Monday, July 11, 2011

Association of CA Neurologists 2005 Report - No Better

Third in the line of reports of studies that were offered to prove that access to care by injured workers would be affected by implementation of an RVRBS fee schedule in California is a report by the Association of California Neurologists - Workers' Compensation Committee, entitled "Impact of Medicare-based Workers' Compensation Fee Schedules on Injured Worker Access to Neurological Care in Texas & Hawaii" (authors unidentified, March 2005).

This study too is a telephonic interview of neurologists making inquiry as to whether they currently accept workers' compensation patients, and if they ever have why they have stopped doing so. In addition the study interviewed 114 private practice neurologists in California to determine if SB228 and SB899 had an impact on their practices.

The conclusion of the study is that nearly one-half of Texas neurologists had stopped accepting workers' compensation cases following the 2003 fee schedule implementation, and that prior to the 2002 reform 61% of all neurologists in the state took work comp cases, but that only 31% do as of the date of the report.

In addition the authors conclude that prior to institution of the fee schedule in Hawaii the participation rate of specialists in the state was 77% and that fell to 29%, which coincidentally is higher than what the state found in its own earlier study - 23%.

With regards to California, the study authors conclude that 51% of the survey population accept work comp cases post reform, compared to 80% prior to reform. (Note, these results are markedly more optimistic than the reports I previously reviewed in my two earlier posts concerning studies commissioned by CSIMS!).

The study had an extremely low population from which to draw in Hawaii, surveying only 34 physicians. This is an extremely low sample and not one that I could consider statistically valid for purposes of extrapolation to a larger population. The authors do not give us a margin of error.

The survey questions were asked of the physician's office receptionist and apparently if answers were negative the interview was elevated to the office manager "if necessary".

The study authors note that the passage of California reform in SB 228 and 889 "dramatically increased the administrative burden placed on medical providers".

According to the study, 63% of Texas neurologists "specifically cited the change to the 125% of Medicare fee schedule as the primary reason for their decision" to stop seeing work comp patients. However the study states, "other reasons providers cited for dropping out of the workers' compensation system include 'paperwork', 'hassle', difficulty with completing certification requirement', and 'couldn't collect payments from insurance company'." The report does not state whether these "other reasons" were in cited in conjunction with the fee issue, or whether the fee issue was a completely separate answer.

The report also lays out geographic impacts noting that the greatest impact was on rural areas in Texas. The authors are also critical of the certification and educational quality of the neurologists who are still accepting work comp patients, stating, "the evidence suggests that the neurologists that do still treat injured workers are actually less experienced and less qualified" noting that prior to the fee schedule change 71% were both board certified and went to school in the US or Canada compared to 52% after the change.

I have the same critical opinion of this study as I did the Levin/Kent reports: they are telephone surveys with the same attendant validity issues that were not correlated to statistical error rates, and they reviewed acceptance rates, which is not the same as actual impact to injured workers. In addition, the sample rate of the study of Hawaii neurologists is precariously low with no attempt to factor in a relative error rate on the extrapolation to a larger population. As in the Levin/Kent studies the implication is that there are other reasons beyond just the fee schedule that impact provider acceptance of work comp cases.

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