In Florida that state's Supreme Court ruled that the limitations on attorneys fees was unconstitutional, reverting the system back to a "reasonableness" standard until the legislature can come up with something better.
The attorney for Marvin Castellanos in that case had to overcome between 13 and 16 different defenses raised by the carrier for employer Next Door, Inc. in order to secure a mere $822.50 in benefits.
Under Florida's fee statute, that meant counsel was entitled to an award of $164.54 for 107 hours of work.
The month after Castellanos, the Utah Supreme Court struck down its workers' compensation attorney fee schedule as unconstitutional, leaving attorneys free to charge any "reasonable" amount for their services.
Utah's workers' compensation attorney fee schedule had similar rigidity as Florida's. The Utah court found that only it could regulate the practice of law, so the restrictions were deemed unconstitutional.
In contrast, New Hampshire doesn't have an attorney fee limitation, relying on the "reasonableness" standard.
So the New Hampshire Supreme Court ruled last week that maybe a $4,138,200.90 fee was not reasonable when the hourly rate would have been $79,369.59, but that the value of the unsettled future medical care needed to be taken into account in a "reasonableness" determination.
Thomas Phillips suffered injuries in an on-the-job accident that left him a quadriplegic.
His employer's comp carrier disputed his claim, and the New Hampshire Compensation Appeals Board determined that the carrier was not liable for benefits to Phillips because the carrier had not received timely notice of his claim.
The state Supreme Court reversed the CAB's decision and remanded the case.
On remand, the CAB ruled in favor of Phillips and awarded him total disability benefits.
Phillips then requested an award of attorney fees, and he introduced evidence of his fee agreement with his attorney. The agreement provided that the attorney was entitled to a contingency fee representing one-third of any medical, indemnity and impairment benefits that Phillips may obtain.
Based on the award he got from the CAB, Phillips said his attorney was entitled to $4,138,200.90.
The carrier conceded that Phillips was entitled to a fee award, but it protested the use of the fee agreement as the basis for such an award. The carrier argued that the CAB should award a fee only for reasonable time expended, at a reasonable hourly rate, and reasonable costs incurred for proceedings before the CAB.
The CAB awarded Phillips $79,369.59 — an amount equal to the hourly rate he would have been charged as set forth in the fee agreement had he elected to be charged on an hourly basis.
The New Hampshire Supreme Court on appeal sent the matter back to CAB because it did not include the value of future medical (which isn't settled via lump sum).
"Absent a clear intent by the legislature to exclude future medical benefits from consideration in an award of reasonable counsel fees, we believe that a categorical bar excluding them from consideration cuts against the broad remedial purpose of the Workers' Compensation Law," the court said. Thus, the CAB erred when it ruled otherwise.
The case was In re Appeal of Phillips, No. 2015-0218, 06/28/2016, published.
Showing posts with label fee schedule. Show all posts
Showing posts with label fee schedule. Show all posts
Wednesday, July 6, 2016
Friday, April 8, 2016
The Customer
A lot of effort and expense goes into controlling medical costs in workers' compensation, but savvy vendors seem to always find a way around those controls.
The Workers' Compensation Research Institute's latest study on physician dispensed medication reflects this "whack a mole" phenomenon.
The conclusion: vendors steer around fee schedule limits with odd-sized dosages that aren't scheduled ... yet.
“When prices are reduced by regulation, the regulated parties — in this case physician dispensers — sometimes find new ways to retain the higher revenues they had prior to the reforms,” Dr. John Ruser, president and chief executive officer of WCRI, said in a press release. “The results raise questions about the effectiveness and sustainability of the price-focused reforms.”
In California, for example, the average price paid to physicians for 5- or 10-milligram pills of muscle relaxant cyclobenzaprine was about 39 cents per pill in early 2014. But a new 7.5-milligram product, introduced in 2012, cost $3.01 per pill.
As of early 2014, the 7.5-milligram cyclobenzaprine pills accounted for 55% of drugs dispensed by physicians in California, compared to only 2% of drugs dispensed by pharmacies in workers’ compensation claims.
In Tennessee, as of August 2012, reimbursement of physician-dispensed repackaged drugs is based on the average wholesale price of the original drug product, with no added dispensing fee. The intent is to curtail repackagers’ practice of giving drugs their own national drug codes and often-inflated AWPs.
So instead, vendors changed the dosage. Before the reform, 91% of physician-dispensed cyclobenzaprine was in 10-milligram pills; by early 2014, that had dropped to 76% and prescribing of 7.5-milligram pills grew to 19%. The 7.5 milligram pills cost $3.97 each at that time, while the 10-milligram pills were $1.08.
There's many different opinions on the topic, and frankly I don't see any reason for physician dispensing on a regular basis for lengthy periods a valid practice whatsoever. Most people have a pharmacy reasonably close, and for those that don't there are mail order pharmacies.
But that's not the point of this rant.
In work comp we tend to focus on the "problem" to look for a solution - hence proposed formularies, or banning of physician dispensing - rather than perhaps more simple, and likely effective, strategies.
This is tied to the way we perceive and treat the person at the receiving end of benefits: the injured worker.
If you are a consumer of nearly anything you have an interest in what you are consuming: what it is, how it is delivered, how much it costs, and whether there are better (however you define "better") alternatives.
Not in workers' compensation. The consumer of the goods and services is left out of the equation. There is no decision power with the injured worker, and even less information and education.
It's cultural - for so long, because the injured worker has no financial stake in the goods and services provided, since work comp is a zero dollar system, it's assumed that there's no need for consumer engagement.
That's wrong.
We need to change our thinking. The injured worker is our CUSTOMER. And the CUSTOMER needs to be informed, and engaged, at all stages, and not with legal mumbo jumbo as required by various state laws (and which causes confusion and a call to the attorney), but with clear, concise explanations of what is being paid to whom, for what and when ... and with comparison to less expensive, potentially better alternatives.
Medicare does this. When I got a doctor's bill for services for Mom, it would be followed up with a Medicare statement of all of the benefits reviewed, paid for, and whether there is any further obligation on behalf of Mom.
We don't do that in work comp. The Explanation of Benefits is rarely, if ever, copied to the CUSTOMER, and if it is, it's confusing and not self-explanatory.
There are many other examples. The injured worker is treated as a non-participating beneficiary and kept in an information void; when in reality the injured worker is the industry's first line of defense against unethical vendor behavior.
Treat the injured worker like a CUSTOMER, like a GOOD CUSTOMER, like a CUSTOMER you want to return for future business (I know, in reality you don't want that customer back because that means another injury...). Good customers return the favor. They look out for their favorite merchants and will return favor if asked.
Tweak all the fee schedules and implement all the formularies you want - but if this industry wants to combat the "whack a mole" phenomenon then engage the CUSTOMER.
The Workers' Compensation Research Institute's latest study on physician dispensed medication reflects this "whack a mole" phenomenon.
The conclusion: vendors steer around fee schedule limits with odd-sized dosages that aren't scheduled ... yet.
“When prices are reduced by regulation, the regulated parties — in this case physician dispensers — sometimes find new ways to retain the higher revenues they had prior to the reforms,” Dr. John Ruser, president and chief executive officer of WCRI, said in a press release. “The results raise questions about the effectiveness and sustainability of the price-focused reforms.”
In California, for example, the average price paid to physicians for 5- or 10-milligram pills of muscle relaxant cyclobenzaprine was about 39 cents per pill in early 2014. But a new 7.5-milligram product, introduced in 2012, cost $3.01 per pill.
As of early 2014, the 7.5-milligram cyclobenzaprine pills accounted for 55% of drugs dispensed by physicians in California, compared to only 2% of drugs dispensed by pharmacies in workers’ compensation claims.
In Tennessee, as of August 2012, reimbursement of physician-dispensed repackaged drugs is based on the average wholesale price of the original drug product, with no added dispensing fee. The intent is to curtail repackagers’ practice of giving drugs their own national drug codes and often-inflated AWPs.
So instead, vendors changed the dosage. Before the reform, 91% of physician-dispensed cyclobenzaprine was in 10-milligram pills; by early 2014, that had dropped to 76% and prescribing of 7.5-milligram pills grew to 19%. The 7.5 milligram pills cost $3.97 each at that time, while the 10-milligram pills were $1.08.
There's many different opinions on the topic, and frankly I don't see any reason for physician dispensing on a regular basis for lengthy periods a valid practice whatsoever. Most people have a pharmacy reasonably close, and for those that don't there are mail order pharmacies.
But that's not the point of this rant.
In work comp we tend to focus on the "problem" to look for a solution - hence proposed formularies, or banning of physician dispensing - rather than perhaps more simple, and likely effective, strategies.
This is tied to the way we perceive and treat the person at the receiving end of benefits: the injured worker.
If you are a consumer of nearly anything you have an interest in what you are consuming: what it is, how it is delivered, how much it costs, and whether there are better (however you define "better") alternatives.
Not in workers' compensation. The consumer of the goods and services is left out of the equation. There is no decision power with the injured worker, and even less information and education.
It's cultural - for so long, because the injured worker has no financial stake in the goods and services provided, since work comp is a zero dollar system, it's assumed that there's no need for consumer engagement.
That's wrong.
We need to change our thinking. The injured worker is our CUSTOMER. And the CUSTOMER needs to be informed, and engaged, at all stages, and not with legal mumbo jumbo as required by various state laws (and which causes confusion and a call to the attorney), but with clear, concise explanations of what is being paid to whom, for what and when ... and with comparison to less expensive, potentially better alternatives.
Medicare does this. When I got a doctor's bill for services for Mom, it would be followed up with a Medicare statement of all of the benefits reviewed, paid for, and whether there is any further obligation on behalf of Mom.
We don't do that in work comp. The Explanation of Benefits is rarely, if ever, copied to the CUSTOMER, and if it is, it's confusing and not self-explanatory.
There are many other examples. The injured worker is treated as a non-participating beneficiary and kept in an information void; when in reality the injured worker is the industry's first line of defense against unethical vendor behavior.
Treat the injured worker like a CUSTOMER, like a GOOD CUSTOMER, like a CUSTOMER you want to return for future business (I know, in reality you don't want that customer back because that means another injury...). Good customers return the favor. They look out for their favorite merchants and will return favor if asked.
