The Judge, The Doctor, The Patient: Who Should Decide?

Why is it that we have such a hard time in workers' compensation breaking free of the concept that judges shouldn't be making medical decisions?  And why do the judges making these decisions fail to recognize the unintended (and negative) consequences of their actions?

Enter Judge Donald Johnson of the 19th District Court in Louisiana.  Judge Johnson recently ruled that the state's approach to dispute resolution surrounding injured worker treatment requests is unconstitutional based on the fact that patients are being deprived of due process rights.  Since 2011, treatment requests from workers injured in Louisiana that are denied by utilization review are ultimately adjudicated by the medical director at the Louisiana Office of Workers' Compensation (OWC).  This way, a physician ultimately decides the applicability of the guidelines given the individual injured worker's clinical circumstances.

Judge Johnson has now suggested we go back to judges making these decisions instead.  I call it a "suggestion" because his decision isn't being enforced until the Supreme Court weighs in (likely some time in the next year).

And the usual suspects have taken their usual positions:

Payers are obviously displeased.  Medical costs had decreased and disability benefits had stabilized in the last few years in Louisiana.  The medical treatment guidelines and dispute resolution process put in place in 2011 appeared to be working.  

Plaintiff's attorneys are celebrating the decision.  Now that they have a shot at going back to the old way of resolving treatment disputes (i.e., requesting a hearing with an administrative law judge at the OWC), there's increased likelihood of care being delivered that's not in alignment with evidence based medicine.  Forget that several defense attorneys have observed that the new process actually resolves disputes faster than the hearing/ALJ approach.

This happens again and again as reforms are enacted to move medical decisions away from judges and back with doctors (where they belong).  Judges routinely attempt to take that power back.  Recall this same debate in California over the Dubon decision?  

Injured workers are best served by medical doctors making medical decisions.  Sometimes, that will involve multiple medical doctors: the treating physician, a peer reviewer, and perhaps the medical director of OWC.  And those doctors may not agree with one another.

But isn't an informed dialog and exchange of information among a group of physicians a vastly superior way to reach the right medical decision than relying on a judge to collect medical opinions, and with no medical expertise, decide which opinion should prevail?  

Michael
On Twitter @PRIUM1

A Terrible Excuse for a Formulary

I'm sitting in New Orleans, Louisiana at the annual RIMS conference and right down the road in Baton Rouge, the state is about to do something that will put a lot of injured workers at risk.  Ironic, right?

Louisiana Senate Bill 256 is scheduled for a hearing at 10 am central tomorrow.  I hope someone at that hearing points out the following:

1) Evidence based medicine isn't produced by a panel.  The bill calls for a panel (made up of one doctor and four pharmacists) to meet regularly and, by majority vote, decide what changes should be made to the formulary.  This is an awful idea.  Evidence based medicine is developed through peer reviewed research and should be adopted as the evidence dictates, not according to a majority vote.  For a brief glimpse into how guidelines adoption by committee works (or, rather, doesn't work) in Lousiana, check this out.

2) But should the state insist on a committee, we need to move beyond a single doc and four pharmacists.  Where is the voice of the employer on this proposed panel?  Where is the voice of the injured worker?  Wh y does a single doc and four pharmacists get to decide?

3) Worst of all... and the point that will lead to the greatest risk to injured workers... and the part of the bill that shows how very little its authors know about medical management: All "non-narcotic drugs" will be approved and not require pre-authorization.  Since when are narcotics the only dangerous drugs in work comp?  Hydrocodone might require authorization under this bill, but injured workers can have all the benzodiazepines, antidepressants, antipsychotics, anticonvulsants, sleep aids,  muscle relaxants, etc that they'd like.  The distinction between drugs that require authorization vs those that do not shouldn't be based on the drug's class.  Rather, good formularies assess the appropriateness of a given medication for first line therapy, regardless of class.  The approach outlined in SB 256 is worse than silly; it's dangerous.

A closed formulary is a great idea in concept and I genuinely hope to see Louisiana adopt one.
Just not this one.

Michael
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