Medical Care Provided Californias Injured Workers: An Overview of - - PowerPoint PPT Presentation

Medical Care Provided California’s Injured Workers: An Overview of Recent Changes

Barbara O. Wynn Presentation at the NASI Symposium Health and Income Security for Injured Workers: Directions for the 21st Century October 12, 2006

10/12/06

Today’s Presentation

• Describe the context for the medical reform

provisions

• Summarize the major reform provisions affecting

medical care provided California’s injured workers

• Suggest early “lessons-learned” from California’s

experience

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CA Workers’ Compensation Paid Losses : 2001-2005

$0 $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000

Medical Payments Temporary Disability Permanent Disability Vocational Rehabilitation Death

2005 2004 2003 2002 2001

Insurers’ Paid Losses (thousands)

Source: CHSWC

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$0 $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 $6,000,000 1997 1998 1999 2000 2001 2002 2003 Calendar Year Paid Amount (in Thousands) Physicians Hospital Pharmacy All Other

SOURCES: WCIRB /CHSWC

Medical Expenditures in CA Workers’ Comp (Paid by Insured Employers Only), 1997-2003

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CA’s WC Costs Per $100 Payroll Rose Much Faster than the National Average over 1999-2003 Period

• 20.0%

0.0% 20.0% 40.0% 60.0% California United States

% Change in Costs Per $100 Wages Medical Indemnity Total

Source: NASI, 2005

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Utilization Was Driving Medical Care Expenses

29.7 11.6 34.1 17 17.4 7.8 16.6 12.2 5 10 15 20 25 30 35 Average Visits per Claim Median Physician Visits Median Chiropractic Visits Median Physical Therapist Visits

CA 12-State Median Source: Eccleston (Workers’ Compensation Research Institute), 2003

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Despite More Care , CA’s Injured Workers Had Poorer Outcomes

Oregon 9.7% Wisconsin 11.8% New Mexico 11.5% California 13.7% Washington 11.2%

Data Source: RAND

Percentage of PPD Claimants Out of Work after Three Years

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Employers/Payers Had Limited Ability To Control Medical Expenses

• Injured worker could select a primary treating

physician after 30 days

• Care provided by primary treating physician was

presumptively correct

• Utilization review physician opinions were not

admitted as evidence in appeals

• Official medical fee schedule inadequate

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Recent Legislation Addressed Utilization and Cost Issues

• Treating physician presumption repealed; ACOEM guidelines

presumptively correct until AD issues a utilization schedule

• UR guidelines repealed; new standards for UR processes
• Employers may establish medical networks and control

medical care for duration of claim

• 24-visit limit per industrial injury on chiropractic, PT and OT
• Second opinion program for spinal surgery
• Up to $10,000 in payments before compensability established
• Fee schedule expanded to include outpatient surgery facility

fees and other services

• Allowable fees for pharmaceuticals lowered and generic drugs

required

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Early Impressions from RAND Interviews and Studies Conducted by Other Researchers

• Substantial reductions in utilization and medical costs
• Unknown impact on access, clinical quality and on

work-related outcomes and expenditures

• Two systemic issues commonly raised by interviewees

– The challenges posed by the complexity of four different medical delivery models with different utilization and dispute-resolution processes – The level of distrust and contention within the system Incentives for various stakeholders warrant analysis

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What is Needed in CA WC to Drive Value-Based Medical Care for Injured Workers?

• On-going monitoring system to assess system

performance: access, quality, cost, utilization, and patient satisfaction

• Clinical criteria to measure appropriate care
• Readily accessible evidence-based treatment

information on common workers’ compensation conditions and modalities

• Implementation of new physician fee schedule and

financial incentives to improve quality

• Evaluation of reform initiatives to inform future

policy development

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What Are Early Lessons Learned for Other States?

• On-going monitoring and evaluation system needed to produce

information at critical junctures:

– Technical assistance in legislative and regulatory processes – Early warning system during implementation – Monitoring and evaluation to inform future policy development

• “Off-the shelf” policies still need to be adapted to local context

– ACOEM guidelines are not comprehensive – Medicare-fee schedules do not address some occupational medicine services and some are not appropriate for WC population – Implementation of new physician fee schedule and financial incentives to improve quality

• Successful implementation requires time and resources

– Involvement of stakeholders in policy development – Educational materials for affected parties – “Ombudsman” to help communication and resolve problems

• Regulatory authority for oversight and ability to address

unintended consequences is important

10/12/06

Sources: California Commission on Health and Safety and Workers’ Compensation (CHSWC), Annual Reports, 1999-2005. Oakland, CA: CHSWC. Online at http://www.dir.ca.gov/chswc. Eccleston, S.M. and X. Zhao, “The Anatomy of Workers’ Compensation Medical Costs and Utilization: Trends and Interstate Comparisons, 1996-2000,” Cambridge, MA: Workers Compensation Research Institute, July 2003. Workers’ Compensation Insurance Rating Bureau (WCIRB), “2003 California Workers’ Compensation Insured Losses and Expenses,” San Francisco, CA: WCIRB, June 2004. Online at http://wcirbonline.org (as of December 21, 2004). National Academy of Social Insurance (NASI), Workers’Compensation: Benefits, Coverage, and Costs, 2003. Washington, DC: NASI, July 2005.