Tweak all the fee schedules and implement all the formularies you want - but if this industry wants to combat the "whack a mole" phenomenon then engage the CUSTOMER.
Wednesday, February 3, 2016
Conflict of Laws
The current dispute between air ambulance companies and state workers' compensation system attempts to regulate their fees is an interesting study on how different laws, enacted at different times for different purposes, even within the same jurisdiction, can create conflicting interpretations.
The legal crux of this conflict of laws is whether the federal Airline Deregulation Act – which prohibits states from enforcing any law or regulation relating to an air carrier's price, route or service – preempts state law generated under authority of the federal McCarran–Ferguson Act.
In short, the McCarran–Ferguson Act gives states the authority to regulate the "business of insurance" without interference from the federal government, unless a federal law specifically provides otherwise.
The question then becomes whether workers' compensation is the "business of insurance" and what the intent behind the laws.
There's been some precedence at the state level.
Last October a federal trial judge in Florida found that the ADA barred a class-action suit over air ambulance service providers' billing and collection practices.
Two years ago California's 2nd District Court of Appeals declined to review a decision by the Workers' Compensation Appeals Board finding a state regulation setting the specific rates of reimbursement that a carrier must pay for air and ground ambulance services ran afoul of the ADA.
In Texas the issue has been brewing on a couple of fronts.
Last year an administrative law judge in the Texas State Office of Administrative Hearings found that state law was not pre-empted because of McCarran-Ferguson and ordered payment of air ambulance services at 149% of Medicare.
That decision has been appealed by both the air ambulance company, PHI Air Medical, and the insurance companies in the case to a state district court.
The other case, Air Evac vs. Texas State Department of Insurance, was filed last Thursday in the federal court in Austin, and seeks declaratory relief that state law is pre-empted and that the Department of Insurance, under which the Division of Workers' Compensation operates, can not regulate its fees.
The insurance companies argue the McCarran–Ferguson Act protects the Texas laws on air ambulance reimbursement from pre-emption by the ADA since the ADA "has nothing to do with insurance," because the ADA "was intended to address the commercial airline industry" and guarantee that a "competitive market" would set the rates for commercial air travel.
With air ambulance companies, the rational goes, there are no market forces, as there's no comparison shopping in an emergency situation because it is not commercial travel.
The flip side is that air ambulance companies have a lot of overhead costs in providing staffing and equipment around the clock, and also incur significant risk providing the service. In addition, they argue there is competition for customers with more than one provider in many geographic regions.
Finally, the air ambulance companies argue, workers' compensation is not the "business of insurance." Rather, it is a state program that happens to be funded, in part (don't forget about self-insurance, which is not insurance, and that in Texas workers' compensation is not compulsory) by insurance programs.
I can't predict how all of this will turn out. What I do know is that if I'm hurt and far, far away from medical services needed to save my life or limb, and the only option is an air ambulance, I don't care what it costs - get me to the doctor. If the courts rule that air ambulance services must abide by a state fee schedule, and that fee schedule is inadequate to the extent that the air transportation company is going to ask whether the matter is work comp before dispatch ... I may not make it to the doctor.
That's not tenable to me.
Friday, November 20, 2015
Trees and Forests
It makes sense that the cost of medical services is less in states with fee schedules, and that costs grow slower, than in states without fee schedules.
A recent study by the Workers' Compensation Research Institute confirmed that in a comparison of 31 states.
Prices paid for a similar set of professional services varied significantly across states, ranging from 33% below the 31-state median in Florida to 124% above the 31-state median in Wisconsin in 2013, the study found.
There was also “tremendous variation across states” in price changes from 2008 to 2014, ranging from a 20% reduction in Illinois to a 28% increase in Wisconsin.
States with fee schedules experienced slower growth in prices paid for professional services compared with most states with no fee schedules. The median growth rate among the fee schedule states was 6% from 2008 to 2014, compared with the median growth rate of 17% among the non-fee schedule states.
Also affecting the delivery cost of medical services are networks - network states have lower costs and likewise experience slower cost inflation.
Presumably these findings are good.
Or are they?
Looking at just a small slice of the workers' compensation pie doesn't tell the whole story.
For instance, what is the correlation between lower medical cost states and disability rates, duration and severity?
How quickly are medical services delivered in lower cost states versus higher cost states?
Are premiums affected by medical costs? Or do employers see greater premium impact via other case management techniques, such as imposition of nurse case managers?
How long do medical providers and vendors wait to get paid in low cost states versus higher cost states? Is there any correlation with litigation?
In lower cost states, is more of the pie paid to claimants for wage replacement? Or are cost containment expenses eating up a greater proportion of the pie?
Lots of additional questions, indeed - because at the end of the day there are only two things that matter: does the injured worker get benefits timely and adequately; and does the employer realize good value for its premium dollar?
Studies like this WCRI comparison are good for understanding at a micro-level how certain elements affect performance, but they need to be married up to the macro-view to see if we're really doing our jobs well.
Controlling costs means nothing if those paying into the system, employers, and the intended beneficiaries of the system, injured workers, don't get the value proposed in The Grand Bargain.
Trees make up a forest. Forests make up an eco-system. Lots of things live in that eco-system. Cut down trees and an unknown toll is exacted upon those things.
A recent study by the Workers' Compensation Research Institute confirmed that in a comparison of 31 states.
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| chart courtesy WCRI, 2015 |
Prices paid for a similar set of professional services varied significantly across states, ranging from 33% below the 31-state median in Florida to 124% above the 31-state median in Wisconsin in 2013, the study found.
There was also “tremendous variation across states” in price changes from 2008 to 2014, ranging from a 20% reduction in Illinois to a 28% increase in Wisconsin.
States with fee schedules experienced slower growth in prices paid for professional services compared with most states with no fee schedules. The median growth rate among the fee schedule states was 6% from 2008 to 2014, compared with the median growth rate of 17% among the non-fee schedule states.
Also affecting the delivery cost of medical services are networks - network states have lower costs and likewise experience slower cost inflation.
Presumably these findings are good.
Or are they?
Looking at just a small slice of the workers' compensation pie doesn't tell the whole story.
For instance, what is the correlation between lower medical cost states and disability rates, duration and severity?
How quickly are medical services delivered in lower cost states versus higher cost states?
Are premiums affected by medical costs? Or do employers see greater premium impact via other case management techniques, such as imposition of nurse case managers?
How long do medical providers and vendors wait to get paid in low cost states versus higher cost states? Is there any correlation with litigation?
In lower cost states, is more of the pie paid to claimants for wage replacement? Or are cost containment expenses eating up a greater proportion of the pie?
Lots of additional questions, indeed - because at the end of the day there are only two things that matter: does the injured worker get benefits timely and adequately; and does the employer realize good value for its premium dollar?
Studies like this WCRI comparison are good for understanding at a micro-level how certain elements affect performance, but they need to be married up to the macro-view to see if we're really doing our jobs well.
Controlling costs means nothing if those paying into the system, employers, and the intended beneficiaries of the system, injured workers, don't get the value proposed in The Grand Bargain.
Trees make up a forest. Forests make up an eco-system. Lots of things live in that eco-system. Cut down trees and an unknown toll is exacted upon those things.
Wednesday, August 26, 2015
Fly The Claim
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| Four One Mike over the LA basin managing risk... |
Last week Mom was still dealing with a bit of pneumonia in the lower left lobe of her lung. She was happy as she normally is, and even referred to me accurately as her son (normally she gets this confused and I've been called grandson, nephew, husband, cousin ... everything but her son).
But Mom still had a bit of a cough, and still required oxygen because her O2 uptake without the supplement was in the low 80s.
My brother had stopped by a few days ago to install new safety cords to her hearing aids because the original installation had broken. He reported an otherwise "normal" Mom.
And of course, Four One Mike hasn't been in the air since then. I know she'll need a half quart of oil before I fire up that Continental IO 520 tomorrow; she may need some air in the tires, and the windshield will need a good cleaning. The GPS database needs its 28 day cycle update.
Otherwise I don't expect any surprises from Four One Mike - the pitch servo is still in Kansas for repair but once properly trimmed the plane flies hands off just fine and the pitch servo is only missed when doing an instrument approach (without a pitch servo there is no autopilot coupling to the vertical gradient, so it must be hand flown).
A couple of days ago the airport manager at Oceanside called and left a message that the left rear window was still open (doh!), but that there didn't appear to be anything amiss with the car I use to visit Mom after landing ... phew!
Here it is, well more than 24 hours in advance and I'm already thinking of what needs to be done to accomplish the mission of checking on Mom.
In our world, we would call this a part of risk management.
Risk management entails thinking ahead and making sure that contingencies are in place to deal with the unexpected. Certainly tomorrow things could go wrong. Part of this phase of risk management, however, is planning.
Planning is a primary and critical risk management technique. It is the basis of risk management.
Risk management isn't rocket science. Hell, it's barely science at all - it's mostly common sense. We have thousands of years of existence on this planet and there's not a whole lot of risk that hasn't yet been experienced by human beings.
The lessons we have learned over those thousands of years have been reinforced by experience. We have documented and chronicled the unexpected. We have studied those events. We have devised methods of minimizing such events in the future, and have strategies for dealing with them in case similar events do occur.
Risk management is, by definition, a conservative practice. It has to be because you can't manage the unknown; one doesn't experiment with risk.
Which is why I cringe when I see phrases touting, "Cutting edge risk management techniques."
That phrase is an oxymoron. There is nothing "cutting edge" about risk management. Being "cutting edge" strongly implies operating outside the norm, on the fringes of what is known and established.
Workers' compensation has no place for "cutting edge." We live in a very basic, fundamental world. Work place safety essentially means don't be stupid, and prevent other people from being stupid, or at least minimizing the possibility that someone will be stupid.
Flying epitomizes risk management, and trust me, there's nothing "cutting edge" about making sure planes don't fall out of the sky or hit things that break them.
The lessons have been learned and repeated, and get repeated thousands of times every day: planning, communication, decision making.
Fail any of those three fundamental risk management techniques in aviation and ... you die.
It's a pretty simple concept.
