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It’s all too often that I am unable to sleep, sometimes for days on end. There are only two days left of 2006. This time in my state of being awake, and looking at my logs for referrers I’ve come across some more interesting stuff to process. The lack of required mental health care and physical treatment has left me altered to say the least. I am emotionally unstable, I cry almost daily, and days I don’t I hold back my tears some how. I write in a blog because it is MY outlet. I don’t have a professional to talk to regularly anymore and this feels like the healthy thing to do. I honestly feel homicidal at times, and suicidal the rest of the time, again I fight my urges, feeling exhausted. I didn’t used to feel this way, I feel the medications that were last prescribed to me had a huge effect on this. You may have heard of it, Cymbalta. But I will get into that later.

I found an interesting article titled ‘Altering the workers’ comp system‘
It’s about the Workers’ Compensation System and the reforms that were put in place coincidentally when my case fell apart and was hijacked by SCIF. [via]

Has workers’ compensation reform gone too far?

YES!

In 2003 and 2004, a series of reforms gave employers and insurers — who pay the bills — more control over how doctors treat and evaluate patients by making them subject to new rules and reviews.

Those changes have transformed the system. The overall cost of workers’ comp has fallen roughly 60 percent in two years, driving down insurance rates by a comparable amount — in large part because of a 46 percent drop in new claims for workers’ compensation.

But since the changes went into effect, injured workers have complained that the new system is so snarled in red tape that doctors sometimes can’t provide needed care.

The insurance company is more likely to just send you to their doctors who will just ignore your treatment regimen entirely leaving you to just rot as they did me, even going as far as committing malpractice in their failure to monitor off label medication use, which they are happy to prescribe, since they get the drug company kickbacks. The ACOEM guidelines allowed or off label prescriptions? (Read NO SCIENCE WAS PUT INTO THE USAGE.) Sure why not, they’re only committing malpractice too.

Now Dr. Anne Searcy, medical director for the Division of Workers’ Compensation, is echoing at least one aspect of those complaints. As the doctor-in-chief for the state agency that polices this program, Searcy fears that an enforcement loophole may give the new reviews an unfairly tight-fisted tilt.

Since the reviews started in 2005, they’ve been conducted under what amounts to an honor system with no specific penalties for non-performance.

Again, let the patient rot, and lose their mind by not providing them care, they save money, while the injured worker pays for their mischief in mental anguish, and physical neglect. I am unable to exercise regularly, and the last time I was able to was when I was in Aquatic Therapy, which allowed me to exercise and build muscle in a buoyant environment, which brought less pain, and strain on my back. I have since lost most of my muscle mass. I haven’t lost much fat, only muscle, and now weigh 176lbs on a good day, I used to weigh 260 when I was injured. My center area, spare tire, hasn’t lost any fat, stomach, and upper thighs. I am skinny everywhere else though, which I’m sure not being able to eat on a regular basis has an effect on this.

“That’s the piece of the puzzle we need to get in place,” said Searcy, who believes some patients seeking sensible care have gotten the runaround.

“I’m hearing now where people are having shoulder surgery and not getting physical therapy and ending up with a frozen shoulder,” Searcy said.

I suppose I’m lucky enough that I did not go under the knife when my case was essentially destroyed, although I had some procedures done the previous year, none of which helped, and only left me in a worse off state.

How extensive is the problem? Searcy estimated that 5 percent of treatment requests may be getting tied up in red tape. Given the size of the system — perhaps 600,000 cases will be filed this year — that could affect 30,000 Californians.

I am one of those poor schmucks!

The division has been trying to write rules to penalize abuse of the review process but insurers and employers have resisted. State officials, poised to release new penalty proposals, anticipate getting pummeled by payers, who are likely to consider the penalties too tough, and patients, who may see them as too little, too late.

Of course they will resist, it again goes towards their bottom line, hell they are a for profit company, their directors and executives I’m sure receive bonuses.

While reviews and penalties may seem arcane, these practices go to the heart of the changes that transformed workers’ compensation from a system that cost employers about $24 billion in 2004 to about $10 billion today.

So if claims are cut by 46%, and they’re not spending the $14 billion dollars, where is the extra $104 million dollars going?

Before the reforms, state law said a physician treating an injured worker was presumed correct. Whatever the doctor ordered, workers’ compensation had to provide. But the reforms stripped physicians of that presumption. Instead, the state designated a set of treatment guidelines — written by the American College of Occupational and Environmental Medicine, better known as ACOEM — the arbiter of medical necessity.

It also stripped Chiropractors of the ability to independently treat workers. You can buy this ACOEM guidelines book for about $250 last I looked. Also around 2004, there was a ruling about required treatments. In “2004 significant panel decisions”

December 8, 2004
(WCAB No. RDG 0091839)
69 Cal.Comp.Cases 1567
NOTE: The Board held that an applicant is entitled to such medical treatment as is reasonably required to “relieve” from the effects of an industrial injury, even if such treatment will not “cure” that injury. Thus, the phrases “cure and relieve” and “cure or relieve” are interchangeable.

