Fix needed for California’s QME physician system

California, recognizing the dignity of work, has been a national leader in protecting the health and safety of workers for over a century.  In 1911, California passed a constitutional amendment that created the foundation for our modern system of workers’ compensation, and since that time numerous laws have been passed to keep California at the forefront of worker protection. 

Yet, today, California is failing the workers that it is supposed to protect, and they sometimes must wait months, if not years, to get the care and coverage that they are entitled to. 

To be sure, California’s core commitment to workers is just as strong as it always has been, if not stronger.  Governor Newsom and the vast majority of our state’s elected and appointed leaders have a rock-solid commitment to workers.  That is not in question.

In recent years, QME physicians have been leaving the system in droves, creating an acute shortage, especially in on-demand specialties like orthopedics.

The true challenge lies elsewhere – in the complexity and bureaucracy of the state’s outdated Qualified Medical Evaluator (QME) system that is being pushed to the breaking point. 

The QME system plays a vital role in workers comp. 

QMEs are physicians who have been certified by the state to help resolve disputes between workers and insurance carriers. If a worker injured on the job believes that he or she qualifies for benefits, and the employer’s insurance carrier turns them down (which happens as you might guess all the time), the worker has a right to seek a second opinion from an QME physician paid by the state.  For many years, this system worked well for both employers and workers.

But in recent years, QME physicians have been leaving the system in droves, creating an acute shortage, especially in on-demand specialties like orthopedics.  As a result, workers often can’t find a local QME physician in the specialty they need or get timely appointments, and their cases languish in bureaucratic limbo for months if not years.

There are many reasons for this shortage, but the most notable one is the fact that the state’s medical-legal fee schedule has not been updated since 2006.  This, combined with byzantine rules and regulations, sends a message to QME physicians that their help is not wanted and not valued – and workers suffer as a result.

There’s one silver lining in this otherwise dark cloud – the state agency charged with protecting workers, the Division of Workers’ Compensation, this week released a proposal to finally modernize the system after years of prodding by the broader medical-legal community. 

Unfortunately, at first inspection, the proposal actually makes things more difficult for QMEs and does not modernize the system.  As drafted, it won’t ease the shortage of QME physicians.  The proposal needs a major overhaul and, at the very least, should be modified to increase reimbursements to physicians in line with other states like Nevada.

Meanwhile, the Legislature has introduced AB1832, legislation that we strongly support to require DWC to modernize the system, and the state auditor is looking into the issue as well.

So, while doctors and lawyers debate this issue, workers are caught in the crossfire.  This is deeply troubling and totally inconsistent with California’s commitment to the workers who are the backbone of the state. 

Yet, we remain hopeful that the DWC will see the pain that our broken system is causing and modify its proposal to bring it in line with the state’s long-standing commitment to workers.
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Editor’s Note:  Dr. Jacob Rosenberg is president of The California Society of Industrial Medicine and Surgery (CSIMS).  This perspective has been endorsed by the CSIMS board of directors.  CSIMS is a non-profit organization dedicated to education and advocacy for physicians who treat and evaluate the injured workers of California.