Pilots and airplane owners can make things complicated. We can get tangled up about operational details: manifold pressure readings at certain altitudes, propeller RPM, indicated airspeed versus angle of attack, comm one or comm two, ATIS reports, TCAD settings, frequencies, approach plates, departure procedures, etc., etc.
Lots of details.
But when something bad happens pilots revert to basic, fundamental risk management techniques and the single most basic those is, "fly the airplane."
"Fly the airplane." Simple, concise, easy to remember ... which is what humans need when panic sets in.
We panic a lot in workers' compensation. We talk about medical marijuana, opt out, reform, fee schedules, waiting periods, and other topics that induce industry anxiety.
We get all confused about "flying the airplane" in workers' compensation. We get hung up on the operational details: TTD, PTD, RTW, ACOEM, ODG, MTUS, MPN, QME, etc., etc.
Ugh ....
There's lots of "cutting edge" risk management techniques propounded by "experts" who sell products and services to keep the industry "cutting edge."
The reality is that all these cutting edge risk management techniques just increase costs because it takes away from just "flying the airplane," or in the case of workers' compensation, just paying the claim.
I know, I know - it's not that simple. There are rules to abide by, hoops to jump through, things to be audited, checks and balances ... all sorts of details to pay attention to.
I suggest that it IS that simple; that it doesn't have to be that hard. Is there an injury - yes or no? Does that injury require treatment - yes or no?
When a pilot "just flies the airplane" he or she makes binary decisions - yes or no. There's no time to consider whether the FAA might get mad or ATC might have an issue. There's no time to fiddle with gadgets, dials and knobs.
Everything is a yes or a no, broken down to the most simple, basic risk management fundamentals.
Tomorrow, I'll check flight conditions. My pre-planning today suggests that everything should be fine and within the capabilities of Four One Mike and its pilot.
I'm planning to fly Four One Mike. I'll check the weather and decide, yes or no, whether to go. I'll preflight the plane and then make a yes or no "go" decision.
I'm planning on seeing you tomorrow Mom! I'm hoping for a "yes" risk management decision, but hope you're not disappointed if it's a "no."
Monday, August 10, 2015
Finance, Politics and Yoga
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| Photo is non-illustrative. Just me windsurfing big waves when I still could... |
That's a pretty pessimistic viewpoint.
But a couple of stories today highlight the truth in that statement.
The State of Nevada is, for the first time in 15 years, is taking a look at the discount rate used to calculate the present value of lump sum settlements and awards.
As you know, the cost of funds, or ability to generate future returns, has been stagnant the past few years as the Federal Reserve Bank has kept the lid on monetary policy following The Great Recession.
I don't need to go into the financial wizardry that has made it so, but the bottom line is that interest rates have never been so low for so long.
That means that a dollar invested today doesn't produce much more than a dollar tomorrow.
Conversely, it also means that if an annuity (a steady stream of regular payments) is based on a higher interest rate than what is market normal, then the recipient of the annuity gets cheated out of future buying power.
A $100,000 award that would be paid out over 20 years has a present value of only $31,180.47 at the 6% rate, but is worth $55,367.58 at a 3% rate.
Las Vegas claimants' attorney Virginia Hunt, with whom I've had the privilege of working in the past, brought this to the attention of Division of Industrial Relations officials, who admit they have been negligent in following the law, which mandates that the division look at the discount rate every year.
The division hasn't reviewed the rate since 2000 and hasn't changed the rate since 1997.
The difference is significant. In September 1997, the federal funds rate was about 5.5%. On Friday, it was 0.14%.
DIR Chief Administrative Officer Chuck Verre told WorkCompCentral Friday, "We did not do what we should have done. It's as simple as that."
Bully for Mr. Verre and Mrs. Hunt for tackling an important financial component of the claims pay process.
In the meantime, the political football that is workers' compensation is being played in Illinois.
There's a budget fight going on in that state between Gov. Bruce Rauner, a Republican, and House Speaker Mike Madigan, D-Chicago; the budget deadline was June 30. Workers' compensation, which was just recently "reformed" in Illinois, is said to be the bargaining chip being used to break the stalemate.
Rauner has said he may support a spending plan that includes a tax increase if Democrats agree to a list of nonfiscal to-do items, including workers’ compensation reform.
But instead of dealing with House Bill 1287, a bill passed by the House of Representatives on June 4 that included a provision to prohibit insurers from charging "excessive rates," a provision that Rauner and his business allies found objectionable, the Senate approved its own version of workers' comp reform, SB 162, introduced by Sen. Kwame Raoul, D-Chicago.
SB 162 incorporated some of the ideas contained in Rauner’s memo, but there are numerous contentious issues in the bill on which the parties are basing fiscal compromise.
In the end, as with everything politics, “It depends who else gets a haircut,” said Raoul.
And the medical part is about yoga.
Yoga has come into vogue as a treatment modality for back pain patients in workers' compensation.
A survey by the Centers for Disease Control and Prevention released earlier this year says the number of yoga practitioners has doubled from 2002 to 2012, highlighting the popularity of this ancient Indian exercise.
One of the best remedies for generalized back pain is exercise - and yoga is exercise.
Even the Official Disability Guidelines recommends yoga for “highly motivated patients.”
The key of course is the injured worker must be "highly motivated," which in practical terms means discipline - participating in the exercise on a daily basis.
Claims payers seem to embrace yoga as "treatment."
"Treating chronic pain is a complex endeavor and in some cases involves utilizing alternative treatment options such as yoga," California State Fund Medical Director Dinesh Govindarao wrote in a statement to WorkCompCentral on Friday. "The biopsychosocial treatment model is an effective way to approach chronic pain patients. State Fund supports the use of alternative treatment options on a case-by-case basis with utilization review oversight."
A difficulty is that yoga providers and claims payers don't particularly gel on billing codes or how to reimburse for expenses tied to yoga instruction and practice.
And that's because there's no standardization of the practice, with literally dozens of different forms or disciplines.
But, regardless, yoga is cheap, it's non-invasive, and its practical effects for the "highly motivated" aren't in dispute - it's good medicine.
Friday, August 7, 2015
Tolerating Nonsense
The California Workers' Compensation Insurance Rating Bureau's latest annual report shows that the average medical benefit payment per claim in California remains almost double the national average.
Medical benefits accounted for about 40% of system costs – $6.6 billion in 2014 and $6.3 billion in 2013 – while indemnity benefits of $2.9 billion in 2014 and $2.6 billion in 2013 accounted for 17% of the total each year.
Average medical costs, meanwhile, have declined each year since 2011. Carriers paid an average of $43,750 in medical benefits per indemnity claim in 2014, compared to $47,817 in 2011.
Average medical severity in California dropped 2.6% in 2012, 3.7% in 2013 and 2.5% in 2014. In NCCI states, medical costs increased by 2.4% in 2012, 3.2% in 2013 and 4% in 2014 – about the same pace as overall medical inflation.
Regardless, California's average medical severity, based on 2011 policy year data, remains about 40% higher than the national median.
Okay - so medicine costs more, and always has, in California. We all know that.
No one tells us why.
Safety National's Mark Walls asked me the loaded question while on a panel before a national audience at the National Workers' Compensation and Disability Conference last year, "Dave, why is California workers' compensation so much more expensive than the rest of the nation?"
I quipped, "Mark, everything in California is more expensive than the rest of the nation; property, gasoline, service... You know why Mark? Because it's worth it."
That got a good laugh, but the truth is that we, in claims here in California, simply tolerate it as a fact, when there's no good reason, except that we tolerate it.
For instance, I was presented a vignette the other day of our incomparable tolerance for just nonsense.
"When I see one of the industry’s best and brightest doctors," an industry consultant wrote me, "sign the PR-2 on the initial visit with ‘Expected Duration’ as 14 days and then, 2 ½ year later, sign a PR-2 with ‘Expected Duration’ as 14 days – I know something is messed up."
He goes on to say, "This guy is one of us – ‘We’re the good guys!’ And this is what he does? We’re not treating injured workers – we’re maximizing billing!"
Perhaps. Maybe there's another reason, but honestly I can't think of one.
Someone remaining under physician supervision because the expected duration of their malady is 14 days, in perpetuity, defies common sense.
Just how many of these perpetual 2 week duration cases are there that comprise a medical severity figure that is twice the national average?
That physician isn't being held accountable for this exercise in absurdity.
We think we're holding the line on medical costs by incrementally squeezing all profit margin out of providers with fee schedules, guidelines and other chicanery.
But the bottom line is that if no one holds this doctor, "one of the industry's best and brightest," accountable for realistic case management, then we have only ourselves to blame.
If we want to make that $43,750 average medical cost per indemnity claim go down, then we need to tell those "best and brightest" doctors that putting 14 days of duration endlessly 129 consecutive times isn't acceptable.
It's not the doctors; it's us, because we tolerate such nonsense.
Medical benefits accounted for about 40% of system costs – $6.6 billion in 2014 and $6.3 billion in 2013 – while indemnity benefits of $2.9 billion in 2014 and $2.6 billion in 2013 accounted for 17% of the total each year.
Average medical costs, meanwhile, have declined each year since 2011. Carriers paid an average of $43,750 in medical benefits per indemnity claim in 2014, compared to $47,817 in 2011.
Average medical severity in California dropped 2.6% in 2012, 3.7% in 2013 and 2.5% in 2014. In NCCI states, medical costs increased by 2.4% in 2012, 3.2% in 2013 and 4% in 2014 – about the same pace as overall medical inflation.
Regardless, California's average medical severity, based on 2011 policy year data, remains about 40% higher than the national median.
Okay - so medicine costs more, and always has, in California. We all know that.
No one tells us why.
Safety National's Mark Walls asked me the loaded question while on a panel before a national audience at the National Workers' Compensation and Disability Conference last year, "Dave, why is California workers' compensation so much more expensive than the rest of the nation?"
I quipped, "Mark, everything in California is more expensive than the rest of the nation; property, gasoline, service... You know why Mark? Because it's worth it."
That got a good laugh, but the truth is that we, in claims here in California, simply tolerate it as a fact, when there's no good reason, except that we tolerate it.
