At the WCRI Annual Issues & Research Conference, Dr. Richard Victor, former CEO of WCRI and currently a senior fellow with Sedgwick Institute, discussed his views of workers’ compensation in the future.
The workers’ compensation system was a compromise between labor and business designed to provide no-fault benefits in an environment that gave exclusive remedy protections to employers. Over the years, there have been ebbs and flows to the system in an effort to maintain balance. There is a constant struggle to balance benefits to workers with the costs of the system paid by employers.
In the past, when the workers’ compensation system got out of balance, it was due to actions from those within the system. That is something the system could correct with regulatory change. However, right now, there are things happening outside of the workers’ compensation system that could significantly affect it and cause a rethinking of the grand bargain.
Emerging labor shortages
Retiring baby boomers will cause labor shortages in healthcare and the insurance industry, which will delay claims and medical care. This will ultimately increase claims costs.
In addition, a stronger economy is ultimately going to lead to a severe labor shortage. When you pair the aging workforce and people retiring with a growing job market, you end up with not enough qualified applicants to fill the positions. Employers have to relax their hiring standards. This leads to unqualified applicants being hired. These people will likely have higher accident rates.
Changes in the non-occupational health system
As workers see their out-of-pocket health insurance costs rise, it becomes more attractive to try to shift illness and injury episodes into the workers’ compensation system. Richard feels that this shifting will result in a 25% increase in workers’ compensation claims by 2030. With soft tissue injuries, it would be very easy for the worker to indicate the injury happened at work instead of at home. Disproving that would be very challenging for employers. Higher deductibles will greatly encourage workers to look for these cost-shifting possibilities.
Millions of workers losing health insurance
The number of uninsured workers is expected to decrease significantly as elements of the Affordable Care Act are repealed or weakened. These uninsured workers are also highly encouraged to shift their treatment into the workers’ compensation system. Richard estimates a 15% increase in workers’ compensation claims due to this.
The injury rates for the older workers is higher than for younger workers. As the U.S. workforce ages, we will see higher injury rates across the employee population.
Federal immigration policies and practices
Limiting the flow of immigrants into the U.S. at a time there is a labor shortage will only compound the problem. The only way to grow our workforce to keep up with the demand is with immigrants. All of the growth in the labor force going forward is projected to come from immigrants.
Roughly 15% of all healthcare workers in the U.S. are foreign-born. If we discourage immigration into this country, Richard feels it could cause a labor shortage in the healthcare industry.
It does not even take a change in policy to see a change in immigration flow. After the Brexit vote there was a significant reduction in European nurses registering to work in the U.K. This is even though there had yet to be a policy change in the country.
Taking all of the outside factors into consideration, Richard estimates a 55% increase in the number of workers’ compensation claims by the year 2030. When you add in medical inflation the costs of the workers’ compensation system could triple by 2030 with no change in indemnity benefit levels.
With this significant increase in costs, there will be questions about the continued viability of workers’ compensation. What is the solution? Are there viable options to traditional workers’ compensation? ERISA-style plans like the opt out in Texas have been widely criticized for providing inadequate protections for injured workers. Union carveout plans only apply to a very small sector of the workforce. Could we see workers’ compensation claims organizations become accountable to both employers and workers, with employees having the ability to choose which claims organization they want to use?
As national conversations occur about the direction of workers’ compensation (WC) systems, I sometimes hear comments that “WC systems are broken.” Rarely are public programs either all black or all white. The material below summarizes relevant information from a variety of published Workers Compensation Research Institute (WCRI) studies about how most workers fare in WC systems. How workers fare is critical to assessing the performance of WC systems, and the effectiveness of these systems affects the competitiveness of American business.
85% to 90% reported no problems or small problems getting desired care
80% to 90% reported being somewhat or very satisfied with the time it took to have the first nonemergency care
While the systems may serve most workers reasonably well, the data also shows that there are injured workers with certain attributes that make them less likely to receive these good outcomes. Discussions that focus on system changes that improve outcomes for these injured workers have high-impact potential. A subsequent post will highlight the evidence on who these workers are.
