Thursday, October 1, 2015

Sam vs. Jane

The Workers' Compensation Research Institute's latest study essentially states that financial incentives influence treatment considerations - that capitated systems will cause a case shift away onto fee for service systems, like workers' compensation.

Sometimes those incentives get reversed too - and it's all about who's paying, and who's receiving.

The following comparison that was communicated to me by a reader is anecdotal for sure, but it is illustrative, and alarming. The only real difference in the quantity of similar medical treatment rendered is an elderly man via Medicare versus a middle age woman on workers' compensation. Guess who loses?


Sam vs. Jane

What a contrast Jane's situation with Sam's dad's situation. 

We can't get the rehab people to stop treating Same's dad (Medicare), versus Jane (workers' compensation) who can't get anyone to treat her. 

Sam's dad, 97,  fell 4 times a few months ago and now the rehab people won't quit. They stop by with questionnaires (all the same) but 3 people have to fill out the same forms. They treat him with occupational therapy 3X/day. He does not want occupational therapy. He's 97, he wants to sit in his chair and read and at 97 he's entitled to do that. 

Sam had several meetings telling them to stop the rehab. Then coming up in the elevator after the last meeting to again tell them - NO REHAB for at least 2 weeks.... when the elevator door opened on the 4th floor ..... guess who was standing there waiting to come downstairs -- the rehab woman!  

Sam politely asked her if she wasn't possibly at his father's apartment and sure enough she had been -- she'd stopped by to "say hi" even though less than 1 hour earlier Sam had had a 20 minute conversation with her and never uttered anything other than "No, we do NOT WANT REHAB."

Contrast to Jane who fell and has had to beg for care. And has had DOZENS of denials of care for her witnessed, admitted, injury.

The rehab woman for Sam's dad gets paid per treatment, and probably an incentive bonus when she treats over 50 times/week, or something.

By contrast, utilization review, the adjuster and the defense counsel get rewarded for refusing care. Defense counsel gets paid more for every hour he works the file to deny care. UR gets paid per review, and they know the expectation is to deny care. The adjuster doesn't really care since the employer has, no doubt, a large deductible policy and they still get their Allocated Loss Expense. The vendors are allowed to run wild.

Sam's dad is in a high quality, expensive facility with vendors that are ruling the roost, running wild providing unwanted treatments. He was an Colonel in Army, and a university Dean, but is now treated like an idiot by the rehab people.

Jane, on the other hand, has had to find her own care, pay for it herself (including the lodging necessary because the only facility she could afford was too far away for a normal commute) and eventually ran out of money, and options.

Anyway, it's interesting to watch the two different systems and how, in different ways, they mistreat those they serve.


While the WCRI was focused on case shifting into or away from workers' compensation, the real take away is further confirmation, reprehensible as it is, that providers of medical care (and those responsible for managing them) will go where the dollars are, and unfortunately that's not always in the best interests of the patient or injured worker.

Business, after all, is business...


  1. THis is so true. Im finding more door open to me under my ACA coverage than I do with comp. And it's thanks to comp that IM on the ACA to start with.

    The State IME Dr.s Says IM fine, he's all good to go now.... yet my Treating ACA MH team, have me going on meds and IOP. Where they come to my home 2 times a week for therapy... to my home..... this is MH therapy.

    Yet the Work comp systems that lured me into the IME under the pretext that she was going to give us all a PPD rating, yet she took upon her self to turn it into a TTD. Closed the claim, and she did not current testing at all.....

    None the less comp try's to deny me for 2 years even though they accept my MH condition being agitated, but never did provide me with care, I had to use the ACA for care, and comp siad that was fine, but yet when they needed medical proffs, the would not use the ACA dr.s recommendations. Only this new IME Dr.s denial.

    WAR ON LABOR thorugh our care. ITs sickening. THey dont want to train old dogs who have not at least earned a two year degree, and even then, industry just does not want to waist the time and money on old dogs injured on the job... its just not cost efficient for them. SAD what making folks compete against one another creates. A Class WAR in our healthcare and employment needs today.

  2. I've got Names & recorded evidence.

    100% accurate evidence from sessions via recorded audio that's been transcribed & corrupt reports of IME sessions.

    100% proof of Attorney Oath breaking & per civil law fraud blown off by state bar association even after an appeal stating talk to MN DOLI.

    100% HIPAA/HITECH breach of privacy by Sedgwick adjuster that was blown off.

    Drs. & Sedgwick corresponding under the table. Drs. not allowed to perform patient diagnostics or report patient symptoms on reports.

    Attorney's frivolous & fraudulent NOID's.

    Pass the buck from State depts.

    Drs. & Attorney's & Bar Assoc. & Adjusters & State WC office & Minnesota Department of Commerce WC Insurance fraud. All playing pass the buck so the patient loses.

    Sounds like a RICO suit to me. How do you get enough on board?