ENCLOSURE ENCLOSURE all training in March 1975 because the workload was prohibitive. Training was resumed in July 1976 on claims examining techniques. It appears that the personnel of the Chicago District Office had not received any better training than the personnel of the Jacksonville and San Francisco district offices. GAO's review of the claims examiners' qualifications at the Chicago District Office showed that these persons' educational and experience backgrounds were similar to those of the claims examiners in the other two district offices. The question of whether the personnel of the Chicago District Office were better trained requires considerations that go beyond GAO's audit. The fact that GAO's findings were consistent in each district office audited does show that the personnel of the Chicago District Office were performing similar to the personnel of Jacksonville and San Francisco's district offices in administering the act. (11) What type of training is currently provided in the offices you surveyed to enable the claims examiners to adequately adjudicate the "sticky" cases you referred to? (R) Labor officials told GAO that claims examiners from the OWCP district offices of Jacksonville, Chicago, and San Francisco have participated in the recently instituted agencywide training program for claims examiners. Generally, the program covers the basic requirements of claims examining and the claims examiners' duties and responsibilities with regard to the requirements. Courses are given on how to develop causal relation for those cases which are most difficult and time consuming to adjudicate, i.e., heart attacks, hearing loss, lung diseases, and nervous problems. GAO has not evaluated the effectiveness of Labor's new training program. (12) Since completion of your review, has the Labor Department implemented in any district office the formalized training program recommended by the OWCP Task Force? (R) Labor reported that in the spring of 1977 all claims examiners attended a basic 4-day course. Since August 1977, all newly hired examiners have attended a 7-day course. A 2-week advanced training course for all experienced examiners was held in early June. According to Labor, as of August 17, 1978, 171 claims examiners had received basic training regarding the act and 33 had received advanced training. ENCLOSURE ENCLOSURE (13) What are the Medical Director's qualifications and duties? How frequently were cases referred to the Medical Director for evaluation? Do you feel the number of referrals is indicative of adequate input by the Medical Director, particularly in difficult cases? are: to: (R) The qualifications for the National Medical Director --Board-certified in some medical speciality, preferably occupational, industrial or preventive medicine, or with an advanced degree in public health. --Substantial experience in administrative medicine or --Substantive knowledge of entitlement programs for medical services and/or compensation. The responsibilities of the National Medical Director are --Oversee the development and implementation of medical --Supervise the design and issuance of specific medical --Provide technical assistance to the regional offices ENCLOSURE ENCLOSURE assist the regional offices in identifying qualified physicians and/or medical consultants who will provide expert medical opinions on claims which involve complex medical evaluation or treatment issues; arrange for the orientation and continuous training of medical personnel in the regional offices; and establish a program to evaluate the effectiveness of regional medical services. --Advise the Director of needed changes in legislation, regulations, policies or procedures to improve the quality of medical evaluation, treatment and care programs, and on medical research in industrial, preventive, occupational or orthopedic medicine, and new developments in evaluating the work-relatedness of injuries and diseases which impact on OWCP programs. --Serve as the senior medical spokesman and authority for --Initiate a program of research and analytic studies GAO found that the medical directors were very active in their roles as medical advisors. For example, a sample of 135 claims from the Jacksonville District Office showed that its medical director gave an opinion in 58 (about 43 percent) of the claims. This sample included both traumatic injury cases and the more difficult nontraumatic injury cases. Indications are that opinions from medical directors are more frequent in the nontraumatic injury cases--especially where causal relation is the issue. For example, GAO reviewed 50 cases at the Chicago and San Francisco district offices to evaluate the adequacy of evidence supporting causal relation. The districts' medical directors gave opinions in 22 of the 26 cases that involved nontraumatic injuries. The number of cases reviewed by the medical directors indicates that claims examiners make frequent use of medical directors during the adjudication process. Aside from the number of cases reviewed, whether their input was adequate would depend on the medical directors' actions and the acceptance of such actions by the claims examiners. Medical ENCLOSURE ENCLOSURE directors must be provided the particular facts of a case upon which to base an opinion. They are not to decide the facts or to make factual conclusions. The case examples in GAO's April 1978, testimony demonstrate that medical directors were often asked for an opinion on causal relation before sufficient employment and medical evidence had been developed. A proper action would have been advising the claims examiners that additional evidence was required to adjudicate the case. In many cases, however, medical directors gave favorable opinions which the claims examiners relied on to award benefits without developing further evidence to support causal relation. (14) Do you see any merit in establishment of a medical review board specifically to handle occupational disease claims, or stress-related ailments where it is difficult to determine a causual relationship? (R) The responsibilities of the Medical Director include assisting in identifying qualified physicians and/or medical consultants who will provide expert medical advice on claims which involve complex medical evaluation or treatment issues. If the authority to use such medical specialists is used on a regular basis, we believe that the benefits derived from the establishment of a medical review board would probably be limited. The medical review board approach, however, is followed in at least 12 States; Labor officials favor the use of medical boards; and Labor recently contracted for the development of a system for medical supervision of occupational disease claims. The system will experiment with referring occupational disease claims to a panel of medical experts for evaluation. When sufficient experience is accumulated under the system, Labor will be in a better position to determine whether a medical review board would, in fact, be a better method of furthering the objectives of the OWCP program than the present system of using medical specialists on a case-by-case basis. (15) Reportedly, pilot programs in claims specialization have been inaugurated in the Jacksonville and Chicago district offices. What have been the results? Would you describe how the program works? (R) GAO has not evaluated the results of claims specialization. However, in July 1978, Labor reported to GAO that a claims specialization pilot program developed in early ENCLOSURE ENCLOSURE 1977 had a successful first test at a large district office with an estimated 25 percent increase in productivity and a significant improvement in quality. After a test of a small district office, a decision will be made regarding extension of the system to other district offices. OWCP officials told GAO in August 1978, that productivity had dropped from the reported 25 percent increase but that quality control was better under claims specialization. To address the problems which accompany the increasing caseload of occupational diseases, OWCP is developing expertise on the unique characteristics and symptoms of certain illnesses. The OWCP Hearing Loss Task Force has adjudicated nearly 7,000 claims to date. In addition, OWCP established in the summer of 1977 panels of medical specialists in orthopedic, cardiac, pulmonary and psychiatric medicine. These panels reviewed current program medical standards and additional factors that could delay return to employment. A report issued in December 1977 with their recommendations is being integrated into a new program medical procedure manual which will be issued shortly. CONTROVERSION OF CLAIMS AND THE APPEALS PROCESS FOR CLAIMANTS (16) Did you have an opportunity to review any of the decisions of the Compensation Appeals Board. If so, did you find that its decisions were valid, based on the record for review? (R) GAO researched the decisions of the Board extensively in determining the criteria OWCP should be following in settling claims for benefits under the act. The published decisions of the Board usually contain a recitation of the evidence of record concerning the employee's duties and working conditions, the nature and extent of the injury and the circumstances surrounding occurrence of the injury; a discussion of the law and of its application to the evidence presented; and its decision to either affirm the action taken by OWCP, to reverse the action, or to remand the case to OwCP for further development of the evidence. GAO's opinion, the Board generally follows the applicable criteria more consistently than OWCP in settling compensation matters. In (17) Did you have an opportunity to review more than the nine cases which you mentioned where a decision had been rendered by the Hearings and Review Branch? 13 |