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WORKERS' COMP Stricter policies force out doctors



Published: Mon, February 7, 2005 @ 12:00 a.m.



The changes are part of a two-year effort to reduce costs.

SACRAMENTO (AP) -- Dr. Francis Pecoraro is trading a San Francisco Bay area medical practice that mainly serves injured workers for one in Wilmington, N.C., that he believes will more doctor friendly.

Dr. Pecoraro, who specializes in chronic pain cases, is among a number of California doctors who say they are fighting time-consuming, uphill battles to get necessary care for workers' compensation patients. As a result, some are limiting their workers' comp practices or dropping them altogether.

Dr. Pecoraro said he decided to move to a state with a "less cumbersome" workers' comp system rather than spend "more time in the office generating reports and begging for medical care for my patients and less time with my family."

Such complaints are coming "a lot more often these days" from doctors since the state imposed a system of treatment guidelines and utilization review in an attempt to hold down skyrocketing workers' comp costs, said Nileen Verbeten, a vice president with California Medical Association.

Those changes, part of a two-year effort to overhaul the system that treats job-related injuries, made guidelines developed by the American College of Occupational and Environmental Medicine "presumptively correct" in treatment decisions until the state develops its own standards of care. Officials said they don't know when the state guidelines will be finished.

The situation appears to be unique to California. Mark Gerlach, a consultant for the California Applicants' Attorneys Association, said others don't use the ACOEM guidelines as rigidly as California.

Paperwork and denials

Since the guidelines took effect last March, Dr. Pecoraro and a number of other physicians say they've been swamped by paperwork and denials of care.

They say the guidelines don't cover all situations and are frequently misused by workers' comp insurers to deny care or medical equipment physicians consider necessary and even cost-cutting.

"I can hardly practice medicine anymore," said Dr. James Sylvain, a specialist in physical medicine and rehabilitation. "I'm practicing politics and writing angry letters to adjusters and altering [workers'] attorneys about what's going on here so patients eventually get treatment."

Dr. Sylvain says he's "declining all sorts of patients" now unless there's a nurse case manager involved to act as a liaison between the insurance company, patient and physician. That's cut his workers' compensation business 40 percent to 50 percent.

Dr. Janine Talty, an osteopath, has stopped seeing workers' comp patients entirely, saying she was being forced to "treat them with both hands and feet tied behind my back."

Nicole Mahrt, a spokeswoman for the American Insurance Association, said guidelines were needed to stop overtreatment and ineffective care that was helping drive up the cost of employers' workers' comp insurance.

"Change is hard; that doesn't mean it's wrong," Mahrt said. "It was certainly no one's intention to drive doctors out of the business. At the same time abuse was going on in the system and we needed to bring in new rules."

Some medical services were overused, said Dr. Jeffrey Coe, a spine surgeon, but the "pendulum has swung too far" toward too much review of treatments and that also has costs.




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