A muffled cheer.

There is more change afoot today in medical care of injured workers than we have seen in a decade. But from what I've seen so far, I'll give the industry's effort one and a half, instead of a full three cheers, for advances in medical intelligence.

The American Society of Workers' Compensation Professionals (AMCOMP) is concerned about poor quality of care. At this year's annual meeting, Bruce Sundquist from American Re made an informed pitch for upgrading the quality of care, from routine back pain to catastrophic cases.

How do you vote on three tests of the medical intelligence of our industry? (Dear friend, you are of course well above average.):

Test 1: Is the workers' comp field more able to learn about medical conditions and treatments? I say yes, and have an example. Test 2: Is the field more able to coalesce around standards of practice? I say sort of. Test 3: Is the field more proficient at molding a better community of practitioners? I say no, but I have a plan for that.

Liberty Mutual provides an example of how learning has improved. Like most claims payers, it hired nurses and doctors in the 1990s. It also built up the Ph.D.-level staff at its disability research center, a unique institution in the United States. It built an internal web-based service, called i-Case Manager, to help workers' comp and disability staffs exchange medical insights.

A lot of credit should go to Dr. Barton Margoshes for being early to use the Internet. With commercially available online tools in instruction and inquiry, any claims payer or employer can afford today its own learning portal.

I think we've seen mixed success in building consensus around standards of practice. As of 1990 there were practically no medical practice standards for work-related injuries that came with the endorsement of insurers and regulators. I have two examples of progress. One is the work by the American College of Occupational and Environmental Medicine. It published in 2003 its second edition of practice standards. This new edition has excellent advice on preventing chronic pain. The other one is the AlMA's promulgation of a fifth edition of its permanent impairment guidelines.

Do I appear caviling in noting that in these two undertakings, as in other practice standard projects, claims payers have been more spectators than participants? They could, for example, provide financial support, but even more they could share claims data for analyzing actual practice variations. Neither ACOEM nor AMA calculates the extent of medical errors in the real world because no claims payer it seems gave them the information.

In my third test--which is to ask, Are we directly encouraging clinicians to improve their practice?--the signs of success are scant. The initiative has got to come from claims payers. I know of one insurer, with a dominant position within its region, at which the people in charge of medical provider relations cannot name a single occupational medicine doctor.

Every insurer with at least 10 percent market share in a state should contact the occupational medicine clinics they prefer. The insurers should bring along report cards of how well the providers are doing, in terms of getting people back to work and seeing as many fresh injuries as feasible. Fee discounting has been undercutting quality, so they should talk about fair compensation. That's my plan.

PETER ROUSMANIERE writes monthly on workers' compensation for Risk & Insurance He can be reached at [e-mail].