Thursday, July 7, 2011

2007 Levin/Kent Report Raises Concerns, But Not Access Concerns

If you will recall, I opined that the medical community had not proffered any valid research reflecting that a change in California to a RBRVS reimbursement schedule would create an access issue for injured workers.

I was taken to task by Carl Brakensiek of the California Society of Industrial Medicine and Surgery (CSIMS), and Robert Weinmann (The Weinmann Report). Mr. Brakensiek offered to supply me with studies that, he said, "indicate there are substantial access problems in RBRVS states with low (below 125%) Medicare conversion factors." I promised to review each report and, if I'm wrong, admit so publicly here and write a letter to the legislature as to my findings; and if I'm right, I would still write to the legislature...

I was supplied with several studies which I listed in my post of July 5. In my opinion, to make my promise complete, each of these reports deserves time alone, and comment alone - thus each report will be reviewed in separate blog postings.

I decided to start with "Workers' Compensation Medical Fee Schedules; New Findings & Implications for California" - Levine, Kent (2007) because it was the first one I clicked on. I note that this study was funded by CSIMS. I am always suspicious of a study that reaches conclusions being advocated by the group funding the study and indeed this report raised more questions in my mind than those it seeks to answer. On the other hand, CSIMS would not be doing its job of advocating for its members and supplying studies and evidence to support its positions.

The study is comprised of a telephonic survey of 1400 neurologists in Florida, Hawaii, Maryland, Texas and West Virginia, and orthopedists in Texas, West Virginia and Hawaii to see if they would accept workers' compensation patients if their fees were set at 125% of RBRVS.

Right off the bat I'm going to admit to a bias in my review of this report: it is NOT a statistical overview of the actual rates at which workers' compensation patients get medical attention. It is a survey asking physicians whether they would accept workers' compensation patients given a fee scenario. These are two different questions requiring explicitly different modalities of research. As I mentioned earlier, the question is NOT whether a physician might see a patient, it is whether a patient was able to get treatment.

In addition, telephone surveys have inherent issues with validity. They are highly dependent on the interpretation by the interviewee of the tone of the interviewer's voice, on the honesty of the interviewee, whether the questions are open or closed, the attitude and temperament of interviewee (bad day at the office, etc.?) and a host of other issues (see

Now that I have laid out my biases and caveats, let's look at the report itself.

Levin/Kent conclude that "Every state that adopted a low-multiple RVRVS fee schedule demonstrated a markedly low rate of neurologist and orthopaedic participation in workers' compensation."

"In the two states where pre-RBRVS and post-RBRVS data are available, there was a dramatic decline in participation with the adoption of a low-multiple RBRVS fee schedule. Neurologist participation levels continued to decline in Hawaii more than a decade after it first adopted its low-multiple fee schedule. In Florida, where fees were raised three years ago to a low-multiple RBRVS level, participation among neurologists nevertheless continued to decline. Two states, Texas and West Virginia, now have neurologist participation rates of approximately ten percent. In contrast, participation in Texas was documented to be 63% a year before the adoption of a low-multiple (125%) RBRVS fee scale in 2003."

Fair enough - the physicians surveyed aren't thrilled with a low-multiple RVRBS schedule. But when you get further into the study we find some anomalies.

For instance: "The present survey also indicates that in California, specialist participation has already begun to decline. While 92% of orthopaedists and 80% of neurologists reported accepting workers' compensation patients in California in 2002, only 65% of orthopaedists and 37% of neurologists continue to do so in 2007." [emphasis added.] This points to a disconnect in the logic that a change in fee schedules affects vendor participation - there is obviously something deeper than just the fee schedule if, as in California the schedule has not yet been changed to RVRBS, physicians say they don't want to take on work comp cases anyhow!

The authors make comments on studies by the Texas Medical Association and the Association of California Neurologists comparing acceptance rates of physicians of workers' compensation patients - again both telephonic surveys of providers. Texas saw the biggest decline in orthopaedists post implementation of the 125% RBRVS, but orthopaedists were by far the largest population accepting workers' compensation cases BEFORE the low-multiple RVRBS with 73% of orthopaedists responding positively compared to only 46% of all physicians surveyed. This finding suggests other underlying reasons than reimbursement schedules and indeed, the authors note, "Perhaps the most important of these in terms of the potential impact on provider participation rates was a requirement that medical providers needed to apply to be on the state's 'Approved Doctor List'" which requires financial disclosure and additional mandatory continuing education.

In Florida the report notes that when reimbursement was a very low 83% of Medicare, 47.5% of all neurologists were accepting workers' compensation patients, but after the legislature RAISED FEES to 125% for specialists and 110% for general practitioners the acceptance rate of neurologists DECLINED to 18%. What's wrong with this picture?

According to the authors, a follow up survey reflects that the participation rate for Medicare/Medicaid patients is far higher than workers' compensation though reimbursement rates are far lower - could this be that in fact the issue is NOT reimbursement rates but some other underlying reason, e.g. administrative burden, the TYPE of patient, return to work issues, etc.? Perhaps this speaks towards a single source payment system where the physician is paid the same regardless of injury/illness causation and the medical component is removed from the indemnity component? Perhaps the issue is the trouble in actually getting paid (i.e. cash flow) as opposed to the actual amount paid?

My bottom line on this report - it is evidence that physicians may be less willing to accept workers' compensation patients depending on reimbursement schedules, but it is not evidence that there will be an access problem occasioned by reimbursement and in fact the indication is contrary: that physicians are less likely to accept a workers' compensation patient regardless of reimbursement rates suggesting that there is some other reason why physicians are less than enthusiastic about work comp cases.

In my opinion this report is not valid, scientific evidence that a change in fee schedule will result in injured workers not being able to get treatment. It is evidence that physicians' attitude is that they don't want workers' compensation patients, a fundamentally different question than whether injured workers are actually impacted.

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