For instance, I was presented a vignette the other day of our incomparable tolerance for just nonsense.
"When I see one of the industry’s best and brightest doctors," an industry consultant wrote me, "sign the PR-2 on the initial visit with ‘Expected Duration’ as 14 days and then, 2 ½ year later, sign a PR-2 with ‘Expected Duration’ as 14 days – I know something is messed up."
He goes on to say, "This guy is one of us – ‘We’re the good guys!’ And this is what he does? We’re not treating injured workers – we’re maximizing billing!"
Perhaps. Maybe there's another reason, but honestly I can't think of one.
Someone remaining under physician supervision because the expected duration of their malady is 14 days, in perpetuity, defies common sense.
Just how many of these perpetual 2 week duration cases are there that comprise a medical severity figure that is twice the national average?
That physician isn't being held accountable for this exercise in absurdity.
We think we're holding the line on medical costs by incrementally squeezing all profit margin out of providers with fee schedules, guidelines and other chicanery.
But the bottom line is that if no one holds this doctor, "one of the industry's best and brightest," accountable for realistic case management, then we have only ourselves to blame.
If we want to make that $43,750 average medical cost per indemnity claim go down, then we need to tell those "best and brightest" doctors that putting 14 days of duration endlessly 129 consecutive times isn't acceptable.
It's not the doctors; it's us, because we tolerate such nonsense.
Thursday, July 16, 2015
Simply Complex
California workers' compensation claims stay open longer, much longer, than the national average and as a consequence cost a whole lot more when compared to other states, and according to the Workers' Compensation Insurance Rating Bureau much of this has to do with when medical treatment is paid for.
Only 39% of ultimate accident year medical payments in California are made within the first 36 months of an injury, compared to a national average of 67%.
As a consequence, California employers pay more for workers' compensation insurance than any other state no matter what study is used to compare statistics.
The WCIRB analyzed 1 million claims and $4.4 billion in medical benefit payments. The claims were divided into categories based on the interval between the date of the accident and the date of medical service.
Of the claims reviewed, 84% had medical services provided within the first three years following the accident. These claims accounted for 66% of total medical payments reviewed.
About 12% of claims had medical services being provided between three to 10 years from the date of injury, accounting for $970 million, or 22% of payments reviewed. And while only 4% of claims were still getting medical services between 10 and 30 years after an injury, payments for these claims totaled $559 million, or 13% of costs.
Only 39% of ultimate accident year medical payments in California are made within the first 36 months of an injury, compared to a national average of 67%.
As a consequence, California employers pay more for workers' compensation insurance than any other state no matter what study is used to compare statistics.
The WCIRB analyzed 1 million claims and $4.4 billion in medical benefit payments. The claims were divided into categories based on the interval between the date of the accident and the date of medical service.
Of the claims reviewed, 84% had medical services provided within the first three years following the accident. These claims accounted for 66% of total medical payments reviewed.
About 12% of claims had medical services being provided between three to 10 years from the date of injury, accounting for $970 million, or 22% of payments reviewed. And while only 4% of claims were still getting medical services between 10 and 30 years after an injury, payments for these claims totaled $559 million, or 13% of costs.
Greg Johnson, director of medical analytics for the WCIRB, said in a WCIRB Research Forum webinar yesterday that claims start to develop similar patterns the longer they stay open: Prescriptions for narcotic painkillers and psychoactive drugs increase for workers still receiving medical care three years following an injury.
Prescription drugs account for 10% of payments made for services provided up to three years following an accident. That number increases to 27% of payments services provided three to 10 years following an injury and 37.2% of payments 10 to 30 years after the accident.
Johnson noted that the amount spent on drugs is about 4% to 5% higher than the amount paid to pharmacies for each cohort, and that physician dispensing is the culprit, and that the longer a claim stays open the more likely narcotic prescriptions become involved.
Johnson couldn't say whether there was a cause and effect in the relationship, only that we know there is a relationship.
In addition, three years after an injury payments for services such as physical therapy and chiropractic care drop off considerably, which makes sense given California's hard cap and reimbursement restrictions on those service codes.
Physical medicine accounts for 11.1% of payments for services up to three years following an injury, 4.2% of payments for services provided three to 10 years after an injury and 2.2% of payments 10 to 30 years after an injury.
Of course those conditions evolve from acute to chronic in nature, further complicating the treatment picture.
"This shows me we've got an aging population," Johnson said. "If you look at the health care statistics in the population, these chronic problems obviously develop with other people, and the comp system is paying for many medical problems of aging. The acute injuries are related to the original injury, but the individuals here evolve in terms of the primary diagnosis to more chronic problems over time."
I'm sure there's all sorts of other explanations as well, and everyone can point a finger at someone else for this phenomenon.
All that doesn't matter. Everyone's to blame and no one does anything about it.
The fact of the matter is that behavior of everyone in the system is a product of the laws and regulations that establish the boundaries. Those boundaries drive incentives. Incentives drive behavior. Behavior drives costs.
I wrote on Tuesday about trust. There is very little trust in workers' compensation. There's even less trust in California.
That's why we have artificial limitations on physical medicine services - because there was a group of providers who couldn't be trusted.
That's why we have fee schedules for copy and interpreting services - because there was a group of vendors who couldn't be trusted.
That's why there's a claims audit process and a penalty system - because there was a group of claims payers who couldn't be trusted.
That's why there's payroll audit and employer premises inspections - because there was a group of employers who couldn't be trusted.
That's why there's sub rosa investigation and prying into the private lives of injured workers - because there was a group of employees who couldn't be trusted.
With each level of mistrust there's greater gesticulation by the conductor, and all of us react in amplified manners to the point where the entire "orchestra" is flailing and creating the comedy that gets ridiculed and despised.
If you look at the top performers in the self-insured/administered category you don't find these statistical anomalies, and claims get closed faster, employees return to work and have less disabilities - because the employers trust their providers and their employees, and the providers trust the employers and the employees, and the employees trust their employers and providers.
It's a complex trusting relationship that takes a lot of work to establish and maintain and frankly it comes down to money.
The friction in the system is money. But the lubrication in the system is also money. There's a fine line between the two. That distinction is understood by those top performers and they use those incentives to drive their claims cultures.
Those with good experiences look at the moon, not at the finger pointing at the moon. They pay for good results up front, not for bad results at the end.
It's really quite simple, yet unnervingly complex.
Prescription drugs account for 10% of payments made for services provided up to three years following an accident. That number increases to 27% of payments services provided three to 10 years following an injury and 37.2% of payments 10 to 30 years after the accident.
Johnson noted that the amount spent on drugs is about 4% to 5% higher than the amount paid to pharmacies for each cohort, and that physician dispensing is the culprit, and that the longer a claim stays open the more likely narcotic prescriptions become involved.
Johnson couldn't say whether there was a cause and effect in the relationship, only that we know there is a relationship.
In addition, three years after an injury payments for services such as physical therapy and chiropractic care drop off considerably, which makes sense given California's hard cap and reimbursement restrictions on those service codes.
Physical medicine accounts for 11.1% of payments for services up to three years following an injury, 4.2% of payments for services provided three to 10 years after an injury and 2.2% of payments 10 to 30 years after an injury.
Of course those conditions evolve from acute to chronic in nature, further complicating the treatment picture.
"This shows me we've got an aging population," Johnson said. "If you look at the health care statistics in the population, these chronic problems obviously develop with other people, and the comp system is paying for many medical problems of aging. The acute injuries are related to the original injury, but the individuals here evolve in terms of the primary diagnosis to more chronic problems over time."
I'm sure there's all sorts of other explanations as well, and everyone can point a finger at someone else for this phenomenon.
All that doesn't matter. Everyone's to blame and no one does anything about it.
The fact of the matter is that behavior of everyone in the system is a product of the laws and regulations that establish the boundaries. Those boundaries drive incentives. Incentives drive behavior. Behavior drives costs.
I wrote on Tuesday about trust. There is very little trust in workers' compensation. There's even less trust in California.
That's why we have artificial limitations on physical medicine services - because there was a group of providers who couldn't be trusted.
That's why we have fee schedules for copy and interpreting services - because there was a group of vendors who couldn't be trusted.
That's why there's a claims audit process and a penalty system - because there was a group of claims payers who couldn't be trusted.
That's why there's payroll audit and employer premises inspections - because there was a group of employers who couldn't be trusted.
That's why there's sub rosa investigation and prying into the private lives of injured workers - because there was a group of employees who couldn't be trusted.
With each level of mistrust there's greater gesticulation by the conductor, and all of us react in amplified manners to the point where the entire "orchestra" is flailing and creating the comedy that gets ridiculed and despised.
If you look at the top performers in the self-insured/administered category you don't find these statistical anomalies, and claims get closed faster, employees return to work and have less disabilities - because the employers trust their providers and their employees, and the providers trust the employers and the employees, and the employees trust their employers and providers.
It's a complex trusting relationship that takes a lot of work to establish and maintain and frankly it comes down to money.
The friction in the system is money. But the lubrication in the system is also money. There's a fine line between the two. That distinction is understood by those top performers and they use those incentives to drive their claims cultures.
Those with good experiences look at the moon, not at the finger pointing at the moon. They pay for good results up front, not for bad results at the end.
It's really quite simple, yet unnervingly complex.
Monday, July 6, 2015
Life At 8000 RPM
That's how far it is, point of origin my house, up Highway 33 through the Los Padres National Forest, into the Cuyama Valley, then to the coast and back home via the 101.
Except for the fast sweeping turns of Hwy 33, The Sewing Machine was not ideally suited for this mission, particularly since the ergonomics had been altered by me a few weeks ago. The majority of the ride was between 70 and 75 miles per hour, where TSM stoically spins the engine at 8,000 RPM without cough, hesitation or complaint. I was tucked in much of the time for aerodynamics to help that little engine, twisted up like a pretzel.
But it was a circuit I had been wanting to complete for some time, in part because I knew the scenery in the back country would be awesome, in part just because I wanted to experiment with the "sport touring" capabilities of TSM. I had time yesterday afternoon, so I suited up, gassed up, and headed for the hills.
