversight by amending the law so that UR has to be done by California licensed physicians. Insurance companies oppose such changes.
California-licensed physicians are subject to discipline by the state medical board which has, as a matter of fact, recommended that all physicians doing UR on California cases be licensed by the state and be subject to discipline by the state board. By contrast, non-California licensed physicians are not subject to this state's medical board so are not subject to state board discipline in California. They are also not subject to discipline by their own state boards since California cases are out of their jurisdictions. This situation has led to frequent appeals, delayed care, further injury to untreated injured workers, and an exodus of doctors from industrial medicine (workers comp).
Now comes SB 1303, introduced by Dr. Richard Pan to make sure that forensic autopsies are conducted by licensed physicians instead of by non-medically trained persons who've been designated or elected as coroners. However, as the bill is currently written, the requirement is for this job to be done by a "medical examiner ... a licensed physician and surgeon duly qualified as a specialist in pathology." No mention is made of licensure in California. At least, not yet.
In order to avoid travesties akin to what has been happening with UR for the last several years my recommendation is that medical examiners (MEs) shall meet the qualifications as already stated in SB 1303 and to these requirements be added mandatory licensure in California with the same oversight by the medical board as is provided for physicians licensed in California. No residence requirement is sought, only medical licensure in California.
Otherwise, in highly disputed forensic cases such as we've described in previous editorials, the door is opened for interested parties to seek out medical examiners who are not subject to the state medical board. The idea would be to secure an ME who is as malleable as some of the UR doctors have turned out to be. An ounce of prevention would be to make sure that physicians accepted as MEs are licensed in California.
References
Senate Bill # 1303 (Pan and Galgani), 16 February 2016
Forensic Autopsy Legislation, SB 1189 and SB 1303, what happens when someone dies while in administrative custody? The Weinmann Report, 19 February 2018
SB 1303, SB 1303 (Pan & Gagliani), would replace coroners with medical examiners, The Weinmann Report, 25 Feb 2018
"Probable Drowning (SB 1189, Pan & Jackson)," The Weinmann Report, 23 May 2016 (www.politicsofhealthcare.com)
When injured workers aren't accepted, viz,, Stanford Med Ctr, The Weinmann Report, 11/25/15
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