WSIB Analysis of the Utilization of Medical Consultant File Reviews

Transcription

1 WSIB Analysis of the Utilization of Medical Consultant File Reviews

2 Utilization of Medical Consultant File Reviews Executive Summary Background: On November 5 th, 2015, the Ontario Federation of Labour (OFL) with six psychologists, and injured worker advocates released a report entitled Prescription Over-ruled. They allege that the Workplace Safety and Insurance Board (WSIB) systematically ignores the advice of treating medical professionals in favour of WSIB staff opinion and/or so-called paper doctors for the purpose of rejecting and limiting otherwise legitimate injury claims. On January 29, 2016 the OFL made a submission to the Ombudsman s Office requesting that an investigation be launched into this issue. Context: The WSIB contracts with a number of firms for Medical Consultant (MC) file review services. MC file reviewers are fully licensed Ontario physicians who do not diagnose or examine workers. Their role is to provide a medical opinion based on the medical information in the case to WSIB staff. The use of medical experts to review clinical information to inform non-medical decision-making is a common practice followed by worker compensation boards and the insurance industry. WSIB staff make approximately 12,000 requests for MC reviews annually. The majority of these cases are referred within the first year of a claim (46% within first year and 11% in second year). More than 20% of referrals are for claims that are beyond 10 years since the injury or illness, often where questions on medications may be raised. To facilitate decision-making, a MC file review may be requested for issues of causation/compatibility, functional abilities/level of impairment, treatment and medications. To ensure appropriate and consistent use of MC opinions, the WSIB guides staff on the purpose and process of MC referrals as set out in an Administrative Practice Document Weighing of Medical Evidence. On the WSIB website, it explains to staff and stakeholders how WSIB uses medical information in decision-making. MC File Review Utilization: Given the serious nature of the OFL allegations, the WSIB undertook a review of the use of MC opinions in decision-making. For the purpose of the review, a stratified random sample of 376 cases from the 2014 total referrals was selected. This number was considered as statistically significant for the purpose of this review. A team reviewed each of the 376 cases to review the allegation of systemic disregard of a worker s treating health professional, and to understand the frequency of difference in opinions, and the subsequent case impact. In 97% of the cases, cases were referred appropriately for a 2

3 MC file reviewer s opinion in accordance with expectations. The WSIB s requirement of staff is to assess the MC reviewer s opinion in combination with all other relevant information in the file in order to make a decision as set out in the Administrative Practice Document Weighing of Medical Evidence. In only 8% of the cases, the claim file documentation revealed the decisionmaker did not consider and assess the MC reviewer s opinion along with all other relevant information in the file in order to make the decision. It was found that in 85% of the cases, MC reviewer s opinion did not contradict the opinion of the worker s treating health care professional. In 15% of cases, there was some level of difference between the MC file reviewer and the treating health care professional. Differing opinions in the case file lead to three case impacts: partial allowance, full allowance, and denied entitlement. Conclusion: The review did not find any evidence of systemic disregard for the opinion of a worker s medical practitioners as alleged in the OFL s report. The review found that decision-makers are using the MC reviewer service appropriately to facilitate decision-making and case management. In the small number of cases where there were differing opinions, WSIB staff appropriately used and weighed all the medical information in decision-making. The WSIB has asked the OFL to provide the 40 cases contained in their Ombudsman submission so that any misuse of this medical service can be addressed. 3

4 WSIB Analysis of the Utilization of Medical Consultant File Reviews 1 The Medical Consultant File Review Context On November 5 th, 2015, the Ontario Federation of Labour (OFL) with six psychologists, and injured worker advocates released a report entitled Prescription Over-ruled. They allege that the Workplace Safety and Insurance Board (WSIB) systematically ignores the advice of treating medical professionals in favour of WSIB staff opinion and/or so-called paper doctors for the purpose of rejecting and limiting otherwise legitimate injury claims. On January 29, 2016 the OFL made a submission to the Ombudsman s office requesting that an investigation be launched into this issue. On February 5, 2016, the WSIB was interviewed by the Ombudsman s office as they determine whether to launch an investigation. While WSIB was confident that these allegations were unfounded, given the serious nature of the allegations, the WSIB undertook a review of the use of Medical Consultant (MC) file reviews in the decision-making process using a statistically valid methodology to determine whether there was in fact systemic disregard for treating professional s opinions. Included was a review of the consistency of staff in following protocols and controls in the referral process and in the application of that information in claim decision-making. This report provides background information about the use of MC file reviews (section 2), the nature and outcome of our review of the MC process (section 3), and findings of the review (section 4) and conclusions (section 6). 2 Background Decision-making: It is the legislated responsibility of the WSIB to determine if a worker s injury arose out of and in the course of employment and, when determined to be work-related, the worker s eligibility for benefits and services under the Workplace Safety and Insurance Act (WSIA). The WSIA places the burden of proof on the WSIB decision-maker to gather all necessary information when adjudicating and managing claims to make an informed decision in a manner that is unbiased and has regard for, and incorporates, all relevant information. Medical information from a worker s treating professional is critical to the decision-making process, starting with the initial report (Form 8). It is not the responsibility of the treating professional to determine whether a worker s claim is eligible for coverage when submitting the Form 8, as the onus for determining entitlement under WSIA is on WSIB decision-makers. In claims for work-related injuries, the decision-maker monitors and assesses new information about the worker s impairment and takes actions to facilitate return to work, assist the worker s recovery, and makes adjudicative decisions as appropriate. The work-relatedness of the 4

