CWCI Examines Changes in California Workers Comp QME Population & Med-Legal Trends

Oakland – The number of qualified medical evaluators (QMEs) who resolve disputes over California workers’ comp claim issues such as the extent of an injured worker’s permanent impairment fell 20% between January 2012 and September 2017 according to a new California Workers’ Compensation Institute (CWCI) study, but the impact on QME accessibility was partially offset by an increase in the median number of office locations per QME, which doubled over the same period.  The study also notes that after climbing steadily from 2007 through 2014, the average payment per med-legal service leveled off in 2015 and 2016, with data from the first half of 2017 suggesting the average may now be declining.

To analyze changes in the QME population, the study compares data from the list of physicians certified by the state as QMEs in 2012 to the certified QME list from September 2017, identifying the number of providers, their specialties, their addresses (by county), and their number of office locations.  Among the findings from that comparison and the review of recent med-legal trends:

• The number of QMEs fell by 20% from 3,239 physicians in 2012 to 2,578 as of September 2017, as 1,244 physicians discontinued their certification (either voluntarily or involuntarily) while 398 were added to the QME list.
• Over that same period, the median number of office locations per QME rose from one to two, so despite the 20% drop in the number of certified QMEs the total number of evaluation locations only declined 14%.
• Most job injury claims involve musculoskeletal injuries, so orthopedists provided more than half of all medical-legal services in both 2012 and 2017 even though they represented only 1 in 6 QMEs in both years. In contrast, 1 in 5 QMEs was a chiropractor, but they only accounted for 5.1% of med-legal services in 2012 and 6.7% in 2017.
• In 2012 and 2017 orthopedic surgeons, spine specialists or chiropractors, or mental health specialists provided more than 70% of all med-legal services. More than 85% of injured workers who requested med-legal services from one of these specialties had access to 5 or more QMEs in those specialties within a 30-mile radius of their home.
• 2007 was the first full year under a revised fee schedule that introduced new time-based billing codes for med-legal testimony and supplemental evaluations. Between 2007 and June 2017, the average amount paid for time-based supplemental evaluations more than doubled and the average paid for time-based supplemental reports rose 162%.

Despite the increases in the average amounts paid for time-based services, average payments for med-legal services overall leveled off in 2015 and 2016 and declined in 2017. The study links the recent change in the med-legal payment trend to a shift in the mix of services, as the results show that since 2015, less expensive basic reports and supplemental reports have represented a larger share of all med-legal services, while more detailed and costly comprehensive evaluations have accounted for a dwindling share.

CWCI has published its study, including additional background, graphics and analyses in a Research Update report, “Changes in the QME Population and Medical-Legal Trends in California Workers’ Compensation,” which is available in the Research section at www.cwci.org.