Thursday, January 31, 2013

Medical Networks and Indemnity Caps

California leads the headlines this morning with two very interesting, but unrelated, developments.

First, the Division of Workers' Compensation (DWC) in a public hearing held in Oakland on Wednesday said it is exploring the possibility of using the Department of Insurance or the Department of Managed Health Care to oversee entities providing physician network services.

There are arguments on both sides of the fence on this issue of course.

Greg Moore, president and chief executive officer of Harbor Health Systems in Irvine, said he is concerned that allowing the Department of Managed Health Care (DHMC) to regulate MPNs would create problems in California similar to what is happening with efforts to implement preferred provider program rules in Illinois.

Moore said the proposed rules in Illinois “reflect very much of a group health influence” with certain standards for approval dealing with co-pays and other issues “that have nothing to do with workers’ comp.” The concern is that this would make it more difficult to establish and maintain networks in work comp.

The other side of the argument is that allowing the DMHC to perform the oversight is that they have experience and expertise in the financial health of medical networks.

In response to the failure of several physician organizations in the 1990s, California lawmakers in 1999 passed SB 260, creating a Financial Solvency Standards Board within the Department of Managed Health Care. Organizations are required to submit quarterly reports and take corrective action if they don’t meet solvency requirements.

A white paper by California’s Integrated Healthcare Association said the regulation has made the group health provider network more stable.

I haven't studied the issues enough to take a position on the proposal, but what I do find fascinating is that this represents another step in the evolution of workers' compensation towards the unification of medical care.

The concept of universal care, 24 hour care, single stop shop, etc. has been floating for a couple of decades now with very little progress.

But the passage of the Affordable Care Act, the signing of HB 1 back in February 2009, and other Federal health related laws and regulations including ERISA, have accelerated the fusion of workers' compensation medicine and general health medicine. Outsourcing MPN oversight to a health care related agency is just another step towards this outcome.

On another note, the First District Court of Appeals (1st DCA) ruled yesterday that the limits of Labor Code section 4656 apply to benefits received by a public safety officer (police officer in this case) under Labor Code section 4850.

To the uninitiated, 4656 essentially limits temporary total disability indemnity to 104 weeks (though there are exceptions) from the start of the first payment. 4850 gives public safety officers a salary continuation benefit in lieu of temporary total disability indemnity (i.e. full weekly salary rather than the capped TTD weekly benefit) for 52 weeks.

The net amount to the injured officer can be dramatic.

And the cost of that benefit can also be dramatic in comparison to TTD.

The 1st DCA, in County of Alameda v. WCAB (Knittel), No. A135889, concluded that salary continuation benefits paid to Alameda County Deputy Sheriff Bryan Knittel counted toward the Labor Code's 104-week limit on payments for an injury causing temporary disability.

Police officer's associations are upset, arguing that giving public safety officers three years of benefits will "in many circumstances allow them time to recover and get back to work." Cutting off benefits after two years means that officers have less time to recover, which can effectively "force them out of the job and onto a disability retirement," thus forcing these people onto the public disability roles.

There are many scientific studies regarding disability status and return to work.

If a claimant isn't back to work after two years of being off work, they aren't returning.

That's pretty much the bottom line.

Time to move that person to the permanent disability roles.

Medical networks and public safety benefits - the complex world of work comp is ever evolving, constantly changing, and continuously entertaining.