The scenery didn't disappoint, and in fact I'd say for the most part was world class spectacular. A stop in Ventucopa and Los Olivos for hydration were small-town charming, and a stop in Santa Maria for fuel relieved the anxiety that started when the fuel gauge started blinking indicating reserve status.
Three counties in five hours. For some reason I thought it could be done in four.
The California workers' compensation insurance industry took a long trip with cost containment. It was something the carriers had been wanting to do for some time, and they embarked on that mission through legislative, regulatory and in-house routes.
Based on the latest report from the California Workers' Compensation Insurance Rating Bureau, the carriers now appear to be benefiting from their cost containment investments.
Though the gross spend on cost containment services has grown yet again, the rate of growth is abating, and the net pay to medical providers has been trimmed considerably.
Carriers paid 5.4% more for medical cost containment last year than they did in 2013, increasing to $471 million last year from $447 million in 2013.
But carriers paid $5.035 billion in medical benefits last year compared to $5.221 billion in 2013, a drop of 3.6%, which compares favorably to general health which saw medical costs increase 2.4%.
In the mid-1990s, total medical costs (both medical-only and indemnity claims) were in the $2.5 billion neighborhood (after deflating from about $3 billion).
Back then, if there was "cost containment" it wasn't separately stated as an allocated expense - that expense was lumped into the overall medical expense category. It wasn't until 2011 that the WCIRB started breaking cost containment out as a separate line item.
Based on the consumer price index inflation rate, that $2.5 billion in 1995 medical expenditure would be $3.9 billion in 2015 dollars.
Using a calculator specifically programmed for medical cost inflation, 1995's $2.5 billion would be $4.9 billion in today's dollars.
Since cost containment is less than half-billion dollars per year, then at least compared to general inflation, the mission hasn't succeeded: $5.2 billion minus $3.9 billion equals $1.3 billion, minus the half billion in services, means a net increase over inflation adjusted dollars of $800 million.
Okay, even compared to the medical inflation index, workers' compensation cost containment doesn't look that successful.
I don't know when cost containment became so prevalent in work comp. WCIRB's chart shows in 2007 the industry spent $245 million but in the next year that figure grew by $100 million. Now it's $471 million.
I'm having a hard time justifying the expense of cost containment services based on that simple analysis. Would it be worse without those services? I don't know, because we can't rewrite history, but based on past activity it certainly doesn't seem so.
What's worse is that these programs benefit the carriers nicely now, but I don't see those savings being passed along to the policy consuming employers. Not only have premiums continued to escalate, but delays, avoidance and denial inherent in cost containment "services" seems to interfere with good claims management: claims stay open longer, much longer, now than in the past and the indirect costs of greater disability frequency and severity come back to haunt the policyholder as well as the injured worker.
It's been an interesting trip these cost containment years. It started out with some compelling winding road as the industry found its way up the mountain, but down in the valley of reality the road straightened out, the hum of 8,000 rpm travelled relentlessly to the bars, numbing our hands and making our knees ache.
If I'd kept TSM's ergonomics stock, the trip wouldn't have been so fatiguing. I would have still had to put up with a singing engine most of the trip, but at least I would have been sitting more upright.
True, I saw some spectacular scenery in a lightly traveled part of California that is essentially in my back yard ... but I wouldn't do it again, not on TSM.
I have to wonder the same about cost containment - what really is the net effect, and should we continue traveling that road?
Since cost containment is less than half-billion dollars per year, then at least compared to general inflation, the mission hasn't succeeded: $5.2 billion minus $3.9 billion equals $1.3 billion, minus the half billion in services, means a net increase over inflation adjusted dollars of $800 million.
Okay, even compared to the medical inflation index, workers' compensation cost containment doesn't look that successful.
I don't know when cost containment became so prevalent in work comp. WCIRB's chart shows in 2007 the industry spent $245 million but in the next year that figure grew by $100 million. Now it's $471 million.
I'm having a hard time justifying the expense of cost containment services based on that simple analysis. Would it be worse without those services? I don't know, because we can't rewrite history, but based on past activity it certainly doesn't seem so.
What's worse is that these programs benefit the carriers nicely now, but I don't see those savings being passed along to the policy consuming employers. Not only have premiums continued to escalate, but delays, avoidance and denial inherent in cost containment "services" seems to interfere with good claims management: claims stay open longer, much longer, now than in the past and the indirect costs of greater disability frequency and severity come back to haunt the policyholder as well as the injured worker.
It's been an interesting trip these cost containment years. It started out with some compelling winding road as the industry found its way up the mountain, but down in the valley of reality the road straightened out, the hum of 8,000 rpm travelled relentlessly to the bars, numbing our hands and making our knees ache.
If I'd kept TSM's ergonomics stock, the trip wouldn't have been so fatiguing. I would have still had to put up with a singing engine most of the trip, but at least I would have been sitting more upright.
True, I saw some spectacular scenery in a lightly traveled part of California that is essentially in my back yard ... but I wouldn't do it again, not on TSM.
I have to wonder the same about cost containment - what really is the net effect, and should we continue traveling that road?
Wednesday, July 1, 2015
Everything Passes
It was one of those rough, emotional visits with Mom yesterday.
She and Dad were married 70 years ago on June 30. I didn't think she would remember. I didn't know if she would even care. It would be interesting to see her reaction though.
Mom wasn't walking yesterday. She was sitting on the chair portion of her walker. She looked and acted slow. At 91, every day is a challenge, but this seemed to me more of a challenge than lately.
Robert was at another table with his wife, Virginia. Robert is a British author. Virginia has Alzheimer's. When I met them 16 months ago Virginia had notable memory impairment, but she could walk, and I could talk with her.
Robert sees her every day and pays incredible attention to her. Recently Virginia has been receiving hospice care and much of the time recently I had not seen her because she was in her room. Yesterday she fidgeted in her wheelchair, nearly emaciated, unable to control her movements. Robert attended to her with his cheerful attitude as best he could.
I don't know how he does it.
Bruno is from Austria originally, though he and his wife Yvette, a French native, had been living in the Escondido area for the past 25 years. Bruno moved Yvette into Mom's facility about a year ago because, at age 81, he could no longer provide her with the care an Alzheimer's sufferer needs.
Bruno was crying. Yvette would not wake up yesterday. She hasn't eaten anything in several days.
Mom seemed less cognizant than normal, and slower. She's never consumed food quickly, but yesterday was slower than normal ... much slower.
She had a haircut recently and her grooming was neat. She wasn't connecting though. She hasn't said my name in a very, very long time.
I showed her the engagement announcement and she stared at it intently. I'm sure she read every single word several times over, trying to make sense of it. She concentrated hard, her brow squeezed tight with effort. Occasionally a smile would emote. Mostly, though, she looked confused.
"Mom, can you imagine that it was 70 years ago today that you married Dad and started a family?"
Her eyes said bewilderment.
We moved on to another topic of conversation as the opening course, a carrot and raisin salad, was served. I showed her pictures of my recent trip to Italy, again, and she smiled pleasantly.
I don't think she remembers Dad anymore. I don't think she understands she was married. She held my hand. Her's were cold and mine felt good against her arthritis. She looked into my eyes and smiled - a warm smile of trust.
I do think she feels I will be there for her. Because it's true.
California's recent copy service regulations and fee schedule should have leveled the playing field, should have evoked more trust between payers and vendors.
But it seems that is not the case.
Copy service vendors believe that payers are going to exploit loopholes created by the new regulations to deny paying for legitimate services.
Claims payers have commented that copy service companies can't be trusted to not abuse the new system and to seek payment for services never provided.
Both are saying that more lawyers are going to be necessary...
All this time, these many years of living together under the roof of the same system, and still no trust.
What's sad about the entire situation is that no one, not the copy services, not the claims payers, not the government, says anything about the injured worker or the employer.
It's a system that feeds upon itself, and that will be the destruction of it.
Like Alzheimer's and dementia.
While we're seeing blank stares from the people and companies that are to be providing the services and goods to make this system work properly, nourishment is ignored, relationships are forgotten, atrophy sets in.
Bruno, Robert, and others will try to keep their spirits up, hanging on to memories of 70 years ago.
Eventually, everything passes.
She and Dad were married 70 years ago on June 30. I didn't think she would remember. I didn't know if she would even care. It would be interesting to see her reaction though.
Mom wasn't walking yesterday. She was sitting on the chair portion of her walker. She looked and acted slow. At 91, every day is a challenge, but this seemed to me more of a challenge than lately.
Robert was at another table with his wife, Virginia. Robert is a British author. Virginia has Alzheimer's. When I met them 16 months ago Virginia had notable memory impairment, but she could walk, and I could talk with her.
Robert sees her every day and pays incredible attention to her. Recently Virginia has been receiving hospice care and much of the time recently I had not seen her because she was in her room. Yesterday she fidgeted in her wheelchair, nearly emaciated, unable to control her movements. Robert attended to her with his cheerful attitude as best he could.
I don't know how he does it.
Bruno is from Austria originally, though he and his wife Yvette, a French native, had been living in the Escondido area for the past 25 years. Bruno moved Yvette into Mom's facility about a year ago because, at age 81, he could no longer provide her with the care an Alzheimer's sufferer needs.
Bruno was crying. Yvette would not wake up yesterday. She hasn't eaten anything in several days.
Mom seemed less cognizant than normal, and slower. She's never consumed food quickly, but yesterday was slower than normal ... much slower.
She had a haircut recently and her grooming was neat. She wasn't connecting though. She hasn't said my name in a very, very long time.
I showed her the engagement announcement and she stared at it intently. I'm sure she read every single word several times over, trying to make sense of it. She concentrated hard, her brow squeezed tight with effort. Occasionally a smile would emote. Mostly, though, she looked confused.
"Mom, can you imagine that it was 70 years ago today that you married Dad and started a family?"
Her eyes said bewilderment.
We moved on to another topic of conversation as the opening course, a carrot and raisin salad, was served. I showed her pictures of my recent trip to Italy, again, and she smiled pleasantly.
I don't think she remembers Dad anymore. I don't think she understands she was married. She held my hand. Her's were cold and mine felt good against her arthritis. She looked into my eyes and smiled - a warm smile of trust.
I do think she feels I will be there for her. Because it's true.
