The Physiatrist as Peer Reviewer:
Medical Necessity, Disability
Assessment, and Tales From The
Dark Side
STUART J. GLASSMAN, MD, MROCC, FAAPMR
GRANITE PHYSIATRY, PLLC
CONCORD, NH
CLINICAL ASSISTANT PROFESSOR, GEISEL
SCHOOL OF MEDICINE AT DARTMOUTH
CLINICAL INSTRUCTOR, TUFTS UNIVERSITY
SCHOOL OF MEDICINE
SJG@GRANITEPHYSIATRY.COM
Disclosure Slide
 No financial disclosures to report
Objectives
 To enhance learner awareness about physician peer
review medical standards and guidelines
 To increase attendee understanding of workplace
disability assessment for reviewers
 To enhance participant knowledge of peer review
outcomes based on case study review
Why a Physiatrist Peer Reviewer?
 Physicians of Function!
 Comprehensive understanding of medical and
rehabilitation needs
 Training and career practice involves interaction
with PCP’s and medical/surgical specialists
 Ability to build ‘team consensus’ amongst different
clinicians
Physician Peer Review History and Standards
 1986—Health Care Quality improvement Act--





provided immunity from lawsuits for physicians
conducting peer review if done:
In good faith
Reasonable efforts to obtain the facts of the review
Adequate notice to ensure fairness of the review
2008 report from the AMA—proving that review
standards were not met is a formidable task, and
falls on the ‘sanctioned’ physician
HCQIA created the National Practitioner Data Bank
Treating Physician vs Peer Review Physician
 Who has better OVERALL understanding of the




issues at hand?
Needs of the patient/claimant versus wants of the
patient/claimant
EMR documentation—what does it REALLY say?
Physical exam findings, omissions/conclusions in
the office notes
Drug test results?!?!
Utilization Review Accreditation Commission
 Also known as URAC
 Quality benchmarks and programs for health care
review companies
 Promotes quality through accreditation, education,
and measurement programs
 Affordable Care Act (PPACA) created opportunities
for Independent Review Organizations (IRO’s)
 Peer reviewers are credentialed and have the
appropriate professional qualifications necessary for
proper consideration of external review case
Physician Reviewer Requirements for
Independent Review Organizations
 Appropriate state licensure and board certification
 Review of any sanctions or disciplinary actions
against the reviewer
 Assess for conflict of interest issues for the reviewer
 Appropriate clinical expertise/practice expertise for
the medical issue being reviewed (physiatry vs
psychiatry?!)
 Must review available medical records, attempt
contact with the treating/attending physician
Uniform Health Carrier External Review Model
Act
 Established by the National Association of Insurance
Commissioners in 2010
 Relates to minimum State external review standards,
which can vary widely
 http://www.naic.org/documents/committees_b_uni
form_health_carrier_ext_rev_model_act.pdf
 Specific timeline requirements for physician review
procedure—usually DAYS, so a relatively quick
turnaround is expected (consumer protection)
Federal External Review Process
 The Affordable Care Act (ACA) ensures that




consumers have the right to appeal health insurance
plan decisions
Applies to US Dept. of HHS, DOL and Treasury
HHS External Review Process is contracted by
MAXIMUS Federal Services, Inc.
http://www.externalappeal.com/
For standard reviews, turnaround time is 5 days for
the organizations; expedited reviews are usually 2-3
days
Treatment Guidelines/Clinical Practice
Guidelines
 Should be evidence based
 Work injury guidelines—ACOEM, ODG
 https://www.acoem.org/PracticeGuidelines.aspx
 http://www.worklossdata.com/
 State treatment guidelines—vary widely, may be based on
ACOEM or ODG
 California—Medical Treatment Utilization Schedule
(MTUS)
 Clinical Practice Guidelines—Agency for Healthcare
Research and Quality (AHRQ):
 http://www.guideline.gov/
Workplace Disability Review
 To work or not to work?!
 Modified duty vs. Regular duty
 Physician physical assessment vs. patient reporting
of capabilities
 Functional Capacity Evaluation?
 Physical issues vs. mental health issues?
Long Term Health Consequences of
Unemployment
 Effects of Unemployment on Mental and
Physical Health (Linn/Sandifer/Stein, Am J
Public Health, May 1985)
 Prospective study in 300 men
 symptoms of somatization, depression, and anxiety
were significantly greater in the unemployed than
employed
 unemployed men made significantly more visits to
their physicians, took more medications, and spent
more days in bed sick than did employed individuals
Job Loss and Health in the U.S. Labor
Market
 Strully, KW; Demographics (May 2009)
 Losing a job because of an establishment closure
increased the odds of fair or poor health by 54%, and
among respondents with no preexisting health
conditions, it increased the odds of a new likely health
condition by 83%.
 increased job “churning” (high rates of job loss but low
employment) within the United States is likely to
increase the number of health conditions suffered by
American workers
 no evidence that job loss effects differ for white- and
blue-collar workers
Unemployment and Mortality Risk
 Morris, Cook; British Medical Journal, April 1994--
followed 6200 British men for 10 years
 TWICE the mortality rate for men who became
unemployed during the first 5 years of the study, as
compared to those who remained employed for the
10 years
 Voss, Nylen; Am J. Public Health, Dec 2004—
Swedish Twin Registry (n=20632)
 “Unemployment is associated with an increased risk
of early death, especially from suicide and external
undetermined cause”
Unemployment and Substance Use
 Unemployment and Substance Use: A Review