5 worker s impairment and treatment is evaluated throughout the life of the claim to ensure continuing entitlement under WSIA. Medical information from all the medical professionals who treat or assess a worker in relation to a work-related injury is therefore key information. Health information is gathered from many sources including a family physician, specialist, physiotherapist, psychologist, or WSIB contracted medical specialists, and may contain differing information or opinions. Additionally, the medical information in a claim file may deal with complex medical issues. While decisionmakers are technically knowledgeable in the administration of the WSIA, they are not medical professionals. As such, decision-makers sometimes require assistance in understanding the medical information received to inform their decisions. In these cases, the decision-maker may request a MC file review for the clarification they require to make a fair and informed decision taking into account all the claim file information relevant to the issue being decided. An MC file review may be requested for issues of causation, mechanism of injury, pathology, or interpretation of medical information, clarification of the relationship between a diagnosis and the accident history, work environment or employment circumstances, the effects of pre-existing conditions or other non-work-related conditions on the workrelated impairment, advice when there is a need for clarification of medical opinions on file. For example, the primary health care professional s treatment plan or list of functional abilities (or precautions) that may be different or contrary to the discharge recommendations from a Program of Care or Regional Evaluation Centre, the necessity and appropriateness of treatment and medications, particularly narcotics. While the MC file reviewers provide an opinion in response to the questions posed to them, they do not make claims decisions. The decision-maker must take into account all the available claim file information, including the MC opinion, that is relevant to the issue being decided. MC File Reviews: The use of medical reviewers of clinical information to inform non-medical decision-making is not a unique WSIB practice. This is a common practice across Worker Compensation Boards and the insurance industry. At the WSIB, many operational policies reference MC opinion or clinical reviews to assist in decisions on application of the policy, (e.g , Pre-existing conditions, , Chronic Pain Disability). Individuals providing MC opinions must not have an established relationship with the employer or the worker to ensure the process of claims adjudication and case management is valid and impartial. To ensure compliance with the decision-maker s legislated responsibility to meet the burden of proof for entitlement under WSIA, the medical opinions used to assist them in claims administration must be provided by individuals with access to all information required to provide 5

6 a fully informed opinion. MC file reviewers do not diagnose or examine workers. They provide a medical opinion based on a review of the medical information on file, including the information from the treating physician. To ensure the appropriate and consistent use of MC opinions, there are two key documents for staff: Considerations for Referral to Medical Consultant for Physician Case File Review informs staff on the referral process and questions that could be asked including: Compatibility between the mechanism of injury and diagnosis; entitlement for secondary injuries/conditions; functional abilities/level of impairment; ongoing treatment; appropriate drug utilization; The Administrative Practice Document Weighing of Medical Evidence, posted on the WSIB website, explains how our staff use medical information in decision-making. These documents establish the controls on the use of this service, including how to pose their questions for the referral to avoid bias. In addition to the documented materials for staff, oversight is provided by managers through comprehensive file reviews at designated key decision points in cases to ensure decision quality and appropriate case management. MC file reviews are encompassed within the manager case reviews. Prior to 2012, MC opinions were provided by staff physicians who, by virtue of their position at the WSIB, were independent of both the employer and worker. However, they were seen as biased towards the WSIB because of their employment relationship. In 2012, the WSIB introduced a new MC model that outsourced this role enabling access to independent, expert and timely medical opinions. With the new model, the WSIB competitively procured for and entered into contracts with a number of firms for file review services. The individuals who provide MC file review services are fully licensed physicians within the Province of Ontario and almost 40% are specialists, e.g. orthopedists, respirologists. The contracts set out expectations for the MC file reviewers that include: Review of all available medical information to provide an opinion in response to the questions posed in the referral Provide an opinion with medical rationale based on a detailed review and analysis of the available medical information, with a strong emphasis on utilizing evidenced-based medical literature and recognized medical best practices Calling the treating health care professional to discuss a case prior to submitting their opinion to the WSIB. WSIB monitors MC file review utilization including reasons for referrals, volumes of referrals, and timeliness of opinions. In addition, WSIB medical staff conduct random quality reviews of up to 20% of the MC opinions received to ensure contractual requirements for the reviews are 6