Again before my case was hijacked, Acupuncture, Chiropractic Care, Aquatic Therapy, and Professional Mental Help from a Psychologist, relieved the effects of my industrial injury. All of which they refused to provide me because they state they are not in the ACOEM guidelines, and of course their doctors would refuse such treatments to me, how else would they keep the stream of insurance recommended patients coming their way.

Back to the article…

Lawmakers also created the utilization review process as a safety valve for both sides. Doctors could request treatments not in the guidelines if they had scientific evidence of their efficacy and necessity. Payers could order reviews if they questioned a request.

Meanwhile the company I had worked for at the time of my injury had disappeared into bankruptcy, and partially absorbed by Google. My Pro Per status ignored by SCIF I of course had no knowledge of a review process, I just had to deal with the Crooked Doctors, and lying insurance company. By the time of the December 8th ruling, now just over 2 years ago, their doctors said I was Permanent and Stationary, and I was losing my mind unable to care for myself, I had to move to Arizona with my father. Where I have been unable to secure mental health care, or any doctor monitored treatments.

The Division of Workers’ Compensation is working with physicians to decide whether, and how, procedures like acupuncture, which are not currently covered, might be added to the approved list. Meanwhile, doctors complain that insurers and employers are taking advantage of the ambiguity and the lack of penalties in the review process to tie up requests in red tape.

TWO FUCKING YEARS! Multiple issues with Adjuster Ex Parte, and have since gone through 3 Adjusters since the summer of 2004. Each time a new adjuster it’s just like starting over again. It’s taken 3 months since my last trip to California, in which the Judge said everything was to be completed in one week while I was there, it didn’t happen. Now I am to return again on January 7th, for 2 days, to have two more consultations. Will I again not have enough time?

Behravan said he’s requested epidural pain-relief injections, costing $180, which have been sent for reviews that can cost $200 per hour to process.

And they were worried about Doctors creating waste.

“This (workers’ compensation review process) is harder than most of the HMOs we’re dealing with in terms of the amount of paperwork my office has to do to get anything done,” Franz said.

Again another reason why Doctors in Arizona are refusing to treat me.

“I know that Mike has a real injury,” Franz said.

But after 13 months of requests to see specialists and get second opinions on options up to and including surgery, Glickman has received only oral painkillers and a limited regime of physical therapy.

Shortly before showing a reporter his accumulated paperwork, Glickman got approval for an epidural injection that might shrink the swelling and reduce the pain but the OK had the wrong doctor’s name on it, and he’ll have to get that corrected to get the shot.

“Since there’s no one to make them treat me and punish them if they don’t treat me, they really don’t have to,” Glickman said.

A statement of truth, from a fellow injured worker with back problems. Incidently one of the most costly workers compensation injuries over the life of a worker I belive. Much more so than a death benefit.

Reform critics cite such examples to argue that the new system is slow and stingy and say much of the money being saved is coming out of workers’ hides.

“The gravy train has not stopped,” said Behravan, the workers’ comp doctor. “It has just shifted from the physician side to the insurance company side.”

I could not have said it better myself, but I did to a degree towards the top of this blog post.

What would explain the drop? Payers would say the word is out that workers’ comp is no longer a pushover. Critics would argue that injured workers, hearing of treatment delays, are shifting work-related injuries to regular insurance if they can.

I lost my regular insurance when the company I worked for died, some what fortunately after I had a kidney stone which I believe was related to the sudden change in my pain medications, and physical withdrawals from Vicodin. It still cost me around $1300, but I’m sure with out the insurance it would have been much greater price, which I believe should have been the WC Insurers liability.

Bellusci’s figures project that by the beginning of 2007, insurance premiums will have fallen 62 percent, on average, from their January 2004 peak. And despite the drop, his records suggest that insurers should be enjoying their most profitable period ever.

There is that word again, PROFIT. Now for something more appalling.

In 2005 and 2004, the most recent years for which data are available, they paid out just 31 cents in medical and disability costs for every premium dollar collected. In the early 1990s, when the state regulated workers’ comp insurance rates, 66 cents was the target payout, he said.

I wonder where the 69 cents ends up. Obviously not Adjuster training or retention, and certainly it isn’t going towards my needed care. I have flown on an airplane more than ever in my life paid for by SCIF.

But she and Searcy, the medical officer, have seen evidence that the new reviews, linked to those crucial treatment guidelines, may create an unintended tilt — unless she gets a stick to help strike the proper balance.

“There’s no penalties,” Nevans said. “I think we need them.”

I AGREE CARRIE NEVANS!

E-mail Tom Abate at tabate@sfchronicle.com

Thank you Tom, for a great article I could comment on just about everything which has affected me.

Even with taking breaks every 30 minutes to get up and move around, writing this it has taken quite a bit of time, over 2 hours. It has also been a very personal post. I’m physically and mentally exhausted, but my pain keeps me awake.

I could tag this a whole lot more, but hopefully this will suffice.