Thursday, July 14, 2011

Johnson Study - Doctors Won't See Patients

Nearing the end of RVRBS report reviews! Next in the line is "RBRVS-Based Fee Schedules In Workers’ Compensation: Implications for California"(Johnson, Huth, Bush - 2002). Note that this report and associated research has already been eclipsed by other CSIMS sponsored studies - namely the Kent/Levin series previously reviewed here.

This study was commissioned by CSIMS and deals with three key issues: How do current California statistics on injured worker access to care and provider reimbursement rates compare to other states? What impact have RBRVS-based workers’ compensation fee schedules had in other states? Are there any risks associated with California implementing an RBRVS-based workers’ compensation fee schedule? All very cogent, important questions.

The opening conclusion I think is telling as it is basically what I have concluded in my prior reviews: more questions than answers, little scientific research, and likely more issues than just the fee schedule involved.

"As the project progressed, we found that these questions did not have many easy answers and in fact raised many more difficult questions. As our research will indicate, there has been little scientific research into the pros and cons of using RBRVS-based fee schedules in workers’ compensation, but what little literature there is suggests a mismatch between the benefits of an RBRVS-based system and the challenges currently facing the California workers’ compensation system. In addition, the experiences of other states suggest the potential for significant unintended consequences such as decreased access to care for injured workers and increased administrative expenses for payers and providers alike."

The conclusions reached by the Johnson study need to be taken with the proverbial grain of salt because there are assumptions that are now 9 years old and no longer true.

In addition one has to be careful relative to the descriptions of the various data elements that are used for conclusions.

For instance, the report states that according to the WCRI medical costs are the primary cost driver in California claims. But then the authors point out that medical expenses at that time comprise 41% of the total claim dollar.

What the authors really intend to state is that medical expenses, at that time, were not the principal inflationary factor of the claim dollar.

The latest data from the WCIRB (see WorkCompCentral story Medical Costs Drive Increase in Loss and Expense Payments: WEST [2011-07-11]) indicates that medical expenses are now $1 of every $3 paid by insurers in 2010, which is less than that portion of the claim dollar than in 2002, apparently - from this perspective then I have to agree that changing the fee schedule to save on medical expenses is illogical - California has already experienced a relative drop in the percentage of claim dollar that goes to medical expenses. But this may not be an apples to apples comparison.

The conclusions of this report are in line with the other reports I have reviewed for this series. First most of the conclusions concern the opinions of physicians about accepting work comp cases. Second, in the same sentence about fee schedules as a reason why physicians don't like work comp cases is the now universal finding that "excessive administrative requirements" are a barrier.

I think what is very curious is that the report states that "Actual orthopedist and neurologist participation rates in Florida and Massachusetts may have been significantly lower if not for the widespread practice of negotiating reimbursements above official fee schedule amounts in those states." What this tells me is that the market essentially corrects itself. It also tells me that surveying physicians about whether they will accept a work comp case is an incorrect method of study - as I mentioned in my original post, I am looking for a valid scientific study that injured workers in fact can not get care - not whether doctors will accept cases but whether injured workers can not find a doctor to take care of them.

This methodology - surveying physicians instead of gathering data that is presumably available through statistical agencies such as the WCIRB - is repeated in the critique of both the Massachusetts system and the Hawaii system. At least the Hawaii report authors attempted to gather data from parties other than physicians.

The authors of this study also reviewed other literature that was available at the time and the primary inflation drivers of the medical component in 2002 were identified as chiropractic and inpatient hospital care, both of which were constricted by the California 2004 reform series.

An interesting comparison is made by the authors of this report between a couple of states with low RVRBS schedules (Florida and Massachusetts) and one state with a high schedule (Oregon - 250% of Medicare). Obviously there was greater physician acceptance in Oregon, with over 95% of all orthopedists accepting work comp cases. But Florida and Massachusetts reported participation rates of "only" 79% and 88% respectively. I'm not convinced that is a marked difference, especially since the study was only able to contact about 30 physicians in Oregon...

Some notable quotes about the Massachusetts system are insightful. Regarding whether that state's remarkably low RVRBS schedule impaired access, one interviewee allegedly quipped, "No, you just have to be willing to pay the going rate for the procedure...which has nothing to do with the fee schedule rate."

All in all, this report and the study upon which it is based is a good report that demonstrates, as have the others, that physicians say they won't take work comp cases, and that fees are among several reasons why doctors don't like work comp cases.

But my statement that started this whole report review process was "I have not seen one study in any state following the restriction of fees or procedures that documents that there is a corresponding failure in the delivery of treatment to injured workers". I still haven't. I have seen many reports thus far that conclude that doctors say they won't see work comp patients at fee schedule reimbursement levels based on RVRBS - at least the "low" scale. But I have not seen yet anything that demonstrates that there indeed was an impact on injured workers.

The one differentiation about this report from the others is that while the conclusion is that physicians say they won't accept work comp cases at a low RVRBS schedule, they WILL accept work comp cases - the payer just has to negotiate the fee which to me indicates that there is in fact no access issue for injured workers based on what the fee is or isn't. Docs will see work comp patients ultimately.

Again, the question as to whether in fact injured workers have had their treatment impaired as a result of a fee schedule change is not answered.

There are still several more reports and studies that require review and critique, including a rebuttal report sent me by the California Workers' Compensation Institute (CWCI), which is an insurance based organization - the opposite end of the spectrum.

No comments:

Post a Comment