CMA last week submitted comments to the Division of Workers' Compensation (DWC) on the division's revised medical treatment utilization schedule regulations. The proposed treatment rules, largely based on the American College of Occupational and Environmental Medicine (ACOEM) guidelines, are the result of the Workers' Compensation legislation passed in 2004.

In its comments, CMA again emphasized the need to develop protocols for treating patients with chronic conditions. Even though chronic conditions are the real cost drivers in the workers' comp system, chronic care is not sufficiently addressed in the guidelines under consideration.

CMA urged DWC to change its definition of "functional improvement" so as not to unfairly deny coverage for the treatment of chronic conditions. CMA is concerned that the proposed definition of "functional improvement" could result in the denial of continued care if "significant" improvement is not demonstrated. "'Significant' is a subjective term and sets too high of a standard," wrote CMA CEO Joseph Dunn in the comments. "The goal should be for the patient to show clinical improvement. When a doctor believes a patient is continuing to improve and needs further treatment, that patient should receive it."

CMA also recommended that the medical decisions of the treating physician be presumed correct in cases where the treatment is not specifically addressed by the guidelines. "In instances where there are no guidelines, the proposed system would deny the clinical experience of the treating physician who is uniquely aware of the specific needs of the patient," wrote Mr. Dunn in the comments. "Payers should not be allowed to deny payment for services on the sole basis that the treatment is not addressed by evidence-based guidelines."

CMA expressed strong support for the proposal to establish a Medical Evidence Evaluation Advisory Committee. This committee would be made up of board certified physicians and would advise the division's medical director on matters concerning the medical treatment utilization schedule. CMA has recommended that "board certified" include boards recognized by the American Board of Medical Specialties or the Medical Board of California.

Click here to read CMA's comments.

Contact: Ronda Paschal, 916-444-5532 or rpaschal@cmanet.org.