Monday, July 18, 2011

"Trends" - Establishes Disconnect in Value of Medical

Trends in Medical Specialist Participation in Workers’ Compensation Systems – Implications for California (Levine, 2007) is a not just a summary of various studies concerning the impact of physician specialists acceptance rates of workers' compensation cases following the implementation of RVRBS fee schedules in different states, and projections of the impact such a system would have on the California system, but also is a review of the actual expense data of 13 neurologists.

Seven did not take work comp patients, six did.

"This data revealed that neurologists who did not routinely accept WC patients had an hourly practice overhead of 91% of Medicare’s estimate of neurologist hourly overhead. By contrast, we found that neurologists who routinely accepted WC patients had an hourly overhead of 295% of Medicare’s estimate. Six orthopedists who routinely accept WC patients had an average practice overhead of 247% of Medicare’s estimate for orthopedists. Similarly, a study by Brinker, et al in 20023 found that practice cost in an orthopedic group was 202% that of a Medicare patient for the same diagnosis.

"Another way of measuring the value of these factors was to compare the willingness of neurologists to accept WC patients compared to their willingness to accept Medicaid and Medicare patients. In all the study states except Hawaii, Medicare acceptance was over 90%. In all the states, however, WC acceptance was well below not only Medicare, but Medicaid acceptance. For example, in Texas, Medicaid pays only 42% of what WC pays, but four times as many Texas neurologists routinely accept Medicaid as accept WC."

The conclusion of this report is that, bottom line, whatever the fee schedule, there is inadequate coverage of physician practice expense relative to the increased burden created by workers' compensation systems.

The authors state:

"We predict that such a thorough inversion of the distribution of fees away from specialists as is currently under consideration in California, without significantly increasing overall payments, will result in markedly reduced access to specialty care for injured workers." [Emphasis original.]

I don't doubt these conclusions - they seem logical.

But remember that this report was forwarded to me as a part of my challenge that there weren't any studies that measured actual injured worker access to physician care in workers' compensation systems.

The studies that were sent to me for review invariably concluded that there would be less physician participation/acceptance of work comp cases.

And each of those studies has indicated to me that the issue of fee schedules is much, much more complex than just the conversion factor or rate of pay.

There is a disconnect between the services physicians provide in workers' compensation cases and the perception of value received by the payor. In the middle of all this is the injured worker who, because of the promise of "free" medical care (i.e. no deductible or other financial requirement) essentially gives up all control over the course and direction of care to third parties (i.e. the insurance company versus physician fight).


  1. I did not see the initial threads leading to this post. However, I find your last paragraph thought provoking. It is my understanding that in a fee schedule world, the state sets the fees, not the payer. So I'm not sure where you find the disconnect between services provided and Perception of value. You also raise an interesting point-of-view stating that because treatment is "free", the injured worker gives up control of his/her care. Do you think the workers just become passive recipients of treatment? I'm curious to hear further insights into your thoughts behind this last paragrah.

  2. Thanks for your comments LT.

    The disconnect is between what the total actual value of services are that a physician provides under work comp versus what a fee schedule proposes. The studies that I earlier reviewed all cite the work comp "overhead" as to why physicians object to a "low percentage" (125% or less) RVRBS schedule.

    In my experience, injured workers are more "passive" in regards to treatment than in the general health context - one of the cost controls that the general health system uses is deductibles to control utilization. This has a very powerful effect because the patient has a stake in the game and thus is more careful with receipt of services.

    Just my humble opinion!