Sacramento, CA – Frank Neuhauser from the University of California, Berkeley published a new study on Qualified Medical Evaluators discussing trends in evaluations, availability to meet panel requests, and other issues. He used extensive electronic administrative data made available by the DWC Medical Unit and Disability Evaluation Unit (DEU), supplemented with summary data from several sources.
The study covers the period from 2007 through 2017. This period covers much of the evolution after the 2004 reforms which introduced utilization and treatment guidelines, a new permanent disability rating schedule based on the AMA Guides, and changes to the manner parties in represented cases can select QMEs. The key findings in this study included the following general observations:
– The number of providers registered as QMEs continues to decline (17% since 2007), but less rapidly than it did prior to 2007.
– The number of requests for QME panels has increased rapidly, 87% since 2007.
– The decline in QMEs and increase in panel requests means that the number of requests per QME has doubled (+101%).
– Coupled with a continuing increase in the average paid amount for QME reports, the average QME earns 240% more from panel reports now than in 2007.
– All the increase in panel requests is from represented track cases, up 400% despite the elimination of panels for most medical treatment issues (replaced by the IMR process). This increase was equally driven by requests from both parties, applicant and defense.
– Panel requests for unrepresented cases declined 55%, entirely driven by a decline in requests from injured workers. The number of requests by claims administrators in unrepresented cases changed little.
– The DWC began collecting the reasons for panel requests on represented cases in 2015. Those data show that the primary reasons for panels are: (1) Compensability (42.5%), Permanent disability (21.4%), and Permanent & Stationary (P&S) status (11.4%).
In response to the earlier study, SB 863 placed limits on the number of locations (10) at which QMEs can be registered. This has had the effect of distributing QME panels more evenly and widely among registered providers.
– Very-high-volume QMEs (with 11-100+ registered locations) have been eliminated.
– However, a high proportion of panel assignments (55%-60%) are still assigned to the busiest 10% of QMEs, nearly all of whom have exactly 10 offices and are in orthopedic specialties.
– Unlike the very-high-volume QMEs studied earlier, the top 10% and 5% of QMEs by number of panels in the current system produce reports that show less bias. Even the top 5% of QMEs by volume rate only slightly more conservatively than average.
Access to QMEs does not appear to be an important current problem, but there are signs that delays in getting an evaluation may be developing.
The DWC has made an effort to eliminate from the workers’ compensation system providers who are accused or convicted of fraudulent activity or violations of professional standards. This study examined the activity of these doctors in the QME process and how their suspension may impact QME evaluations. The study found:
– Of providers suspended or restricted under Labor Code sections 139.21 & 4615, 41 were registered as QMEs at least one year between 2007 and 2016.
– They represented a small minority of all QMEs (1.6%) and were assigned to a minority of all 3-doctor panels (4.6%).
– While these percentages are small overall, there were some areas where problem providers appear to be concentrated and represent a special issue. The “Pain” specialties (PAP, MAA, & MPP), stood out, with 40% -50% of QME panels including at least one restricted or suspended provider.
– The more general “pain” category (MPA) that is more commonly used now, as well as the Physical Medicine and Rehabilitation (MPR) and Internal Medicine–Hematology (MMH) had 15% – 17% of panels include a restricted or suspended provider.
– Overall, the restricted and suspended doctors gave much more generous evaluations to injured workers than the average QME: higher ratings, less frequent use of apportionment and more frequent “Almaraz” ratings. Read More…