of the Literature (1990-2010) (Henkel, Curr
Drug Abuse Rev, March 2011)
Reviewed over 130 studies
Risky alcohol consumption is more prevalent among
the unemployed
Unemployment is a significant risk factor for
substance use and the subsequent development of
substance use disorder
Unemployment increases the risk of relapse after
alcohol and drug addiction treatment
Unemployment and Substance Abuse (cont.)
 2012 National Survey on Drug Use and
Health(http://archive.samhsa.gov/data/NSD
UH/2012SummNatFindDetTables/DetTabs/N
SDUH-DetTabsTOC2012.htm)
 About 1 in 6 unemployed workers are addicted to
alcohol or drugs (17%), compared to 9% for full-time
workers
Exploring the Link between Drug Use and
Job Status in the U.S.
 Alejandro Badel, Brian Greaney , The Regional
Economist (Federal Reserve Bank of St. Louis),
July 2013
 A person who moves from employment to
unemployment observes an increase in his/her odds
of consuming illegal drugs
 during episodes of large increases in unemployment,
the number of drug users can increase dramatically
Illegal Substance Use Type and Unemployment
(2001-2011)
Illegal Substance Use and Employment (2005-11)
Why Do Physicians Keep Patients Out of Work?
 Social Security Disability definition: "inability to engage
in ANY substantial gainful activity (SGA) by reason of
any medically determinable physical or mental
impairment which can be expected to result in death or
which has lasted or can be expected to last for a
continuous period of not less than 12 months.“
 The disability programs are designed to provide longterm protection to individuals who are totally disabled,
using Social Security criteria, and unable to do ANY kind
of work in the national economy
 http://www.ssa.gov/disability/professionals/answerspub042.htm
The Physician Reviewer Disability Question
 ‘Reasonably Supported Restrictions and Limitations”
 Hours per day, days per week, activities (bend, kneel,





squat, climb, sit, stand, walk, reach, drive, grasp, fine
motor activity)
Diagnostic work up
FCE/PCE data
Office note documentation of ROM, strength,
mobility/ambulation deficits
Surveillance Video—did the treating clinician see this?
Mental health limitations and work capability?!
Typical Physician Responses to Disability Peer
Review
 ‘I don’t address work issues’
 ‘My patient says he/she can’t work’
 ‘I refuse to look at surveillance video. I have to
believe my patient’
 ‘I haven’t seen my patient in 3 months, so I can’t
comment on the current status’
 ‘I am a pain management specialist. The PCP
handles the disability status’
Tales from the Dark Side
Tales From the Dark Side (#1)
 Peer review for ongoing lumbar epidural steroid
injections (Arizona physiatrist)
 Diagnosis—back pain, lumbar DDD L4-S1, bilateral
facet arthropathy
 Already had 2 LESI’s in 3 months, pain rating went
from a 9/10 to a 7/10 for one week with first
injection, no improvement with next injection
 No PT ordered, no return to work release given
Tales From The Dark Side (#2)
 Peer review for ongoing opioid prescribing (Arkansas




Pain Clinic nurse practitioner )
Oxycontin 20 mg Q8h
Oxycodone 10 mg TID PRN
Two urine drug test results done within the prior 3
months showed NO evidence of
oxycodone/oxymorphone; + presence of THC
NP’s office notes (templated?) state: ‘urine tests
reviewed, no unexpected results’
Tales From The Dark Side (#3)
 Disability Review (Florida orthopedic surgeon)
 Diagnosis—UE Complex Regional Pain Syndrome
after CTS release 1 year ago; no work release,
ongoing opioids
 Physician notes document decreased volitional
motion of dominant arm, pain on palpation
 No documentation of hair, skin, nail, color or
temperature changes
 Surveillance video shows claimant moving garbage
cans, carrying multiple packages from shopping
center, driving, full motion of dominant arm
Summary/Questions