Stakeholders at a recent meeting of California’s Commission on Health and Safety and Workers’ Compensation (CHSWC) did not mince words in describing what needs fixing in the state’s beleaguered, dysfunctional workers’ comp system.

CHSWC examines workers' compensation and recommends improvements. CHSWC Chairperson Nicholas Roxborough opened the floor to frustrated providers, attorneys, and others who declared in no uncertain terms that California has gone too long without substantive reform, with Roxborough at one point noting (emphasis ours):

“...it’s been 12 or 13 years since we’ve had any sort of workers’ comp reform legislation…It’s probably necessary at this point.”

The meeting accurately addressed impediments to care for injured workers, particularly those resulting from the redundant combination of Medical Provider Networks (MPNs) and the Utilization Review (UR) system.

What the discussion only hinted at was the cost of these inefficiencies to employers, who pour increasingly higher premium payments into a system that is failing their employees. As the barriers to treatment keep injured workers injured, the costs to employers mount. As Jason Marcus of the California Applicants’ Attorneys Association (CAAA) pointed out (emphasis ours):

“I have clients with accepted knee, shoulder, joint injuries who often wait six or more months to see a surgeon even when everything is going as it should be.”

During that time, an injured worker in the (depressingly common) situation above may be receiving disability payments, rather than getting the care they need to return to full employment. As Commissioner Meagan Subers stated with regard to the RAND Corporation’s use of AI to study workers’ comp in the absence of real data (emphasis ours):

“I think that when you’re talking about medical access, I do feel strongly that it has to include discussions with the impacted community. So the injured worker, the doctor, the employer. The employers are paying into the system for the workers to get treated.”

The question is whether those employers are getting their money’s worth.

Stakeholders: MPN and UR Systems Impeding Care

CAAA’s Marcus was unsparing in his condemnation of the UR system, decrying its opacity and the lack of meaningful rationales behind treatment denials that can seem, in our view, almost random:

“Very often, the decisions, to me, are opaque, meaning I will have two clients with similar injuries, treating with the same treating physician, who submits the same request for treatment.

One gets approved, one gets denied. That, to me, is inconsistent, and it's frustrating…”

daisyData underscores Marcus’s point. Consistently, our analyses reveal wide disparities in treatment approval rates between different payers, indicating that UR decisions may have less to do with medical necessity and appropriateness and more to do with which payer is making the call.

Dr. Basil Besh of the California Orthopaedic Association further unpacked the UR problem, pointing out that UR is utterly redundant given that payers can restrict their injured workers to MPNs (emphases ours):

“Why would we possibly have both UR and the MPN? It would be one or the other.

If you have a tight network, then you relieve them from the burden of UR, right? Because they're your trusted physicians. But you have a loose network, like any willing provider, then you apply UR across the board. One or the other are reasonable. Why have both other than rationing by inconvenience?”

All that “rationing” can cost an employer thousands of dollars per month for a single injured worker.

CA Needs to “Weed the Garden” of Workers’ Comp

As Workers’ Comp Executive pointed out in its coverage of the meeting, optimistically titled “Workers’ Comp Reform Coming,” Commissioners and attendees likened California comp to an overgrown garden choked with weeds, an analogy that became a theme of the meeting after Jason Schmelzer of the California Coalition on Workers’ Compensation opined:

“Our workers’ comp system is like my garden, no matter how many times I weed that thing the next day when I’m outside one’s going to be popping up. I have to constantly go back to it…

…I think what we need is…to get back and sit down and start weeding our garden together as a group. It’s been too long.”

This prompted Chairperson Roxborough to focus the discussion on the need for new legislation to overhaul the system.

CHSWC’s previous chair, Mitch Steiger, later added critical context, noting that legislation is of limited value without enforcement by the California Division of Workers’ Compensation (CA DWC).

As daisyNews has repeatedly exposed, the CA DWC historically does next to nothing to impose consequences on habitually non-compliant payers. Steiger stated (emphasis ours):

“…we probably need to have someone from DWC at the next meeting. Or people from DWC at the next meeting, and ideally, those who could answer pretty weedy questions about enforcement, where we ask, ‘What happens if this? If a UR reviewer does this. If a TPA does this. If an insurer does this, then what happens to them? And then what does the enforcement look like?’”

Whether through new laws and regulations, stricter enforcement (any enforcement, really), or a combination of both, the meeting’s single biggest takeaway was clear: something needs to change. As Commissioner Kristi Montoya noted with respect to the lack of proper auditing of MPN and other systems:

“I think just like anything, the weeds growing in the garden, it constantly needs to be adjusted.”

The question is whether the CA DWC, under new leadership since the departure of previous Administrative Director George Parisotto, is willing to break out the rakes and spades.

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