Your employee was just injured at work. He is in pain, cannot perform regular job duties and is unsure how quickly he can return to work. His mortgage, medical care and kid’s tuition payments are due next month. It is a vulnerable time for him, with substantial uncertainty.
When a football player goes down on the field and is carried off, the crowd applauds in support of the player, and the player often returns a smile. When a worker is injured on the job, what happens at the workplace before and after the injury can affect the costs incurred by the employer and the outcome achieved by the injured worker.
Twelve new state studies from the Workers Compensation Research Institute (WCRI) aim to help CFOs and other stakeholders identify ways they can improve the treatment and communication an injured worker receives after an injury, leading to better outcomes at lower costs.
The studies interviewed 4,800 injured workers from across 12 states who suffered a workplace injury in 2010 and 2011 and received workers’ compensation income benefits. The 12 states surveyed were Arkansas, Connecticut, Indiana, Iowa, Massachusetts, Michigan, Minnesota, North Carolina, Pennsylvania, Tennessee, Virginia and Wisconsin. The surveys were conducted during February through June in 2013 and 2014—on average, about three years after these workers sustained their injuries.
The research found that a worker’s fear of being fired after an injury had a large and pervasive effect on costs and worker outcomes, like return to work. The fear of being fired may arise out of the relationship between the worker and the supervisor. If the relationship is low trust, the worker is more likely to fear firing when injured.
To describe the level of trust or mistrust in the work relationship, workers were asked to agree with the statement, “I was concerned that I would be fired or laid off.” Workers were given four possible answers—strongly agree, somewhat agree, somewhat disagree and strongly disagree. Depending on the state, 18% to 33% of workers strongly agreed that they feared being fired when injured.
Overall, workers who were strongly concerned about being fired after the injury experienced poorer return-to-work outcomes than workers without such concerns. Across all 12 states, 23% of those concerned about being fired reported that they were not working at the time of the interview—double the rate observed for workers without such concerns. The following are other findings from workers who were strongly concerned about being fired:
Concerns about being fired were associated with a four-week increase in the average duration of disability.
Workers who were strongly concerned about being fired had higher rates of dissatisfaction with care (21% were very dissatisfied with care) when compared with workers who were not concerned about being fired after the injury (9%).
Workers who were concerned about being fired were much more likely to report problems with access to care. Among workers who were concerned about being fired, 23% reported big problems getting the services they or their provider wanted. The rate was double the 10% among workers who were not concerned about being fired.
16% of workers who were strongly concerned about being fired reported large earnings losses at the time of the interview predominantly because of injury, compared with 3% of workers who were not concerned about being fired.
What do these findings really signify? The following are some alternative possibilities:
Workers reporting a strong fear of being fired might know they have a difficult relationship with their supervisor. That difficulty might translate into fewer opportunities to return to work, or more active management of the nature of medical care and the selection of medical care providers.
The worker may be exaggerating the possibility of termination, being a pessimist by nature, and that tendency to overreact might characterize the workers’ general performance on the job—perhaps resulting in fewer return-to-work opportunities and more active management of the care by the payers.
The worker may be more likely to retrospectively report a fear of being fired if the worker has had a poor outcome. Poor outcomes color the worker’s view of most events in the course of the claim. Conversely, workers who have experienced excellent outcomes tend to see events in the course of handling the claim in a much more positive fashion.
This is not the first time we looked at trust as it relates to workers’ compensation. A study we did several years ago on attorney involvement, which was covered by CFO magazine, looked at why injured workers hired attorneys. The character of the employment relationship, for example, was a factor for the 23% who strongly agreed that they hired attorneys because they feared being fired or laid off. 15% also strongly agreed that they needed attorneys because their employer could perceive their claims as illegitimate.
