The ACA Is Our Opportunity

As I said yesterday, one of the more exciting things to me about attending the Workers' Compensation Research Institute's annual conference was to learn more about the Affordable Care Act and what folks more well studied on the subject than I (not hard to achieve) feel the impact will be on our industry.

The morning started off full speed ahead on the ACA with a presentation by WCRI president Dr. Richard Victor followed by a panel consisting of David North (Sedgwick), Donald Hurter (AIG) and Christopher Cunniff (Liberty).

First the WARNING per Dr. Victor - what was presented was preliminary and inconclusive; as has been reiterated ad nauseum, no one really knows what the impact of the ACA is going to be, but eventually the WCRI will publish a study with more conclusive findings.

I will jump to my conclusion, which basically is a restatement of Mr. North's comments - the immediate impact of the ACA to workers' compensation is that for the first time in a very long while that workers' compensation can be included in the conversation about health care.

And I completely agree.

For most of the history of workers' compensation it has been dealt with completely separately from general health even though the basics of both systems - providing treatment to the ill and injured - is the same.

In other words, the ACA is going to cause conversations about all of the things that we care about.

"Tremendous opportunity to have a voice," Mr. North said, about how health care is delivered in this country and how we in work comp need to have new and different ways to have access to health care in the county.

When we started talking about health care costs in work comp we took the managed care model and made it so much a part of our industry that we let managed care BECOME health care and consequently we have forgotten that health care occurs at the point of treatment.

Instead we have piled on post care services to cover the fundamental fact that we didn't provide good treatment right up front.

That's a serious indictment of our industry from one of our own industry leaders. The system has taken away what matters most in the delivery of benefits because in our quest to define and measure we have lost sight of the when and where that makes the most difference.

Dr. Victor used the metaphor of a hurricane when he introduced his presentation: right now the hurricane of the ACA is out over the Eastern Caribbean and building intensity. But like an early stage hurricane we can not predict its trajectory over the long haul, and the intensity of the storm depends on the trajectory and whether it picks up more moisture by hanging out at sea before hitting land, or whether it goes more direct and does not pick up so much damaging power.

And I agree - the impact of the ACA is going to be different in different states because of numerous factors and it is also unrealistic to believe that the ACA will be successfully implemented as written without further changes in the coming years.

Remember that this is a volatile political animal and essentially anything can happen over the course of the next three to five years as this thing matures. There are so many variables that depend on psychology and human behavior that it is nearly impossible to predict that any part of the ACA will survive without some amendment.

For instance, nearly all of the experts agree that one of the reasons why US health care costs are greater than the rest of the world is because the US subsidizes the cost of innovation - the US innovates, we pay for the research and development, the testing, the practical application, and then once that's done our technology is exported to other nations without those pre-distribution costs.

The current system is rife with conflicts of interest because our system of regulating prices is seen as unfair by providers and tends to undermine values.

And I agree with Dr. Victor that the ACA has the potential to affect so many people both financially and personally that it is an order of social adjustment along the same magnitude as the Vietnam  War draft, the Great Depression, and other huge social and cultural alterations to American society.

So this is big. Really big.

Some of the perplexing questions:

Will the predicted expansion of demand create shortages on the work comp end and if so will there be delays in care which will increase costs? And if so, where are the shortages likely to occur (or not) and how will work comp adjust?

At least in the general health model, adjustments are made by increasing the use of non-physicians and increasing reliance on technology, outsourcing to other countries, and ultimately adjusting (usually increasing) prices to meter demand.

Affecting supply and demand are different state laws that, for instance, handle the licensing of different medical professionals differently.

If one were to compare to Canada, which has a single payer health care system for both general health and work comp, there is an impact on access. In the US about 6% of the patient population wait 2 months to see a specialist; in Canada that figure is 29%.

And at least in Ontario, work comp pays more to providers for expedited access but this raises questions of fairness, implying that providers in the US (where there is greater free market enterprise available) would raise prices to allow easier access since medical treatment directly affects other parts of  the work comp equation (e.g. indemnity).

Perhaps a benefit to most system participants, employers, and workers - states may have to alter their systems to alleviate the "hassle factor" physicians complain of in order to compete for access to care.

Either way, Dr. Victor opined, the ACA will increase the cost of work comp in some fashion, at least in the short term.

There were, of course, many citations to examples and studies in the past to support Dr. Victor's cursory conclusions, and since he's analytical and I'm not I'd venture to put my betting money on his outlook.

Except if Mr. North's opinion is followed and this industry is able to take advantage of this rare opportunity to educate the rest of the medical world, and in particular the politicians behind all of this, about how things work in the workers' compensation system and find ways to make the ACA and work comp exist beneficially to each other.

And we start with altering the fundamental question, because if you don't ask the right question you can not get an answer that is going to help.

We have been asking how the ACA is going to affect work comp. That is an incorrect, as Mr. North points out.

What we should be asking is how is health care going to affect work comp? Because the ACA affects health care, not work comp. Health care affects work comp...

Its not the legislation that is going to affect us, but the "conversation." Health care affects the things that we do care about - wellness and comorbidities. We complain about how we don't have access to the tools to deal with these issues: medical records, data and studies from the general health market, effecting quality care on the front end rather than Monday Quarterbacking with reviews and other cost control features built into the law.

Now we have people who have to make a judgment about something that they don't have real good information about or a good handle on, which influence the cost of what we deal with - not just medical itself, but social, economic, health and welfare, relationships, etc.

With the ACA we now have a rare opportunity to think about medicine holistically - we are on just one component. We have the opportunity to raise the conversation and participate in the dialogue and help make work comp and medical care rational to the way people live their lives.