California's recent copy service regulations and fee schedule should have leveled the playing field, should have evoked more trust between payers and vendors.
But it seems that is not the case.
Copy service vendors believe that payers are going to exploit loopholes created by the new regulations to deny paying for legitimate services.
Claims payers have commented that copy service companies can't be trusted to not abuse the new system and to seek payment for services never provided.
Both are saying that more lawyers are going to be necessary...
All this time, these many years of living together under the roof of the same system, and still no trust.
What's sad about the entire situation is that no one, not the copy services, not the claims payers, not the government, says anything about the injured worker or the employer.
It's a system that feeds upon itself, and that will be the destruction of it.
Like Alzheimer's and dementia.
While we're seeing blank stares from the people and companies that are to be providing the services and goods to make this system work properly, nourishment is ignored, relationships are forgotten, atrophy sets in.
Bruno, Robert, and others will try to keep their spirits up, hanging on to memories of 70 years ago.
Eventually, everything passes.
Wednesday, May 20, 2015
Back of the Bus
 |
| Cesar Chavez |
Speaking Spanish is less valuable than any other language, according to the California Division of Workers' Compensation in its latest release of SB 863's mandated interpreter fee schedule and regulations.
Karla Navarro, a certified medical interpreter, argued that paying less for Spanish interpretation will create a shortages.
“According to the U.S. Census, by 2050 the Hispanic population will be double what it is today,” she wrote in comment. “Many of these Spanish speaking people will take labor based jobs in which they will most likely be hurt and file a workers’ comp claim. This will lead to needing interpretation for medical appointments and with the proposed changes for regulations and fees, there is very little chance that the work force will be able to meet these needs.”
“We know of no other government fee schedule that singles out Spanish for sub-standard remuneration,” wrote Carl Brakensiek, executive director of the California Society of Industrial Medicine and Surgery.
What DWC is thinking, I'm sure, is that there are so many hispanic workers in the work comp system, and so many that interpret Spanish to English and visa-versa, that they are nearly a majority, and ergo, should be subject to the same expectations that English speaking workers are subject to - i.e. virtually no interpretation.
It's almost as if the government is saying that Spanish is now just a dialect of American English...
Or perhaps the thinking is that market forces will solve the pricing differential and only those truly dedicated to Spanish/English interpretation will stay in the game.
The message that is conveyed, unfortunately, is that discrimination is alive and well in 2015.
Ironically, California state government, including DWC, recognizes with a day of rest the efforts of the late, great Cesar Chavez, who fought long and hard for Hispanic immigrant rights.
As a lawyer, I had been through many depositions and court proceedings where the claimant was mono-lingual Spanish. Not only is there limitation in the native language, but nuances between regions and dialects can result in many different interpretations; subtle differences can result in substantial interpretation challenges.
What's spoken in the fields of the Central Valley is not Castilian Spanish. What's spoken in the court room, or the medical examining room, isn't the Queen's English.
I've argued before that the proposed regulations are overly complicated and invite work arounds and abuse. The resolution can be very simple...
In the meantime, if you speak Spanish, sit in the back of the bus.
As a lawyer, I had been through many depositions and court proceedings where the claimant was mono-lingual Spanish. Not only is there limitation in the native language, but nuances between regions and dialects can result in many different interpretations; subtle differences can result in substantial interpretation challenges.
What's spoken in the fields of the Central Valley is not Castilian Spanish. What's spoken in the court room, or the medical examining room, isn't the Queen's English.
I've argued before that the proposed regulations are overly complicated and invite work arounds and abuse. The resolution can be very simple...
In the meantime, if you speak Spanish, sit in the back of the bus.
Wednesday, May 6, 2015
Interpreters, Fees and Fingers
The showdown on interpreter fees in California typifies why workers' compensation ends up with convoluted rules, ineffective enforcement, and diverts attention away from the main task of taking care of injured workers at a reasonable cost.
DWC proposed late last month, and two years past SB 863's mandate, an interpreter fee schedule.
The rules would create separate reimbursement rates depending on whether the services are provided in a medical or judicial setting, the language being interpreted and whether the interpreter is certified.
Proposed payments for medical appointments are:
- $52.50 for Spanish language certified interpreters and $82.50 for certified interpreters in all other languages.
- $25.75 for provisionally certified Spanish language interpreters and $33.25 for interpreters provisionally certified in any other language.
- An interpreter at a medical-legal exam would be entitled to payment for a minimum of two hours for each exam.
- An interpreter at a medical treatment appointment would be entitled to a minimum of one hour for each appointment.
- $210 for each half day of service – defined as 3.5 hours – and $388 for a full day of service for certified Spanish interpreters.
- $240 for each half day and $418 for each full day of service for all other certified interpreters.
- $103 for each half day and $187 for a full day of service for provisionally certified Spanish interpreters.
- $133 for each half day and $217 for each full day of service for interpreters provisionally certified for any other language.
At least based on WorkCompCentral's story this morning, nobody is happy with the proposal. Some say it is discriminatory against Hispanic workers because Spanish is compensated at a lower rate than other languages. Some say there are still loopholes for interpreters to over bill for multiple appearances at a hearing. Still others say the schedule hasn't kept up with inflation, causing in reality a 50% pay cut for interpreters.
And nobody seems happy with workers' compensation judges declaring who is, and who isn't, "certified."
Everybody misses the point.
Fee schedules don't arise out of thin air - nearly universally, fee schedules are the aftermath of perceived abuse. In the case of interpreters, there are likely a couple that indeed abused the freedom of no schedule and loose rules that created an "issue" with certain folks; and perception is a powerful policy driver.
So the response is to create even more rules, more technicalities, more issues.
Ugh.
Guess what will happen? There will still be those who abuse whatever is put out there, and there will be those who don't want to pay.
Nothing will really change.
The solution is very simple: wrap everything into one package at a single price.
What I mean by that is that interpreters should just be paid by the day for whatever service they provide; half day if they can't show that services were tendered on a certain minimum of cases.
For instance, set the daily interpreter rate at $500, regardless of whether the context is medical, legal or both, and regardless of the language required. Assume that in a single day an interpreter should have provided services on six cases - the interpreter would need to note those cases by name, claim number and case number, on the bill. If there's six of them, or more, then the interpreter gets $500. If there's fewer than the interpreter gets the half day rate, or $250.
And if only one case is serviced, but that case lasts a whole day ... oh well, it all works out in the end and maybe that interpreter won't be available in the afternoon, or a judge could order an override because the interpreter was in fact present all day. There are simple solutions.
Sure, some will fraudulently inflate bills by listing more cases than they tendered services on. That's no different than any other sort of abusive behavior that less scrupulous professionals are going to engage in anyhow.
That's a cost of business, and an enforcement issue for the government.
We're spending all this time, all this money, all this energy arguing and debating about a very small expense. In the meantime people are getting hurt, but not getting the treatment or indemnity mandated by the law which costs the employer more money than it should.
In other words, stop looking at the finger when pointing to the moon....
The DWC will continue to accept comments on the draft fee schedule until Thursday at 5 p.m. Comments can be sent by email to dwcforums@dir.ca.gov. The DWC will review comments and consider whether to make change to the interpreter fee schedule proposal before initiating the formal rulemaking process.
The proposed rules are here.
Sure, some will fraudulently inflate bills by listing more cases than they tendered services on. That's no different than any other sort of abusive behavior that less scrupulous professionals are going to engage in anyhow.
That's a cost of business, and an enforcement issue for the government.
We're spending all this time, all this money, all this energy arguing and debating about a very small expense. In the meantime people are getting hurt, but not getting the treatment or indemnity mandated by the law which costs the employer more money than it should.
In other words, stop looking at the finger when pointing to the moon....
The DWC will continue to accept comments on the draft fee schedule until Thursday at 5 p.m. Comments can be sent by email to dwcforums@dir.ca.gov. The DWC will review comments and consider whether to make change to the interpreter fee schedule proposal before initiating the formal rulemaking process.
The proposed rules are here.
Thursday, February 19, 2015
Why It Is The Way It Is
A couple of weeks ago Joe Paduda in his Managed Care Matters blog posted that there was a suspicious upcoding of physical therapists billings by some networks using the "59 modifier."
It seems there are some medical networks that are adding the 59 code to bills without a) telling the actual provider of the services, and b) automatically and systematically without supporting documentation.
And they have been getting away with it.
Paduda states that there is a concerning lack of appreciation for what this means - the actual providers, the physical therapists, aren't too concerned as long as they get paid, despite the fact that someone or some entity is modifying their billing without their knowledge against professional protocol.
The modifier is typically used when two procedures are used on the same patient within 15 minutes. In some cases, those services would be bundled together and reimbursed as one item. But for others, the provider appends the number 59 to the code to indicate that they should be reimbursed separately.
Paduda, a principal in the firm Health Strategy Associates, says that some of his clients have seen modifiers on more than 40 percent of their bills, but also notes that there is some official documentation floating around that indicates that the 59 modifier shouldn't be seen on more than 10% of the bills.
Something is amiss.
One commentator to Paduda's blog post states, "I am in CA and this is on my radar. I am concerned. Several of my colleagues can confirm what you are saying is 100% true. I have seen the smoking gun. In this case, the gun is still red hot and has not come even close to cooling down. The gig is up…"
What is the gig?
The motivation on the part of the networks and the third party administrators they are tied to, it seems, goes to their marketing and reimbursement practices whereby the TPA gets a percentage of billings saved.
Inflating bills creates the illusion that the network is saving payers more than it actually is. Because a network might reimburse for 80% of a bill, it would show the payer that it saved $20 off a $100 bill for physical therapy. But if the bill was $120 because of a 59 modifier, the network would report to the payer that it saved $24.
In an interview with WorkCompCentral, Paduda wouldn't identify who is doing what, and clearly these bad apples are the exception.
And it comes down to transparency, which is tied to the number of entities through which a bill is passed until payment is rendered.
“The only way we could show that this has been done is if we were able to get the bill that was sent on to the third-party administrator or the employer and compare it to what we've originally sent in,” Jeffrey Hathaway, president of the Physical Therapy Business Alliance, told WorkCompCentral. “So there's no transparency. We have no idea what the network is getting paid, we have no idea what the network is telling the third-party administrator.”