7 being met. WSIB medical staff review the opinions to ensure the responses are clear, supported with medical rationale and that MC reviewers conduct telephone consultation with treating professionals where appropriate. 3 Process of the Review Quality Program Review: A team with members from the Office of the Chief Statistician and Operations Program Quality developed a plan to conduct a review of the application of our Medical Consultant process beginning in November To review the practice objectively, the Chief Statistician s team provided a stratified random sample of 376 cases from the total referrals (12,347) sent for an MC opinion in The sample included referrals from all WSIB offices. To calculate the sample size, the following considerations and assumptions were made: Stratified design by referral reason Stratified allocation with oversampling for better representativeness in strata with smaller number of referrals An apriori assumption on the proportion of contrary opinions of 0.5 (the most conservative option on sample size due to lack of prior knowledge) A 95% confidence interval with a +/- 5% error around the estimate. A review template was developed with questions that would provide information relevant to the purpose of the review. Prior to initiating the review, Quality Reviewers refreshed their understanding of the related resource documents. To ensure consistency and common understanding, a calibration session was held whereby all members of the review team independently reviewed the same case followed by debrief to resolve any disparity in the responses prior to commencing the file review. Once the file review was completed, the data analysis phase began. Internal Audit Review: To provide the WSIB further assurance as to the appropriateness and sufficiency of the MC file review process, Internal Audit (IA) conducted an additional independent examination of aspects of the MC review process. The IA review scope included the following: Review of the appropriateness of the Quality Program Review, described above, to draw conclusions regarding the integrity of the MC File Review Process Validation that the sampling methodology applied was appropriate for drawing conclusions over the MC File Review Process 7

8 Review the process followed to refer a claim to a MC in order to confirm consistency with procedural guidance Re-performance of select file reviews performed by the Quality Program team to provide greater assurance over the conclusions drawn from the review. IA s review consisted of the following activities and procedures: Obtain a high-level understanding of key governing documents, sampling methodology and interim results from the quality review; o Administrative Practice Document: Weighing of Medical Evidence; o Considerations for Referral to Medical Consultant; and o Initial Referral for Physician Case File Review. Review the method followed to select sample claims for the quality review; Perform walk-through testing of the process followed to refer, make use of and document opinions obtained from medical consultants to confirm compliance with procedural guidance; Perform sample testing of injury claims from the quality review to understand the process followed and results reported; Understand the process used to measure and report the results of the quality review; and Review the data analysis performed and final results of the quality review. Additional Work: The IA review identified some differences in documentations from the review, but the differences appeared to be minor in IA s judgement. To validate the significance of these findings, it was determined that a blind validation of the original quality review results should be conducted for additional assurance of the results. Three of the original questions were used to determine inter-rater reliability and assess the range of any human error within the original file review. The Chief Statistician s office conducted analysis of the difference in how the reviewers questions were answered. To do so, the Cohen s Kappa coefficient was applied by the Chief Statistician. This is a statistic which measures inter-rater agreement for categorical items. Items such as physical exam findings, interpretations, or other tests often rely on some degree of subjective interpretation by observers. The agreement between two observers can be measured using Cohen s Kappa coefficient. Kappa above 0.81 is considered Almost perfect agreement. Analysis of the results found the Kappa was between 0.85 ( ) and 0.87 ( ) which signifies substantial agreement to almost perfect agreement 1. 1 The interpretation of Kappa is from the research paper Understanding Interobserver Agreement: The Kappa Statistic, Anthony J. Viera, MD Joanne M. Garret, Phd. (Fam. Med 2005; 37(5):360-3) 8

9 4 Findings The total population MC referrals in 2014 involved 10,664 unique claims. The following pie chart shows the distribution of the timing of the MC referral in 2014 relative to the date of the accident for the claim. <= in the legends above means less than or equal to The following chart shows the referrals for MC File Review by reason for claims referred in 2014 (n=12,347 annual). This population is greater than the population noted above as some claims were referred for MC file review more than once in