Employers Can Make a Difference
WCRI contacted Lisa Healy, who is a manager of claims at AGL Resources, a natural gas-only distribution company in the U.S. She told us that AGL has been very successful in managing and reducing its workers’ compensation costs. In part, she ties this success to practices where employees in the organization feel engaged and trust the company. The following are five things she told us the company is doing to facilitate trust:
Establishing a set of values and a code of conduct with the ability to report those who violate it without fear of retaliation. This gives an organization depth in terms of morals and standards, which appeal to workers of all ages.
Holding claim adjusters accountable for treating injured employees in an honest fashion with dignity and respect.
Encouraging employees to identify possible safety hazards as well as recommend opportunities to improve safety. When workers are encouraged to point out safety issues or offer suggestions on how to improve things and these comments are taken seriously and addressed, trust is formed.
Providing a 24/7 nurse triage program to speed treatment for injured employees so they get the care they need as soon as possible. The employee can contact the nurse triage line immediately after feeling a twinge of pain or sustaining an injury that doesn’t require emergency treatment. This service not only ensures the employee gets the right care immediately, it also cuts down on unnecessary visits to the physician when the employee can use self-care treatments such as ice, rest, elevation or an aspirin.
Promoting early return to work with transitional duty positions whenever possible. Research has shown that the longer a worker is out, the harder it is to for the worker to return―not to mention that the costs go up the longer that person is out, so getting him or her back quickly shows the worker you care and is good for the worker and the employer.
The WCRI research is an important first step in realizing how important trust is between employee and employer to ensuring good outcomes when the employee is injured on the job. Additional studies by WCRI and others will provide further information on which policymakers can base appropriate measures. But employers can act now, as AGL Resources has demonstrated, to improve trust while lowering their workers’ compensation costs — through early intervention, putting safety first, effective return-to-work programs and access to medical care.
After 18 states enacted reforms to limit the prices paid to doctors for prescriptions they write and dispense, a new study from the Workers Compensation Research Institute (WCRI) finds that physician-dispensers in Illinois and California discovered a new way to continue charging and to get paid two to three times the price of a drug when compared with pharmacies.
“When prices are reduced by regulation, the regulated parties — in this case physician-dispensers — sometimes find new ways to retain the higher revenues they had prior to the reforms,” said Dr. Richard Victor, WCRI’s executive director. “Although this study uses data from two large states, it raises questions for all states where physician-dispensing prices are regulated.”
The study — Are Physician-Dispensing Reforms Sustainable? — identifies the mechanism that allows doctors in Illinois and California to dispense drugs from their offices at much higher prices when compared with pharmacies. It involves the creation of an opportunity to, once again, assign a much higher average wholesale price (AWP) to a physician-dispensed drug – a practice targeted by the earlier reforms enacted in many states using language limiting reimbursement to a price based on the AWP assigned by the manufacturer of the original drug.
Consider a drug where the most common strengths are 5 milligrams and 10 milligrams. If a new strength, say 7.5 milligrams, comes to market, the manufacturer of that new strength can assign a new AWP. According to the report, the AWP of the new strength was much higher than the 5-milligram and 10-milligram AWPs set by their original manufacturers.
In Illinois, the average prices paid for cyclobenzaprine HCL of 5 and 10 milligrams ranged from $0.99 to $1.74 per pill. Before 2012, 7.5-milligram cyclobenzaprine HCL was rarely seen in the market. The 7.5-milligram product was introduced in 2012, and almost all were dispensed by physicians at an average price of $3.79 per pill in post-reform Illinois. The market share of physician-dispensed cyclobenzaprine HCL of 7.5 milligrams increased from 0% in the third quarter of 2012 to 21% in the first quarter of 2013.
Similarly, in California, before 2012, 7.5-milligram cyclobenzaprine HCL was rarely seen in the market. The average prices paid for 5- and 10-milligram cyclobenzaprine HCL, the two common strengths, ranged from $0.35 to $0.70 per pill. Since the introduction of the 7.5-milligram product in 2012, the market share of physician-dispensed cyclobenzaprine HCL of 7.5 milligrams increased from 0% in the fourth quarter of 2011 to 47% in the first quarter of 2013, when it became the strength of the drug most commonly dispensed by physicians. The average price paid for the new strength was $2.90 to $3.45 per pill.