So, once again, give someone an inch and they'll take a mile - which is exactly why work comp is the way it is today: because people can't behave themselves without someone overlooking them with baseball bat in hand to keep things in check.
You don't have to wonder why work comp is the way it is. Just open your eyes (ears and wallets).
It seems there are some medical networks that are adding the 59 code to bills without a) telling the actual provider of the services, and b) automatically and systematically without supporting documentation.
And they have been getting away with it.
Paduda states that there is a concerning lack of appreciation for what this means - the actual providers, the physical therapists, aren't too concerned as long as they get paid, despite the fact that someone or some entity is modifying their billing without their knowledge against professional protocol.
The modifier is typically used when two procedures are used on the same patient within 15 minutes. In some cases, those services would be bundled together and reimbursed as one item. But for others, the provider appends the number 59 to the code to indicate that they should be reimbursed separately.
Paduda, a principal in the firm Health Strategy Associates, says that some of his clients have seen modifiers on more than 40 percent of their bills, but also notes that there is some official documentation floating around that indicates that the 59 modifier shouldn't be seen on more than 10% of the bills.
Something is amiss.
 |
| "I think I'll take a mile..." |
One commentator to Paduda's blog post states, "I am in CA and this is on my radar. I am concerned. Several of my colleagues can confirm what you are saying is 100% true. I have seen the smoking gun. In this case, the gun is still red hot and has not come even close to cooling down. The gig is up…"
What is the gig?
The motivation on the part of the networks and the third party administrators they are tied to, it seems, goes to their marketing and reimbursement practices whereby the TPA gets a percentage of billings saved.
Inflating bills creates the illusion that the network is saving payers more than it actually is. Because a network might reimburse for 80% of a bill, it would show the payer that it saved $20 off a $100 bill for physical therapy. But if the bill was $120 because of a 59 modifier, the network would report to the payer that it saved $24.
In an interview with WorkCompCentral, Paduda wouldn't identify who is doing what, and clearly these bad apples are the exception.
And it comes down to transparency, which is tied to the number of entities through which a bill is passed until payment is rendered.
“The only way we could show that this has been done is if we were able to get the bill that was sent on to the third-party administrator or the employer and compare it to what we've originally sent in,” Jeffrey Hathaway, president of the Physical Therapy Business Alliance, told WorkCompCentral. “So there's no transparency. We have no idea what the network is getting paid, we have no idea what the network is telling the third-party administrator.”
So, once again, give someone an inch and they'll take a mile - which is exactly why work comp is the way it is today: because people can't behave themselves without someone overlooking them with baseball bat in hand to keep things in check.
You don't have to wonder why work comp is the way it is. Just open your eyes (ears and wallets).
Monday, January 26, 2015
What The Doctors [Don't] Know
I was honored to be on The Great Debate panel at the California Applicants' Attorneys Association Winter Convention in San Diego on Friday afternoon.
Presenting with me were:
- Christine Bouma, a member of the California Commission on Health Safety and Workers' Compensation;
- Dan Bagan, a member of the California Commission on Health Safety and Workers' Compensation;
- Jamie Berenson, a partner in the applicant law firm of Glauber/Berenson; and
- Barry Pearlman, founding partner in the defense law firm of Pearlman, Borska & Wax
The Great Debate was, as you would expect, about SB 863, whether it's meeting expectations, how it has impacted employers, workers, and the industry, and observations as to its efficacy.
As one would expect with such a diverse selection of experience, opinions diverged on some issues, and interestingly, converged on more issues that I expected.
But one part of the presentation really caught my attention and points to a significant problem with California workers' compensation, and perhaps many other states: doctors don't know how to interface with the system, and the more complex the requirements on physician participation, the less likely they are to understand their roles, the expectations and the rules.
And this means failure in compliance, less effective treatment, increased disability, failed outcomes and increased expense.
Pearlman raised this issue with an anecdote about a recent presentation he gave to a large Medical Provider Network group of physicians.
Pearlman said that there were about 150 doctors in the audience, and he asked them several questions that drew complete blank stares: what is an MPN, are you in an MPN (remember this was a presentation TO an MPN!), what is the Medical Treatment Utilization Schedule, what is ACOEM, etc.
Blank stares. None of these physicians had any clue about workers' compensation regulation of their professional activity.
No wonder Utilization Review and Independent Medical Review are such road blocks - the physicians that are supposed to be complying with various standards don't even know a) that there are standards, or b) how to comply.
Ugh!
Remember that this is an anecdote and is not necessarily representative of all physicians that become involved in industrial medicine.
But it is a troubling anecdote nevertheless.
I don't think it's just a matter of education. I think it's a matter of motivation - what is the motivation to learn all this complexity if there is no financial or other incentive? The practice of medicine, in the end, is a business and that means that there are income and expense columns that get interpreted to profit.
If profit is not a positive number then either the expense column needs to be trimmed, or the income column needs to be bolstered.
Trimming the expense column is easier than bolstering the income column - nearly anyone that runs a business will tell you that. The amount of resources necessary to capture new revenue increases exponentially compared to retention of existing business.
Part of the expense column is education. There is the direct expense of acquiring the education, but there are also all of the indirect expenses, including intrusion into personal time.
And the more complicated a system is (as can be evidenced by the number of acronyms in any given system), the more expensive it becomes to become and stay educated, and deploy that education into practice.
This doesn't portend well for workers' compensation because part of the Grand Bargain is delivery of medical benefits: treatment and the reporting necessary for the legal/indemnity end to work.
Without doctors in the system able to do what the system asks of them means the system will fail.
There's a difficult balance between regulating the behavior of the professionals that make the system run in an efficient manner, and regulation to the point of stifling participation. If what Pearlman described is more that just a passing anecdote then we're on the wrong side of the fulcrum.
*************edited 01/27/2015*************
Steve Cattolica, Director of Government Relations for the California Society of Industrial Medicine and Surgery, provided this response to the above post - it was too long for a comment so I have included it as part of this original post:
David, while I agree with you for the most part, having heard the “Debate” panel, Barry Pearlman’s revelation absent any detail, may have led listeners to draw errant conclusions or diverted them from a clear picture of a much different and pervasive source of the problem he seemed to want to convey.
Regarding physician education and expertise; motivation to learn is important and that certainly tracks to some degree with reimbursement. However, one must keep in mind that some providers’ reimbursement comes in the form of a salary check or a contracted percentage based on production. Therefore, in what could be a surprisingly high number of instances, the profit motive lies with the network itself, with a leased sub-network or with another corporate entity, rather than the provider.
To this attendee, this segment of the “Debate” seemed to lay the blame for poor results on the ignorance of physicians. Notwithstanding your statement that it was, “not necessarily representative of all physicians that become involved in industrial medicine,” I believe it is an extreme disservice to providers to lay that ignorance or their motivation to learn about the comp system, solely at the feet of their own reimbursement.
Pearlman did not choose to tell the audience to which MPN he was speaking. I can understand at least one reason why – as I outline below, the MPN might become open to unwanted (if not deserved) scrutiny.
He also left out the background of his physician audience – were they specialists or primary care? Were they solo or small group practitioners? Were they independent contractors to a large health insurer’s medical group or employees? Did they even know that they were contracted with the MPN in the first place? All of these facts matter, when for lack of them the speaker leaves the audience to draw an over-generalized conclusion regarding the training, competency and motivation of the provider community at large.
Often employee physicians, even in specialized work comp clinic chains, have little idea how the work comp system actually functions. They are trained in their employer’s operating system and someone else takes care of the rest. In this context, the chain’s corporate decision how to “train” its physicians could be based upon the notion that rote compliance with policies and procedures equals the lowest cost (and highest margins).
More importantly, he did not mention how his audience came to be contracted to the MPN in the first place. He may not have known that information. As I queried above, did these providers even know they were providing services in a work comp network? Were these providers part of a leased network? How did they get in? Who is watching the store?
He also did not offer to explain the reason why a work comp network would contract with these providers in the first place. I suspect he did not know this information either. What was the network thinking when it presented these physicians to its workers’ compensation clients and prospects as being part of an MPN? Did the network bother to tell the client or prospect about the providers’ lack of knowledge or expertise about the comp system? Did the network even know this information itself? What kind of an informed buying decision could any carrier, TPA or employer make when the baseline expertise of the contracted providers is unknown or its disclosure may be withheld? Caveat emptor doesn’t really do justice to this situation. From this point of view, Barry’s education program appears to have been motivated by the network’s or its customer’s need for damage control rather than quality healthcare.
We have long maintained that direct contracting between providers and employers is the best and least expensive relationship available to assure the highest quality healthcare for injured workers. That’s motivation.
Wednesday, August 13, 2014
Listening and Touching
My daughter forwarded me this TED talk that was given several years ago, and I'm sure some of you may have already seen it.
The speaker is Dr. Abraham Verghese, a practicing infectious disease physician, writer and teacher at Stanford University.
It's about medicine losing the human touch and how important psychologically to the patient a simple physical examination is.
"We're losing a ritual that is at the heart of the relationship," he says, referring to the ritual of the physical examination.
It is RITUAL , i.e. routine, that makes us good at what we do and that's why it's called "practice" as in the practice of medicine or the practice of law or any other professional "practice."
While I don't really agree with his statement that the next big thing to come to medicine in the next "10 years is the power of the human hand to touch, comfort, diagnose and bring about treatment," Verghese in my opinion makes some powerful argument about the ritual, the practice, of medicine and it is particularly applicable to workers' compensation cases.
Workers' compensation, as we all unfortunately know, is all about numbers and volume. It is discount medicine. It is all about economies of scale. The basic economics of workers' compensation almost dictate this reality.
Verghese talks about how technology has come to dominate the "practice" of medicine - how physicians are quick to order tests, MRIs, x-rays and other technologically advanced diagnostic assists, and that we now have two patients: the one on the examining table and the one in the ether world.
The "iPatient" (the patient in the computer) is "getting wonderful care all across the country," Verghese says. But the REAL patient is left wondering "where is everyone? when are they going to come by and explain things to me? and who's in charge?"