10 The following are the key findings of the quality review: What was the experience of MC opinions differing from treating professional s opinions? For these findings, treating professional may refer to a family doctor/general practitioner, specialist (including Psychiatrist), Psychologist, sports medicine physician, pain management physician and/or contracted health care provider of the WSIB, such as the Regional Evaluation Centre. Fully or in full refers to cases where the MC agrees with all of the recommendations the treating professional(s) has made. Partially or in part refers to cases where the MC agrees with some, but not all of the treating professional s recommendations. Partially or in part examples include, but are not limited to: Agreement on the treatment proposed but a difference of opinion with respect to the duration of treatment Agreement on the prescription of opioid medication but a difference of opinion on the appropriate dosage. Here are the findings: In 65% 2 (weighted 54% 3 ) of the cases, the MC opinion was fully or partially in line with the treating professional s opinions(s) on file. In an additional 24% (weighted 36%) of the cases, there was no treating professional s opinion with respect to the issue(s) under review by the MC. In 6% (weighted 6%) of cases, the MC did not provide a medical opinion and recommended either outstanding medical reports be obtained or that further medical investigation(s) and/or consultations/exams were required. In 5% (weighted 5%) of the cases, the MCs opinion differed from the treating professional s opinion on file. Given the importance of the existence of a difference in opinions from the perspective of the OFL allegations, the percent of cases with any disagreement irrespective of its impact on benefits was examined. The percent of cases found to have some level of difference is 17% (weighted 15%) while 83% (weighted 85%) of cases had no level of difference of opinion. 2 This is the crude percentage which represents the percentage within the sampled observation only and without considering the representativeness of each sample case in the population 3 The weighted percentage represents the estimated percentage within the total population. Each sampled observation represents a total number of responses equal to its weight. The weights are based on the true proportion of the strata in the population. 10

11 Where differing opinions arise was all information consistently and appropriately reflected in decision making? Of the 63 cases reviewed where the MC opinion differed in full or in part with the treating professional(s), the decision maker allowed entitlement to benefits in full or in part in 62% (weighted 59%) of the cases, and denied entitlement in 38% (weighted 41%) of cases. Of these 63 cases with differing medical opinions, there were 24 cases which resulted in a denial of entitlement to benefits (10 of the 24 related to medications). In these cases there was evidence the decision maker considered all the relevant information in the case including, but not limited to the MC opinion, and applied key case management activities arriving at their adverse decision. The decisions involving denials mainly involved medication entitlement or dosage level approvals. A small number of denials concerned compatibility of the diagnosis related to the workplace injury. Were there any opportunities for improvement? There are opportunities for improvement, primarily with respect to communication of decisions, and these are being developed. These were not related to the two guiding documents on how and when to use MC file review services. Any other notable findings discovered? The sample contained a wide array of complexity with respect to the issues under review. In 24% of the cases reviewed there was no treating physician opinion with respect to the issue being reviewed by the MC. In some cases the MC was asked for an opinion on more than one issue and in many cases the injured worker was under the care of more than one treating physician. As a result, there were cases where the MC opinion was fully or partially in line with one treating physician but may have differed with another. 5 Conclusions Decision-makers must consider all available information relevant to the issue, including the MC opinion, when deciding on an issue. The quality review indicated that 97% (weighted 96%) of cases were referred appropriately for an MC reviewer s opinion in accordance with the documents noted earlier. In approximately 85% of the cases, the MC reviewer s opinion did not contradict the treating health care professional. The total includes cases in which the MC reviewer requested further medical investigation or where there was no original treating professional s opinion. In 15% of the cases, the MC reviewer s opinion was fully or partially different from the health care professional. Within this 15% of cases, we noted three types of decisions followed - denied entitlement (entitlement decisions included loss of earnings benefits, health care treatment and/or medication), limited entitlement and some cases being fully allowed entitlement. We also examined whether the appropriate use and weighing of the medical opinions was evident in decision-making. In only 8% of cases, the claim file documentation did not reveal the decision-maker considered and assessed the MC reviewer s opinion together with all other relevant information in the file in order to make the decision. 11

12 In conclusion, this review found that decision-makers are using the MC reviewer service appropriately to facilitate decision-making and case management. The review did not indicate a systemic practice of ignoring the opinion of medical professionals to reject or deny cases as alleged. The review did identify the opportunity to improve the written communications of decisions and options to do so are being developed. 12