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Independent Medical Review Decisions: January 2015 Through December 2021

CWCI's latest update on Independent Medical Review, derived from IMR decision letters from 2015 through 2021, measures changes in IMR volume, shifts in the mix of services reviewed; changes in IMR response times; regional variations; and IMR uphold rates by medical service category. The study also looks at the distribution of prescription drug IMRs and uphold rates by drug category; the proportion of IMRs involving medical service request modifications among six treatment categories; and the concentration of IMR activity among high-volume physicians named in IMR letters.

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Can Access to Medical Care in California Workers' Compensation Be Improved?

CWCI takes a detailed look at issues surrounding injured worker access to medical treatment in California workers compensation. The study measures the average and median days to initial treatment for various services and injured workers proximity to care, and notes provider perspectives, gleaned from individual interviews, on the administrative burdens associated with rendering care in the workers' compensation system.

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California WC Inpatient Hospitalization Trends, 2010-2020.

A CWCI Research Update report uses OSPHD data to track changes in the volume and types of inpatient hospitalizations in California workers compensation from 2010 through 2020 and compare workers compensation inpatient hospitalization trends to those in Medicare, Medi-Cal and private coverage. While updating the long-term inpatient hospitalization trends, the report also provides a focused look at the changes in inpatient hospitalizations between 2019 and 2020, highlighting the impact of COVID-19 on California workers compensation inpatient care, identifying changes in the types of conditions treated and the services delivered to injured workers during the first year of the pandemic.

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COVID-19 Death Claim Trends and Characteristics

COVID-19 Death Claims: a new CWCI report takes an in-depth look at the trends and characteristics associated with 1,032 California workers compensation death claims from the first 18 months of the pandemic. The report tracks changes in the number of COVID and non-COVID death claims from January 2020 through June 2021 as well as changes in the percentage of all death claims ascribed to COVID during that 18-month span, and compares the distributions of COVID death claims vs. all COVID claims, and non-COVID death claims based on the workers age and gender, as well as by region and industry.

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CWCI Analyzes Bill to Cut WC Claim Investigation Times & Increase Employer Medical Liability

A CWCI report examines SB 335, a bill that would cut the amount of time claims administrators have to investigate job injury claims and increase employers liability for medical benefits during the investigation period by 70%.

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AB 1465 and Medical Provider Networks in the California Workers' Compensation System

A CWCI analysis of a 2021 legislative proposal (AB 1465) intended to increase injured workers access to medical care by requiring the state to create a medical provider network (CAMPN) as an alternative to private networks that render 90 percent of California workers' compensation treatment. The report provides background information on the use of medical networks in California workers' compensation, reviews how the proposed statewide network would be structured, and evaluates the potential for improving injured worker access to care. The analysis includes data on time to initial treatment and injured worker proximity to treating providers for current MPN and non-MPN claims, shows the percentage of injured workers treated within and outside MPNs who meet the states access to care standards, notes the average distances these workers must travel to receive primary care and surgery services, with results broken out for urban, suburban and rural residents, and estimates the cost of building and maintaining the CAMPN.

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IMR Decisions: January 2014 Through December 2020.

A CWCI Research Update report documents the sharp decline in IMR volume in 2019 and 2020, fueled by the reduction in prescription drug IMRs and the economic slowdown brought on by the COVID-19 pandemic in 2020. The report also looks at the distribution of IMRs and IMR outcomes by medical service category, regional distributions, IMR response times, and examines the distribution of pharmaceutical IMRs among therapeutic drug groups.

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California Workers' Compensation Prescription Drug Trends.

A CWCI Research Update Report provides new data on prescription drug utilization and reimbursement trends, based on 5.85 million prescriptions dispensed to California injured workers from 2011 through June 2020. The report looks at changes in the distribution of prescriptions and payments by therapeutic drug group; details opioid utilization trends for AY 2007 -2018 claims at 24 months post injury using four different metrics; and measures pre- and post-formulary shifts in the mix of prescription drugs and payments among the formularys drug categories.

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California WC Inpatient Hospitalization Trends, 2010-2019.

A CWCI Research Update report finds that the steep drop in inpatient hospitalizations involving California injured workers over the past decade was largely due to the ongoing decline in spinal fusions and a more recent decline in lower extremity joint surgeries. The study reviews OSHPD discharge data on 35.9 million inpatient hospital stays from 2010 through 2019 paid by workers' compensation, Medicare, Medi-Cal and private insurance to identify workers' comp inpatient trends and compare the volume and types of inpatient hospitalizations covered by workers comp to those covered by the three other systems. CWCI members and subscribers can log in to view a summary Bulletin under the Communications tab, and the full report under the Research tab. CWCI members can also log in to the Research section to access the updated version of the Inpatient Hospital interactive data tool.

