Can someone explain to me how the physiology of a human being that lives in one state can differ so dramatically from human beings in other states? As some physicians and state regulators would have us believe, a doctor lacking licensure in a given state simply cannot understand the unique circumstances faced by patients in that state. Biology, it seems, recognizes state borders.
Take, for instance, the treating physician that recently refused to make any changes in her patient's drug regimen (which included the usual suspects - an opioid, a muscle relaxant, a sleep aid, etc... all for a twisted knee from 15 years ago). Her reasoning for not making changes? Despite the evidence presented and the collegial nature of the conversation, she stated that she was offended that the PRIUM reviewer wasn't licensed to practice medicine in her state. Our apologies, doctor. By all means, carry on with your medically unnecessary treatment.
Take the state of Illinois, where the Department of Insurance can't get out of its own way regarding some rather simple principles of utilization review. A bulletin from December appears to indicate UR physicians must be located within the state of Illinois... an unofficial response to inquiry indicates this doesn't apply to work comp... a follow up bulletin this month indicates that UR activities can't be "offshored", but doesn't provide any guidance as to the definition of offshoring, what constitutes UR activities, or whether it applies to work comp. Glad we cleared that up.
In a workcompcentral article on this topic, I noted the risk inherent in requiring UR doctors to be licensed and domiciled within the state from which the request was generated. Doctors in the same geographic area are much more likely to have trained together and may even be tied to one another's referral patterns. UR loses its independence and objectivity when conflicts of interest arise between reviewing and treating physicians that may have personal relationships or economic ties to one another.
But that's a more nuanced argument than is necessary here. The simple reality is that state licensure is a red herring - an excuse used by treating physicians when they're called out (however collegially) by a peer regarding medically unnecessary, and in some cases dangerous, treatment.
I'm tired of it. State legislators and regulators need to recognize that the injured workers in any given state will be better served by the input and oversight of the very best doctors... even if those doctors aren't the worker's treating physician... and even if they're not licensed in that state.
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