Data on California workers’ compensation independent medical review (IMR) decisions issued in the first quarter of this year shows that the medical dispute resolution process established as part of the 2012 workers’ comp reforms continues to produce consistent outcomes.

There has been little change in the number of IMR determination letters and decisions; the percentage of modified or denied treatment requests that are upheld; the types of treatment requests reviewed; and the small number of physicians who are linked to a majority of the disputed medical service requests.

The latest IMR results come from a California Workers’ Compensation Institute (CWCI) review of IMR decision letters issued in the first three months of this year in response to applications sent to the state Division of Workers’ Compensation after a utilization review (UR) physician modified or denied a medical service requested for an injured worker.

The Institute’s review of the first quarter IMR decisions found that IMR doctors upheld the UR determination 90.6% of the time, while in 9.4% of the cases they deemed the service medically necessary and overturned the UR decision.

That uphold rate nearly matched the 91.2% rate noted for IMRs from the two prior years, and just as in each of the five years since the IMR process began in 2013, pharmaceutical requests represented almost half of the IMR decisions in the first quarter of 2018.

As in the past, requests for opioids were the most common pharmaceutical request submitted for IMR, accounting for 31.0% of all prescription drug IMRs in the first quarter, even though in 91.1% of the IMRs involving opioids, the UR modification or denial was upheld.

Those percentages could change in the future, as most of the first quarter IMRs involved UR decisions from 2017, prior to the January 1 implementation of the workers’ compensation prescription drug formulary and regulations, which set new limits and rules for prescribing opioids to injured workers in California.

The latest results also show that compound drugs represent a dwindling share of the prescription drug IMRs, accounting for just 2.1% of the pharmaceutical IMRs in the first quarter, down from 4.2% in 2017 and 8.1% in 2015, a decline that may be linked to the 98% uphold rate for compound drug denials and modifications submitted to IMR.

As in prior results, the latest IMR data also showed that a small number of physicians continued to account for a disproportionate share of the disputed medical services submitted for IMR. CWCI found that the top 1% of requesting physicians (117 providers) accounted for 44% of the disputed service requests, while the top 10 percent (1,169 providers) accounted for 85% of the disputed service requests.