Date: 08/31/2009
Final
Medical Testimony
INTERIM COMMITTEE TO STUDY ISSUES RELATED TO PINNACOL ASSURANCE
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09:18 AM -- Medical Testimony
John Hughes from the Colorado Medical Society (CMS) and Chair of the CMS Worker's Compensation Committee testified. (Attachment B) When Pinnacol had a medical director, he was included on the WC Committee but in November 2008, when the medical director resigned, communication between CMS and Pinnacol dropped. CMS has tried to be collaborative. They are meeting with Pinnacol to develop an ongoing relationship. Hugh McCauley, the new medical director at Pinnacol has been invited to sit on the committee. Dr. Hughes shared his concerns about Pinnacol. These included the gap of medical direction, issues with physician requests being denied without a medical explanation, lack of accountability, authorization of care issues, independent medical exams (IME) not aware of a particular treatment, and long-term care being difficult for patients. He mentioned an example of video surveillance of a claimant by Pinnacol.
Representative Miklosi asked how often there is not a match between the injury and IME. Dr. Hughes wasn't sure.
Ken Ross clarified that Pinnacol and CMS will be meeting regularly to provide better medical care. When asked to compare Pinnacol with other carriers, Dr. Hughes responded that Pinnacol's process is the most fair and transparent of carriers in Colorado.
Several committee members asked questions about Dr. Hughes' role as a physician advisor for Pinnacol Dr. Hughes doesn't know when a claimant is represented by an attorney but thinks it would be a good idea to know. His opinions are usually respected but not by all claim teams. The cases he reviews tend to be complex and severe.
09:43 AM
Dr. Kathryn Mueller, medical director from the Division of Workers' Compensation gave her presentation. (Attachment C) Dr. Mueller discussed the elements of workers' compensation law affecting physicians. She discussed the two levels of accreditation; medical treatment guidelines; the AMA Guide, 3rd Edition; impairment ratings; and what level of accreditation is required for each step of the medical portion of a claim. She talked about the emphasis on function in evaluating impairment rather than pain and noted that the guidelines don't give points for pain alone.
Dr. Parrry asked if the division is looking at outcomes over long terms. Dr. Mueller replied that they would like to but they don't have the funding for such a study.
Senator Mitchell asked why the division is using the AMA Guide, 3rd Edition and why no one has brought a request to update the volume in statute. Dr. Mueller said that it could be done and would simplify ratings for doctors. Senator Mitchell asked if using the newer edition would have an effect on benefits. Dr. Mueller has not done a comparison but thinks it could reduce spine ratings. Senator Carroll suggested having a comparison done on guides.
When asked about education of patient, Dr. Mueller said there is no system in place but there are incentives for doctors to provide education.
Representative Gerou asked about the division sunset date and whether updating the AMA Guide could be covered in sunset. Dr. Mueller didn't know the date. Representative Gerou asked if the reference to the edition could it be taken out of statute and Dr. Mueller said it could.
10:11 AM --
Dr. William Woo, an occupational doctor with Exempla testified from his perspective as a medical provider for Pinnacol. He surveyed other network providers, physicians, physical therapists, case managers and a billing specialist and received favorable comments with noted improvement over time.
Dr. Parry asked a series of questions about his participation with Pinnacol. Dr. Woo is a member of SelectNet and approximately 40% of his work is with Pinnacol. Complex medical cases are referred to specialists but coordinated by primary care physician.
Mr. Ross disclosed that he met with Dr. Woo about becoming Pinnacol's medical director.
Senator Carroll asked about ex parte conversations about patients. Dr. Woo state that inquiries from carriers should be in writing.
10:22 AM --
Dr. Chris Ryan, a specialist in physical medicine who is often the physician of last resort, testified. He was involved in the implementation of the workers' compensation law change in 2002. He uses the AMA Guidelines 6th Edition for federal WC claims. Dr. Ryan said Dr. Macaulay (new Pinnacol Medical Director) will be an excellent medical advisor. Dr. Ryan has had a 20-year association with Pinnacol and said that care is often denied. He believes that the many questions he gets from IME's is money poorly spent because IME's rarely win. He's seen hundreds of his patients under surveillance which he said is also money poorly spent. Dr. Ryan wishes he had access to Pinnacol physician advisors. He has never received a call from one but would like their input. He commented that the AMA Guide, 6th Edition is a radical departure and will be difficult to implement and teach physicians. Ratings are quite a bit lower generally but it is well written and uses evidence-based medicine.
Representative Gardner asked for a definition of physician of last resort and posed questions about Dr. Ryan's practice. Dr. Ryan only sees complex cases of people who have seen 10-20 or more doctors. Of his patients, 20 to 30 percent are insured by Pinnacol and 70 to 80 percent are other carriers. Pinnacol is in some ways better, some worse. The physician advisor is critical, and needs to be made available to treating physician. He's not sure if Pinnacol uses surveillance more than any other insurer but thinks its used too much generally.