From these patterns, the study’s authors infer that the shift in strength was unlikely to be driven by new evidence about superior medical practices. Rather, it is likely that financial incentives drove some physicians to choose the strength for their patients. The study cites several reports that provide evidence of behavioral changes in response to price regulations.
The data used for the report came from payers that represented 46% for California and 51% for Illinois. The detailed prescription transaction data were organized by calendar quarter so that, for each quarter, all prescriptions filled for claims with dates of injury within 24 months of the observation quarter were included. On average, for each of the quarters reported, WCRI included 219,572 prescriptions paid for 60,448 claims in California. The same figures were 43,034 prescriptions paid for 12,714 claims in Illinois. The detailed prescription data cover calendar quarters from the first quarter of 2010 though the first quarter of 2013.
Policymakers in many states increasingly enact medical fee schedules in the quest to limit the growth of hospital costs. They often seek a reference point or benchmark to which they can tie reimbursement rates. Usually, that benchmark is either Medicare rates in the state or some measure of historic charges by the hospitals. Medicare rates are usually seen by healthcare providers as unreasonably low; charge-based fee schedules are often seen by payers as unnecessarily high.
This study examines an alternative benchmark for workers’ compensation fee schedules—prices paid by group health insurers. In concept, this benchmark has certain advantages. Unlike Medicare, the group health rates are not the result of political decisions driven by the exigencies of the federal budget. Rather, these rates are the result of negotiations between the payers and the providers. Unlike a charge-based benchmark, group health rates are what is actually paid to providers. This is important given the growing public attention to the arbitrariness of many hospital charges.
The major limitation of using group health prices paid as a benchmark for workers’ compensation fee schedules is that these prices are seen by group health insurers as proprietary. However, one state, Montana, has adopted a fee schedule based on group health prices paid and implemented relatively straightforward processes to balance the need for a fee schedule and the need to protect the proprietary information of the group health insurers.
This article does the following: (1) describes the major findings of the study, (2) suggests a framework for thinking about whether prices paid by workers’ compensation payers are too high or too low, and (3) discusses the Montana approach.
What do we find when we compare the prices paid to hospital outpatient departments by group health and workers’ compensation payers? Among the major findings of this study are:
In many study states, workers’ compensation hospital outpatient payments for common surgical episodes were higher, and often much higher, than those paid by group health. For example, in half of the study states, workers’ compensation paid at least $2,000 (43%) more for a common shoulder surgery (see Figures 1a and 1b).
The amount by which workers’ compensation payments exceeded group health payments (“the workers’ compensation premium”) was highest in the study states with either no fee schedule or a charge-based fee schedule (Tables 1a and 1b).
Are Prices Paid By Workers’ Compensation Payers Too Low or Too High?
The comparison of workers’ compensation and group health hospital outpatient payments raises the question in many states as to whether workers’ compensation hospital outpatient rates are higher than necessary to ensure injured workers access to good quality care. For example, in Indiana, hospital outpatient services associated with shoulder surgery were, on average, reimbursed $9,183 by workers’ compensation as compared with $7,302 by group health. Is this differential of $1,881 necessary to induce hospital outpatient departments to provide facilities, supplies and staff to treat injured workers in an appropriate and timely manner?
Consider the following framework for analyzing the question. If hospital outpatient departments were willing to provide timely and good-quality care to group health patients at the prices paid by group health insurers, then two questions should be answered by policymakers:
What is the rationale for requiring workers’ compensation payers to pay more to hospital outpatient departments than group health insurers pay for the same treatments?
If there is such rationale for higher payment, is a large price differential necessary to get hospital outpatient departments to treat injured workers?
In addressing the first question, let’s say that the hospital outpatient department provided identical treatment for a group health patient and a workers’ compensation patient. If the care was identical—same facilities, supplies and staff—and workers’ compensation imposed no unique added costs on the hospital outpatient department, then there is little rationale for workers’ compensation payers to pay more than the group health payers.
