Tuesday, July 12, 2011

Dembe Report Indicates More Issues to Access than Fees

The Dembe study ("Access to Medical Care for Work-Related Injuries and Illnesses: Why Comprehensive Insurance Coverage is Not Enough to Assure Timely and Appropriate Care (Dembe, Harrison - date unknown) is a review of the empirical literature concerning access questions and the fourth report forwarded to me in response to my post about lack of scientifically valid studies against the implementation of an RVRBS fee schedule in California.

The authors of the Dembe report start out by defining access to care in a more specific style than any of the reports I reviewed earlier and come up with a more complex definition consisting of three tiers: primary which means getting into the a health care system in the first place, secondary which involves things like getting timely appointments, specialist referral, etc. and tertiary which may involve lack of physician skill, failure of communication or inappropriate care.

Since insurance coverage is generally not an issue in workers' compensation (the authors estimate based on the studies they reviewed that approximately 98% of all workers have some form of workers' compensation coverage) other primary access issues include failure of employers to accurately report payroll, no work comp insurance at all, fear of employer reprisal, safety incentive programs which discourage reporting of claims, and job loss for any health issue reporting.

Lack of knowledge about how the system works by employers, employees and physicians is seen as a large barrier to primary access with a whopping 61% of injured workers surveyed in 1997 as feeling they had not received sufficient information about access to work comp services, and over 21% of workers in Florida surveyed in 1999 stating they had received no information whatsoever about work comp.

In addition, establishing AOE/COE is reported as a significant barrier to entry. In one New York study cited by the authors, 79% of 135 carpal tunnel cases were denied, but after adjudication 96% of those were resolved in favor of the injured worker after an average wait of 429 days - I find this a much more disturbing trend concerning access issues to health care for injured workers than fee schedules! In Florida it was found that 12.8% of all medical treatment had been denied at some point during a claim, due to various factors.

Secondary issues cited in a 2001 New York study concerning access in work comp cases cited by the authors include delays in payment, nonpayment, "time-consuming nature of WC cases", excessive paperwork and distrust of the work comp legal system.

One paragraph in the Dembe study notes the prior reports I have reviewed as potentially indicating that low reimbursement rates for work comp cases impact the secondary level of access (page 6). This is not an independent study and the authors do not appear to have critically reviewed the reports as I have posted earlier.

The authors do state that utilization review appears to be more aggressively applied in work comp cases than in the general health arena and that this may impact secondary levels of access.

Tertiary care issues provide unique challenges to medical care in the work comp setting, according to the authors. For example, the emphasis on return to work and restoration of vocational function generally requires intensive specialists services and tests. This level of service requires special training and unique familiarity with an injured worker's employment setting or job requirements.

In addition, "many workers report pervasive feelings of mistrust and suspicion surrounding workers' compensation medical care that can jeopardize the provider-patient trust that is essential for attaining optimal care and outcomes (citation)" leading to some injured workers to perceive their interactions with physicians as adversarial and humiliating.

Overall, the Dembe report is an excellent review of the literature that has been prepared concerning the issues of medical care delivery in the workers' compensation system. It points to many, many issues that not only increase costs in care delivery, but also decrease patient satisfaction, increase patient treatment duration (and consequently indemnity duration and amount), deter the provision of medical care and generally increase costs and decrease effectiveness throughout the work comp equation.

The report does not, however, provide an independent statistical analysis documenting that an RVRBS fee schedule prevents injured workers from getting care and in fact provides fuel to the argument that care to injured workers is a much, much more complex issue than just fees.

I do agree, however, that this is one report that should be required reading by state legislators, and regulators, any time a "reform" proposal is brought up - there are many problems with medical care delivery in work comp. Fees might be part of the equation, but fees alone are not the sole source of access issues and dealing with fees in a vacuum, ignoring all of the other "access" issues will only exacerbate problems with medical care delivery to injured workers.


  1. I'm currently providing voc rehab/placement services to a client who mistrusts both his back surgeon and his PM&R doctor...and believes he is being "swept under the rug". The client is not progressing with pain issues and the relationship between his health care providers leads to additional thoughts of disability and self-helplessness.

  2. Amy - this is a huge problem in the work comp medical context in my opinion. The very people that are supposed to be helping the injured worker are often viewed in an adversarial context that just prolongs disability, inhibits healing, etc. I've seen much of this behavior when I was a work comp attorney and it is a very difficult situation to overcome. I think part of the problem is the fact that since the employer/carrier pays for the physician completely that there is this built in mistrust that the physician is working for the the employer/carrier rather than for the IW. But as we have seen, employee choice doesn't do any better in most situations. There must be some middle ground where the IW has some control or at least feeling of control and the employer/carrier is satisfied that they aren't getting taken to the cleaners as well.