Levin/Kent 2008 Study Does Not Prove Access Issues

Next on my list to review in the debate about the lack of scientifically valid research concerning injured worker access to medical treatment in the ongoing RVRBS debate in California was A Methodology for Predicting Provider Participation in Workers' Compensation Medical Fee Schedules Levin/Kent 2008.

As in my critique of the Levin/Kent 2007 report (post 7/06/2011), this too was paid for by the California Society of Industrial Medicine and Surgery (CSIMS), was again a telephonic survey and the issue is whether there is an impact on physicians accepting workers' compensation cases, not whether injured workers experienced limitations in getting treatment.

What I found most interesting in this report was the conclusion that, "The four most recent states to convert to new fee schedules have provided reimbursement at an average of 211.7% of Medicare, with higher fees for specialty codes. In addition, two low-fee RBRVS states have recently raised fees, with the greatest increases going to specialty procedures, in order to try to restore access to care." The reason this caught my attention was because I expected there to be an answer to the question: did this result in greater "acceptance" of WC cases? Conspicuously, there did not even appear to be an attempt to address this question.

The authors reflect that, with the 2007 study, "a significant question remained as to whether provider participation rates were truly correlated with fee levels; whether those states that had adopted higher-multiple RBRVS fee scales actually achieved higher specialist participation levels; and whether there were other system determinants of participation." For this the authors institute a nice regression analysis to come up with determinative statistics to support their hypothesis that, yes, there was some correlation. What that correlation was, however, was not conclusively that higher fee scales achieved greater participation - this was done in a predictive model, i.e. no real data. Further, the second part of the question, whether there were other system determinants of participation, were more significantly identified than in the prior study.

The authors state: "There is growing recognition that low RBRVS fee scales do not maintain specialist participation: The four most recent states to convert to new fee schedules have provided reimbursement at an average of 211.7% of Medicare, with higher fees for specialty codes. In addition, two low-fee RBRVS states have recently raised fees, with the greatest increases going to specialty procedures, in order to try to restore access to care." 

But there is no follow up data to suggest that the reverse happened in response to higher fees - i.e. that there was an increase in provider acceptance of WC cases, and in fact recall the 2007 study that suggested, at least in Texas, there was continued decline in participation regardless of the increase in fees with the implication that issues which included the need to become "approved" and other issues may be the cause of the decline in participation.

Referencing the 2007 study: "a significant question remained as to whether provider participation rates were truly correlated with fee levels; whether those states that had adopted higher-multiple RBRVS fee scales actually achieved higher specialist participation levels; and whether there were other system determinants of participation." This question remained unanswered in the 2008 report.

Note also that the survey, as with the 2007 study, is not a tit for a tat comparison of acceptance by neurologists because the definition of "acceptance" is unconditional acceptance, or what the authors call "without significant limitations": 

"The survey process involved calling the neurologist’s office and asking whether the doctor(s) accepted WC patients. If the answer was yes, it was determined through follow up questions whether there were any significant limitations on acceptance (pre-pay requirements, severely limited appointment availability, accepting from only a single carrier or employer, etc). Following the precedent of multiple prior studies, only those neurologists accepting WC patients without significant limitations were counted as accepting." 

In my opinion, this is a serious design flaw in the study if the object of the research is to truly determine acceptance levels of physicians in work comp because we don't know how many physicians DO accept cases with limitations.

Finally the study essentially admits to a profound reason for physician non-participation - that the regulatory burden in California accounts, by itself, for an 18.8% predicted decline in physician acceptance of work comp cases.

As with the 2007 Levin/Kent report, I can not accept this research as indicative of impairment to treatment by injured workers as a consequence of conversion to an RVRBS fee schedule. The report does not measure the actual rates by which injured workers may receive or be declined treatment by a physician due to money, the report fails to conclude whether raising fees actually resulted in higher acceptance rates by physicians, and the report is highly suggestive that there are issues well beyond reimbursement rates that affect physician acceptance of workers' compensation cases.