Tuesday, November 25, 2014

The Mom Standard

"Pretend the injured worker is your Mother. Now tell me how you’d like to have this case handled."

That's how one industry consultant describes what he tells claims administrators handling cases for his client employers.

The analogy is perfect in my mind, particularly when I ask audience members at various speaking engagements whether they would choose to be treated for an injury or illness under the work comp system, or defer to general health.

Every time I ask there is only one, maybe two, people that choose work comp over general health - despite the fact that work comp entails much less out of pocket expense (no deductible) and, despite the proliferation of treatment guidelines, a greater menu of available services covered.

I suppose these informal, highly non-scientific, anecdotal surveys reflect a concern among industry professionals that the care they would receive if there were a work injury or illness would fall below the Mom Standard.

Last month the Mom Standard was tested, and I wrote about it - Mom, at 90 years old, contracted pneumonia. Her care facility acted quickly, and largely because of the rapid response by them and the medical team at Palomar Medical Center had her back to her residence in 3 days, and fully rehabilitated in 2 weeks.
Palomar Medical Center, Escondido, CA

That's the Mom Standard of care - quick, direct, aggressive medical care early - and the result is a positive outcome.

There's a lot of times when that standard isn't met in workers' compensation cases, and there's a number of reasons, all of them fall under an overarching cause: work comp might be a "no fault" system, but it is very much a liability allocation system.

Fault is "responsibility for failure or a wrongful act."

Liability on the other hand deals with "money owed; debts of pecuniary obligations."

Liability in workers' compensation gets in the way of the Mom Standard of care, particularly when the obligation to pay is assumed by a third party under an insuring contract.

The industry seems consumed with "costs." It seems that no matter what the analysis of any particular case or situation, there is always some mention of costs - and that's because someone or some entity is liable; i.e. is responsible for paying the bill.

For instance, the California Workers' Compensation Institute released a report the other day reviewing trends in medical benefits in workers' compensation.

A 19.4% increase in costs for prescription drugs and durable medical equipment in 2012 drove an overall 2.3% increase in average medical benefit payments per indemnity claims, CWCI concluded.

Carriers paid an average of $16,375 in medical benefits per indemnity claim at the 24-month period for accidents occurring in 2012, compared to $16,003 on claims for injuries occurring in 2011, but the overall amount paid for medical treatment actually dropped slightly to $10,903 on 2012 claims from $10,931 on 2011 claims.

In the meantime, medical cost-containment expenses increased about 2% to $2,330 from $2,283 per indemnity claim.

This is all good and well - the payer part of the industry does need to know where the money is going. I get that.

But obsession with where the money is going tends to overshadow why the money is going there.

CWCI reported that average medical costs dropped on 2004 and 2005 claims following the reforms of the early 2000s. From 2005 to 2009, payments for all four subcategories of medical benefits increased steadily.

Medical-cost containment expenses were the fastest-growing subset during this period. CWCI attributes this to the adoption of the Medical Treatment Utilization Schedule, mandatory utilization review and the introduction of medical provider networks through the early 2000 reform measures. Average medical-cost containment expenses of $2,173 on 2009 claims were 217% higher than the $685 paid in 2002.

But average total medical benefit payments at the three-month valuation point were relatively stable until accident year 2008, when they increased 32.1% to $2,483 from $1,879.

"The average amount paid for medical benefits at three months post injury on more recent claims declined slightly in AY 2011 and AY 2012, but then jumped 28.1% in AY 2013 and 12.1% in AY 2014," CWCI wrote. "These sharp increases in average medical paid at three months post-injury may indicate faster delivery of initial medical services rather than a significant increase in the volume of medical services that were eventually delivered. The impact of the SB 863 medical reforms may become clearer as more developed data from AY 2013 and AY 2014 become available, though the preliminary data on medical payments at three-months post-injury indicate the 2012 reforms were not associated with any reduction in overall medical payments per indemnity claim during the initial period following the injury."

All of that to say, basically, we're not sure whether effective care is being obtained by injured workers in a timely fashion.

Then there are the anecdotes that our focus is misplaced, that we're not using the Mom Standard.

In a comment to the story in WorkCompCentral about the CWCI report, "screwed in this system" says he has been denied the only follow up post surgical therapy he can tolerate, aqua therapy, so he pays for it himself. He has been through the Utilization Review and Independent Medical Review process.

He states, "How much did two UR reviews and an IMR cost as apposed to just providing me with the post spinal surgery PT? The ONLY reason it was denied in the first place is due to claims adjuster not providing relevant records."

Failure of the Mom Standard...

Because concerns of liability trump the Care of Mom.

Think of Mom, then deliver the care.

Maybe then, by next time I take an informal poll of our colleagues, I'll get more hands favoring work comp care over general health.

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