Wednesday, August 17, 2011

The AZ Managed Care Experiment - Is Choice Material?

Arizona is experimenting with managed care concepts in workers' compensation.

Arizona state Rep. Judy Burges, R-Skull Valley, introduced HB 2584 during the 2011 legislative session, which was objected to by various constituencies. As a consequence HB 2584 was amended to implement a pilot program where one city with a population of 150,000 or more that is self-insured for the purposes of workers' compensation and the Arizona Counties Insurance Pool, a group of 11 rural counties, will be allowed to direct care for injured workers starting Jan. 1, 2012. The program will terminate Jan. 1, 2015, and the results of the pilot program will be analyzed to determine whether more employers should be allowed to direct care.

The bill had unanimous approval from the House and the Senate in votes taken last spring. Arizona Gov. Jan Brewer signed the bill on April 13.

The impetus of course is controlling medical costs by directing care. The hypothesis is that by directing care the employer will see better return to work outcomes, ergo lower overall costs.

There is some validity to that hypothesis based on some other state studies.

In Texas directed care was instituted in 2001. According to the Workers' Compensation Research Institute (WCIRB) medical costs per claim fell 19% from 2002 to 2006 because of fee schedule cuts included in HB 2600 and because of "increased management of medical costs by payers."

The WCIRB report reflected that patient outcomes were improved under the directed care model, but that patient satisfaction was lower because they didn't have the freedom to pick a doctor.

The issue of freedom to pick a doctor to me is interesting. I reflect upon my own experiences with medical treatment and the freedom to pick a doctor.

In those (unfortunately not so rare) instances where I needed care beyond my annual physical I did not know who to pick and relied upon others to direct me to a physician (or physicians) of competence within a given specialty. 

There have been two general types of situations where I required medical care for injuries: catastrophic injuries requiring emergency medical treatment, and more routine (for me) medical emergencies.

The former type of situation involved life or death consequences where my care was directed essentially by health care providers who were foreign to me - I didn't know where to go other than the emergency room and they sent me to physicians and facilities who did a fine job of patching me up. These were situations where it was literally life or death if the proper care wasn't administered in a timely fashion and involved hospital stays (a couple of times, up to a week - I'll tell those stories some other time!) along with follow up care for up to two months post hospital stay.

The latter type of situation involved serious injuries and a quick trip to urgent care at the direction of my medical insurance (i.e. an approved facility). Again, I did not know the physicians and I was patched up and sent on my merry way - no wear for the worse.

Now, in both situations there were no industrial issues - no one had to opine about my disability or return to work status. And even if they did I would probably have ignored their advise anyhow because I'm a bit hyperactive and bed/rest time to me is the antithesis of life.

I know that is not how many people would react so I don't hold myself out as a model for physician choice versus return to work outcomes and patient satisfaction.

The point with my experience though is that physician choice didn't make a difference. The patient/physician relationship was limited in duration to dealing with the injuries at hand and once those were resolved that relationship terminated. And I was repaired and returned to life.

In long term care situations physician choice may make a difference to the injured worker and perhaps may make a difference in the long term prospects of the patient. I suspect that these situations are rather rare however and may be based more on the comfort and security of seeing a familiar face whom one would associate with being intimately knowledgable about the case at hand.

I also suspect that much of the benefit of physician choice is rooted mostly in either culture or individual psychology, or a combination of both. Some people don't like being told what to do regardless of the benefit, and this can adversely affect outcomes. Others will persevere to a desired outcome regardless of who is "directing" the path.

The Arizona experiment is set to expire in 2015. A report to the legislature on the outcomes of this experiment is due before then so the state can determine whether to continue the program, expand the program or terminate it. How results are measured and the conclusions of this experiment will provide some interesting debate in the future.

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