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Commission on Health and Safety and Workers' Compensation (CHSWC)

Evaluation of treating physician reports

Background

The 1993 reforms increased the role of the primary treating physician (PTP). They require the PTP to render opinions on all medical issues necessary to determine eligibility for compensation, and when additional medical-legal reports are obtained, the findings of the treating physician are presumed to be correct. These legislative changes had the effect of reintroducing the importance of the treating physician that had been curtailed by the 1989 reforms and adding the additional authority of rebuttable presumption.

Incomplete physician reports have been cited as a major factor leading to inconsistency in permanent disability ratings. Many of DWC's disability evaluators have said that their largest problem with the current system is the poor quality of medical reports that have been submitted to them for rating.

Description

The Commission undertook a study to:

  • Determine the nature and magnitude of the problem.
  • Ascertain who is producing incomplete reports and why.
  • Develop quantitative analysis.
  • Provide recommendations for improving the quality reports.
  • Calculate the cost-benefit obtained from the system.
A random sample of medical reports was drawn from the DWC Disability Evaluation Unit and evaluated by the project team and representatives from the Industrial Medical Council. The costs of the reports were estimated separately using data from bill review companies or carriers.

Preliminary findings indicate that:

  • Treating physician reports are of substantially poorer quality than reports by Agreed Medical Evaluators (AMEs) and Qualified Medical Evaluators (QMEs) writing reports for the applicant or defense side or as QMEs selected from a panel by an unrepresented worker.

  • Of PTPs whose reports are submitted to the WCAB most are also QMEs

  • Most of the problems with PTP reports are on those reports where the PTP is not also designated as a QME by the Industrial Medical Council.

  • The application of presumption to the PTPs’ reports has not reduced the number of reports requested by parties on permanent disability claims at insured employers.

In short, changes to the status of the PTP made during the 1993 reforms have resulted in medical-legal decisions based on poorer quality reports without any apparent cost savings. In addition, there is consensus within the WCQB that presumption has increased litigation and curtailed the discretion of Workers’ Compensation Judges to craft reasonable decisions within the range of evidence.

In view of these findings the Commission is recommending that consideration be given to curtailing the presumption given to the findings of the primary treating physician. This could involve elimination of the special authority given to the PTP or the use of some lower legal standard granting the reports "great weight" but not presumption.

Status

This project was completed in 1999.

Further information

Report on the quality of the treating physician reports and the cost-benefit of presumption in favor of the treating physician, August 1999