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Impact of the Calif. WC OMFS New Geographic Adjustment Factor

Impact of the OMFS's New Geographic Adjustment Factor: CWCI Research compares E&M service and payment data before and after the switch from a statewide to an MSA-based geographic adjustment factor within the OMFS. The study compares 2018 and 2019 data to identify changes in the distribution of E&M services and payments among MSA-assigned counties; average amounts paid within MSA-assigned counties; the overall mix of E&M services used within the state; and the proportion of E&M services that were paid below the amount allowed by the fee schedule and the change in the average discount.

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Changes in Medical Treatment Trends After 20 Years of Incremental Workers' Compensation Reform

Institute research tracks changes in California workers' compensation treatment patterns, including utilization and payment trends for different categories of medical services, following the implementation of major legislative and regulatory reforms enacted over the past two decades. The study has been released as a Research Note which includes background on the reforms, plus exhibits and analyses for the various service categories. A news release is in the Newsroom, and members and subscribers can log in to view a summary Bulletin as well as the full report.

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Integrating COVID-19 Presumptions into California Workers' Compensation

A CWCI Report examines the historic role of WC presumptions, the current and proposed COVID-19 presumptions, and results of a survey detailing characteristics and outcomes of initial COVID-19 claims.

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IMR Decisions, January 2014 Through March 2020

The number of IMR determination letters in California workers' comp fell 11.3% in 2019, led by a sharp decline in prescription drug disputes, with initial data from 2020 showing the decline is continuing.

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Trends in the Utilization and Reimbursement of Professional Medical Services in California Workers' Compensation, 2013-2018

CWCI's analysis of changes in the volume and reimbursement of California workers' comp professional medical services from 2013-2018, which includes the 4-year transition to the RBRVS fee schedule that began in 2014. The study reviews data from nearly 36 million medical services rendered to injured workers during that period to measure shifts in the mix of services and payments across and within 9 major services categories, and discusses the underlying changes to the fee schedule that affected those moves.

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The Impact of Declining Opioid Use on Lost-Time Claim Development and Outcomes in California WC

A 30-page CWCI Report to the Industry details CWCI research that quantifies the declining prevalence of opioids in workers comp lost-time claims, the impact on average benefit payments and average days away from work, and in light of the opioid trends, estimates projected costs for 2010-2017 claims at 10 years of development.

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Post-Reform Medical Service Approval Rates in California WC

A new CWCI study on California workers comp medical care approval rates shows 94% of all treatment services performed or requested for injured workers in the first 10 months of 2018 were either approved or approved with modifications, though outcomes varied by type of service.

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California Workers' Compensation Inpatient Hospitalization Trends, 2010-2018

CWCI's updated look at changes in the volume of inpatient hospitalizations in WC, Medicare, Medi-Cal and private plans from 2010-2018. The study shows the most common WC inpatient diagnosis-related group codes (MS-DRGs) and the top 5 Major Diagnostic Categories (MDCs); and provides detailed data on other workers compensation inpatient trends, including changes in the volume of implant-eligible spinal surgeries and a listing of the top 10 hospitals based on injured workers as a percent of their total inpatient discharges. CWCI members and subscribers can log in to view the summary Bulletin under the Communications tab, and the full report under the Research tab. Institute members can also log in to access the updated version of the Inpatient Hospital interactive tool from the Research section. CWCI members and subscribers who log in may read the full report, others may purchase a copy from the Store.

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IMR Decisions: January 2014 Through December 2018

Independent Medical Review Volume and Outcomes Through Q4 2018. Click below for the Research Update report. Summarized results are included in the news release in the Newsroom, and CWCI members and subscribers may log in to access the summary Bulletin.

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Calif WC Pharmaceutical Utilization and Reimbursement: Emerging Outcomes Under the Formulary

A CWCI Spotlight Report examines the impact that the Medical Treatment Utilization Schedule has had on the types of medications dispensed to injured workers and recent shifts in the total drug spend.

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California Workers' Compensation Prescription Drug Utilization & Payment Distributions, 2009-2018: Part 1

CWCI's analysis of changes in the types of prescription drugs used in California workers' compensation over the past decade. The report looks at the breakdown of prescriptions and payments by therapeutic drug group by service year, as well as the generic utilization rates for the different drug groups and how the average amounts paid for drugs within each group changed over the 10-year study period.

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