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Division of Workers' Compensation (DWC)

Industrial Medical Council - Survey of QME/AME reports 2001

Introduction

The Industrial Medical Council is mandated by Labor Code Section 139.2(i) to continuously review the quality and timeliness of medical-legal evaluations written by Agreed and Qualified Medical Evaluators. The review is mandated to include a random sample of reports submitted to the division as well as a review of reports that are alleged to be inaccurate or incomplete by a party to the case for which the report was prepared.

Structure of the review

The IMC staff uses a three tiered system to review medical-legal reports. The first tier includes an inspection for the presence or absence of the elements of a report required by the Labor Code, primarily sections 4628 and 10606. The second tier examines the more complicated issues raised in medical-legal reports, such as apportionment and factors of disability. The third tier consists of a review to ascertain whether the report complies with the IMC evaluation protocols for pulmonary, cardiac, psychiatric, immunologic or neuromuscular problems.

After the completion of the review of an individual report, the IMC generates a customized letter to the physician concerning the findings of the review. Reports with potentially serious problems, such as ghost writing, changing offices or treating the injured worker during a medical-legal evaluation, are forwarded to the complaint tracking system for appropriate action.

The results of the survey have been periodically reported in the last year in public meetings and in such forums as the IMC's newsletter and educational seminars. Topics that have proven to be problematic for a significant number of physicians are then highlighted in these forums as case study material.

Source of the reports

The reports that are reviewed in this study are received from many sources. Many reports were submitted from the Disability Evaluation Unit. These reports are selected randomly by computer. We also solicited reports from the Workers' Compensation Appeals Board in order to broaden the sample of reports. Some of these reports are randomly selected, while others are hand picked because they had flaws. In the latter instance, some of the "problem" reports were identified as such, while others were not. We would like to express our appreciation to these units for their invaluable assistance.

The Industrial Medical Council receives a number of complaints about Qualified Medical Evaluators concerning a specific case. In these instances, the Discipline Unit staff asks the complainant to submit the applicable report, which is then reviewed in our survey.

We also received reports where the quality of the report was the only complaint. These reports were not included in the "complaint" records sent to the Discipline Unit. In the past, some groups in the community were reluctant to send us reports as the educational letter, which we sent to the QME, indicated that we had had a complaint about the report. The groups thought that the physician who wrote the report would know who sent it to the IMC and the knowledge of that complaint would damage their relationship with that physician. Therefore, these reports can be submitted anonymously and are are not flagged as a "complaint" report.

Results of the review

A total of 1040 reports were reviewed this year by the IMC staff. Sixty-seven of these reports were part of a complaint submitted to our Discipline Unit. As noted above, some groups such as the WCAB sent us reports that contains flaws. As these reports were not labeled as flawed, the total number of "problem" reports cannot be tracked. This is a departure from previous surveys where we could clearly identify the reports that were sent to us as being problem reports as only the Discipline Unit received them.

As in the last few years, the most common oversight was failure to note that the evaluator complied with the required face to face time with the injured worker. This fact was omitted in eighteen percent of the reports, down from twenty two percent last year and forty four percent in 1998. The next most frequent mistake was omission of county or date where the declaration was signed which occurred in fourteen percent of the reports. The mandatory declaration was not included or was altered in eleven percent of the cases. The name or qualification of an assistant was not given in ten percent of the files.

All of the "complaint" reports submitted to the Discipline Unit were reviewed using Tier II and Tier III. Forty eight percent of the "complaint" reports had an internal inconsistency within the report. This is compared to a five- percent rate in all of the reports. Twenty two percent of the Discipline Unit reports had a problem with apportionment. Twenty percent had problems with the subjective factors and fourteen percent with work restrictions. An example of an error is failure to apply the restrictions to the open labor market.

Most of the reports that were reviewed in Tier III were neuromusculoskeletal evaluations. The most common error was failure to report a complete physical examination, according to the IMC Evaluation Protocols or Packard Thurber. This error was seen in seventeen percent of the complaint reports. The history was not complete in six percent of the reports.

Of the 1040 reports that were reviewed, 148 were written by an AME, with the remainder being written by QMEs. Although each group did slightly better in a few areas, there was no statistically significant difference in the performance of the two groups.

Conclusions

In 2001, the IMC staff reviewed one thousand and forty reports written by Qualified Medical Evaluators and Agreed Medical Evaluators. The ultimate goal of this project is to improve the overall quality of reports through education and by decreasing the number of reports, which contain errors or omissions. Physicians' reports serve as expert testimony before the WCAB. This review is important in that it is currently the only direct feedback physicians in the system receive as to the overall quality of their work.

QME and AME reports continue to improve. As half of our reports were not selected randomly this year, we expected to find more errors than last year. We were pleasantly surprised to not find this to be true.

It is a common belief that AME reports are superior to QME reports. However, in our study, there was no statistically significant difference in their quality.

Goals for 2001

    1. The Legislature has given us the mandate to survey the quality of medical-legal reports. The IMC has taken a step further and has been giving specific feedback to the evaluators. We would like to see the quality of the reports continue to improve, especially the ratability of the reports. To this end, we have received approval from the Legislature to hire a rater. We hope to be able to have this rater review each of the reports next year. We should be able to provide the QMEs and AMEs even more valuable feedback next year.
    2. The feedback from these surveys has already been incorporated into the latest edition of The Physician's Guide to Medical Practice in the California Workers' Compensation System.
    3. The Industrial Medical Council is updating the examination given to incoming QME's. The results of this survey will be used to help develop and prioritize the types of questions that should be asked.