Healthcare providers often cite a special “hassle factor” in workers’ compensation that does not exist in treating or billing for the group health patient. Common examples of the alleged hassle factor include longer payment delays, higher nonpayment rates (where the compensability was contested or where care given was not deemed appropriate), more paperwork, more missed appointments, lower patient compliance with provider instructions and so on. If these hassles are unique to workers’ compensation patients, then this forms a potential rationale for workers’ compensation paying higher prices than group health, for the same care. Let’s assume that this accurately describes the real world.
Then the question becomes: Are the unique costs imposed on hospital outpatient departments large enough to justify workers’ compensation payers having to pay $2,000-$4,000 more per surgical episode than group health payers pay for the same care? If the costs of these hassles total less than, say, $2,000, then workers’ compensation fee schedules could be lowered without adverse effects on access to care for injured workers. In other words, the large price differentials observed in this study can only be justified by the large costs of these hassles that are unique to workers’ compensation.
In applying this framework to different types of providers, where these hassles exist, some types will be larger for some kinds of providers than for others. For example, the first doctor who treats may be more exposed to nonpayment risk than other providers who treat later in the claim; or the hospital outpatient departments’ use of the operating and recovery rooms would be less affected by paperwork but exposed to payment delays. Because the majority of payments to hospital outpatient departments are for physical facilities (e.g., recovery room), equipment (e.g., the MRI machine but not the radiologists’ professional services) and supplies (e.g., crutches), it is more likely that hospital outpatient departments are more exposed to billing delays, nonpayment risk (at emergency rooms for initial care) or canceled appointments and less exposed to time-consuming paperwork hassles or patient compliance issues.
Moreover, if the additional burden that the workers’ compensation system places on hospital providers (e.g., additional paperwork, delays and uncertainty in reimbursements, formal adjudication and special focus on timely return to work) is sizable, policymakers have two choices. The first is to adopt a higher-than-typical fee schedule that embraces large costs for the hassle factor. The alternative is to identify and remediate the causes of the larger-than-typical hassles — especially where these are rooted in statutory or regulatory requirements.
The Montana Approach
The major limitation of group health as a benchmark for workers’ compensation is that the group health rates are the proprietary competitive information of commercial insurers. The Montana legislature found a way to use group health prices as a benchmark for its workers’ compensation fee schedule while respecting the confidentiality of the commercial insurers’ price information. The approach used is to obtain the price information (conversion factor) from each of the five largest commercial insurers and group health third-party administrators (TPAs) in the state and compute an average. The average masks the prices paid by any individual commercial insurer or TPA. In addition, the statute guarantees the confidentiality of the individual insurers’ information.
This study raises a number of concerns about whether fee schedules are too high or too low. There are two key pieces of information needed to address this — (1) how much other payers in the state are paying, and (2) whether there is a unique workers’ compensation hassle factor.
This study addresses the first question for common surgeries done at hospital outpatient departments. A related WCRI study does the same for professional fees paid to surgeons and primary-care physicians.
Quantifying the presence and magnitude of any unique workers’ compensation hassle factor remains to be done. However, in some states, these studies show that workers’ compensation prices were below those paid by group health. For those states, policymakers may want to inquire about access-to-care concerns, especially for primary care. For other states, the workers’ compensation prices paid were so much higher than prices paid by group health insurers that policymakers should ask if the large differences are really necessary to ensure quality care to injured workers.
One way of framing that question using the results of the WCRI studies is as follows: “Workers’ compensation pays $10,000 to hospital outpatient departments for a shoulder surgery on an injured worker, and group health pays $6,000 for the same services. Does it make sense that if workers’ compensation paid $9,000 that hospital outpatient departments would no longer treat injured workers—preferring to treat group health patients at $6,000, or Medicare patients at a fraction of the group health price, or Medicaid patients at prices lower than Medicare?”
Ms. Tanabe is sharing this article on behalf of its authors, Richard Victor and Olesya Fomenko.