May 24, 2005

A Few Thoughts on Comp Medical Networks

Workers comp is about injuries and injuries require medical attention. Our colleague Joe Paduda blogs the problem of finding good medical care under the comp system. Back in the 90's, there seemed to be a proliferation of occupation medical practices: from hospital based occ clinics to the "doc in a box" walk-in clinics, there were a lot of options for treating injured workers. These options have diminished dramatically over the past few years. Why? It's pretty simple: a combination of not enough volume (injury rates are declining) and suppressed rates of reimbursement (rate schedules for medical services under comp tend to be low). In addition, you need to consider the context: total health care in this country costs $1.4 trillion, while the comp portion of this is only $30 billion. Comp, in other words, is chump change in comparison to medical care in general.

Paduda's blog shows that the prevalent trend is away from networks specializing in work related injury and toward bringing injured workers into conventional health networks -- in other words, family practices. This is far from an ideal situation. Occupational medicine brings a unique and essential focus to work injury: the goal is always to keep people as productive as possible; to help them heal faster by returning them to work as soon as possible, often through the prudent use of temporary modified duty. I'm not sure that traditional family practices view injuries the same way. Family doctors are perhaps more sensitive to the pressures and issues outside of work. I suspect they are more inclined to give the injured work time away from work, especially when they know that any lost wages will be covered by indemnity payments. They are not used to communicating directly with their patient's employer. Indeed, if the patient doesn't like his or her job, the doctor may be inclined to separate the goal of getting the patient better from returning him or her to work.

Paduda highlights one exception to this trend: the recently announced merging of The Hartford's workers comp business with Aetna's workers comp specialty network, which is available in Pennsylvania, New Jersey, Connecticut, Texas and Virginia. Aetna's network includes 130,000 physicians, hospitals and other health care providers. Aetna, along with Corvel, HealthFirst, Concentra and Focus, and a few others, continue to offer occupational services for injured workers.

Preferred Provider Networks that Really Work
I have long been intrigued with the issue of medical care in the workers comp system. I'm not sure that anyone has got it quite right. In the ideal system, doctors explicitly buy into the notion that a rapid return to work is the optimum result. They are committed to a "sports medicine" approach. They limit office visits and therapy to what is truly needed. They prescribe the necessary medications, but are careful to use generics where appropriate (even though the patient doesn't really care, because there is no co-pay). These doctors are able to resist the raucous pitch of drug companies to experiment with off-line use of branded medications. And they communicate readily with their patients, the employer and the insurance carrier.

In exchange for all this good work, occupational doctors should be paid reasonable rates -- which in many states means paying well above scheduled rates. Too often, the established rates (and the rates within many of the formal medical provider networks) are ferociously suppressed, which can lead doctors to make up the difference by over-utilization; in other words, suppressed rates do not necessarily produce lower costs. In addition to paying occ docs above rate schedules, they should also be reimbursed for certain key activities that usually are provided for free -- such as filling out return-to-work status reports. If you don't pay for such reports, the message to the doctor is that the reports are not important. In the comp system, there is no more important communication than the doctor's take on medically necessary restrictions -- what the employee can and cannot do.

We recommend that employers with any significant volume of injuries develop a relationship with their local providers, whether or not they are in a formal provider network. Make sure that the provider understands your commitment to modified duty. And let your carrier or TPA know that you are not interested in saving a few pennies by forcing your medical provider into a punitive rate schedule. Rather, you want to pay a little extra, in order to secure the level and quality of service that ensures success in workers comp cost control.

| 1 Comment

1 Comment

Good point re protection WC act provides employers from civil litigation. I agree if a person is paid for services, they are an "employee" and are entitled to wc if injured.

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This page contains a single entry by Jon Coppelman published on May 24, 2005 12:34 PM.

Pre-existing conditions and second injuries was the previous entry in this blog.

S. Carolina to bar workers comp for undocumented immigrants? is the next entry in this blog.

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