Physician rounds used to be held bedside with the lead physician taking a troupe of others to each patient's bed and conducting inquisition and seeking answers, he notes.
Rounds now a days take place in private rooms far away from the patient - everyone looking at computers and data, but the one critical component missing is the patient.
Verghese gives an early practice anecdote about an experience he had with chronic fatigue syndrome.
He said, "they come to you thinking you will be joining the long list of people that are about to disappoint him."
Verghese thought he would do something a little different in the 45 minutes allotted for the initial exam - just listen.
So he invited the patient to tell his entire story and would try not to interrupt ("we know that the average physician interrupts his patient within the first 14 seconds"). He just listened to the patient give his entire life's history and set a return appointment for 2 weeks hence for the actual physical exam.
In the second visit, to Verghese's surprise, the patient continued to tell more of his story and voluntarily provide more of his history. But when Verghese started with the ritual of exam this "very voluble patient began to quiet down."
"And when I was done, the patient said to me with some awe, 'I have never been examined like this before.'"
Verghese proclaims this a condemnation of the medical system, but really it is recognition that communication is probably one of the most important parts of the physician's role - and not communicating what the doctor knows, but listening to what the patient has to say.
It may not be profound and it may not lead to actually figuring out what is going on physically, but the psychological impact of a caring individual taking the time to HEAR what the patient has to say had remarkably powerful implication.
Verghese said he told the patient, "This is not in your head. This is real. The good news, it's not cancer, it's not tuberculosis, it's not coccidioidomycosis or some obscure fungal infection. The bad news is we don't know exactly what's causing this, but here's what you should do, here's what we should do."
It was about wellness, about taking responsibility for one's own condition, regardless of the outside influences of illness, disease or injury. The doctor earns the TRUST of the patient by virtue of listening, and then conducting the ritual of the physical examination, which allows the patient to FEEL that there is a caring person in that smock.
Someone gives a damn...
As youngsters we are taught to trust our doctors - they have the gentle hand, know how the body works, have superior intellect.
Most of all, at least when I was growing up (and remember I was on a first name basis with my childhood orthopedist since I was such a frequent visitor!) we could tell the doctor things we would not tell anyone else.
Verghese says that the act of listening deeply first, and then conducting the actual physical examination, laying hands on the patient, palpating, rubbing, feeling, provided a transformative exchange:
"Rituals are terribly important. They're all about transformation. Well I would submit to you that the ritual of one individual coming to another and telling them things that they would not tell their preacher or rabbi, and then, incredibly on top of that, disrobing and allowing touch -- I would submit to you that that is a ritual of exceeding importance. And if you shortchange that ritual by not undressing the patient, by listening with your stethoscope on top of the nightgown, by not doing a complete exam, you have bypassed on the opportunity to seal the patient-physician relationship."
Verghese tells a story about a terminally ill patient who, even in his last hours of life, willing submitted to the ritual of the physical examination, that it was so important to that person.
"And the message, which I didn't fully understand then, even as I delivered it," Verghese says, "and which I understand better now is this: 'I will always, always, always be there. I will see you through this. I will never abandon you. I will be with you through the end.'"
Most of modern medicine misses this important message and certainly in workers' compensation that message is eviscerated.
The work comp system does not reward patience or communication. We look at numbers, lots of numbers, that we think describe different things to help us try and understand what is going on in this complex world and system.
But we do a miserable job of listening and performing necessary rituals that would gain trust, that would say "we'll be there for you."
Like Dr. Verghese, I submit that if we just listened more we could reduce the amount of unnecessary disability, reduce the expense of workers' compensation, and have a better, more robust, more credible role in the lives of injured workers, their employers and society.
Our challenge is how to reward positive behavior and allow physicians to listen, and injured workers to trust.
Tuesday, May 13, 2014
Golfing To A Resolution
The Workers Compensation Research Institute has published a study reflecting that California's medical-legal process is more expensive, by quite a bit, that any of the other 15 study states, which includes some of the bigger players such as Florida and Texas.
Here's some of the basic conclusions (but don't rely on these, you should purchase the study to get the full picture):
General medical-legal expenses (includes medical-legal evaluations and reports, independent medical evaluations, depositions and medical expert fees) increased by between 7% and 11% annually from 2006 through 2012, depending on claim maturity.
That growth rate exceeded the average among 15 other study states, including Illinois, Florida and Texas, WCRI said.
Average med-legal expenses per claim with 12 months of experience increased 7% between 2006 and 2011 in California, compared to the 5% average growth in the study states. The average med-legal expense per claim with 36 months of experience increased 11% from 2006 to 2009, almost doubling the 6% average increase among the other states.
The average medical-legal expense for California claims with at least seven days of lost time was $3,200 for 2009 claims with three years of experience. California's average cost was about 20% more than in Minnesota, which had the second-highest average med-legal expense per claim.
This of course is not the whole story. For instance California requires payment to applicant attorneys fees for attending depositions of their clients, in addition to the fees that are paid to defense attorneys for conducting the depositions.
In the WorkCompCentral story about the report this morning, Rui Yang, author of WCRI’s report, said that one of the reasons may be that California's processes are more complicated than those used in other study states.
Below is an excerpt from the WorkCompCentral 2014 Flowchart that highlights the medical-legal process for resolving disputes concerning only disability questions and some other disputes other than treatment (which are now the purview of Independent Medical Evaluations).
Frankly, to make this process better graphically literate it should be broken down into several more steps, but there's only so much room on a piece of paper that is 3 feet tall and 4 feet wide...
I haven't seen any other state's medical-legal process graphically depicted so I can't say whether California is more or less complicated than any comparison state, but remember that the California system has evolved substantially in the 30 plus or so years I've been around work comp.
Which brings me to golf.
Yesterday was the Pepperdine School of Law 9th Annual Golf Tournament held at the Calabasas Country Club. I have attended this annual event for the past five years with my closest law school buddies.
Other than the complication of keeping track whose drive qualifies, the rules are pretty simple, particularly since there really aren't any course monitors, and the event is designed to raise money for the school's Global Justice Program, which funds international human rights projects, summer stipends in public interest work, and students' efforts to help establish the rule of law around the world.
It's a noble and worthwhile fund raising tournament.
What I do is not called playing golf, but I do get lucky enough to actually hit the ball and make it go where it's supposed to go once in a while.
The rules for the shotgun start, best ball play require that at least one drive of every team member be used towards the final goal of getting to the hole.
I'm proud to say that I contributed twice to this grand effort. It took me the front nine to get "my game" and then I was reasonably consistent with my drives, but the field game was still questionable.
Honestly, the tournament yesterday has nothing to do with workers' compensation, except that getting to the goal (putting that stupid little ball into the equally stupid little hole several hundred yards away) required a team effort.
But I suspect that someone, somewhere, is going to point to the WCRI study and lobby for some changes to "simplify" workers' compensation and attempt to save money on claims, incognizant of the team effort that is required to put the ball into the hole.
Here's some of the basic conclusions (but don't rely on these, you should purchase the study to get the full picture):
General medical-legal expenses (includes medical-legal evaluations and reports, independent medical evaluations, depositions and medical expert fees) increased by between 7% and 11% annually from 2006 through 2012, depending on claim maturity.
That growth rate exceeded the average among 15 other study states, including Illinois, Florida and Texas, WCRI said.
Average med-legal expenses per claim with 12 months of experience increased 7% between 2006 and 2011 in California, compared to the 5% average growth in the study states. The average med-legal expense per claim with 36 months of experience increased 11% from 2006 to 2009, almost doubling the 6% average increase among the other states.
The average medical-legal expense for California claims with at least seven days of lost time was $3,200 for 2009 claims with three years of experience. California's average cost was about 20% more than in Minnesota, which had the second-highest average med-legal expense per claim.
This of course is not the whole story. For instance California requires payment to applicant attorneys fees for attending depositions of their clients, in addition to the fees that are paid to defense attorneys for conducting the depositions.
In the WorkCompCentral story about the report this morning, Rui Yang, author of WCRI’s report, said that one of the reasons may be that California's processes are more complicated than those used in other study states.
Below is an excerpt from the WorkCompCentral 2014 Flowchart that highlights the medical-legal process for resolving disputes concerning only disability questions and some other disputes other than treatment (which are now the purview of Independent Medical Evaluations).
Frankly, to make this process better graphically literate it should be broken down into several more steps, but there's only so much room on a piece of paper that is 3 feet tall and 4 feet wide...
I haven't seen any other state's medical-legal process graphically depicted so I can't say whether California is more or less complicated than any comparison state, but remember that the California system has evolved substantially in the 30 plus or so years I've been around work comp.
Which brings me to golf.
Yesterday was the Pepperdine School of Law 9th Annual Golf Tournament held at the Calabasas Country Club. I have attended this annual event for the past five years with my closest law school buddies.
Other than the complication of keeping track whose drive qualifies, the rules are pretty simple, particularly since there really aren't any course monitors, and the event is designed to raise money for the school's Global Justice Program, which funds international human rights projects, summer stipends in public interest work, and students' efforts to help establish the rule of law around the world.
It's a noble and worthwhile fund raising tournament.
What I do is not called playing golf, but I do get lucky enough to actually hit the ball and make it go where it's supposed to go once in a while.
The rules for the shotgun start, best ball play require that at least one drive of every team member be used towards the final goal of getting to the hole.
I'm proud to say that I contributed twice to this grand effort. It took me the front nine to get "my game" and then I was reasonably consistent with my drives, but the field game was still questionable.
Honestly, the tournament yesterday has nothing to do with workers' compensation, except that getting to the goal (putting that stupid little ball into the equally stupid little hole several hundred yards away) required a team effort.
Workers' compensation is a team effort. We essentially play "best ball" in work comp claims. No one is so good, so right, so perfect that they dominate the game of work comp.
But I suspect that someone, somewhere, is going to point to the WCRI study and lobby for some changes to "simplify" workers' compensation and attempt to save money on claims, incognizant of the team effort that is required to put the ball into the hole.
We would have a very difficult time unraveling the complications put into the workers' compensation system that have become part or the processes over the past 25 years. Doing so would, I believe, just introduce more complications and issues.
California's claims processes, including medical-legal processes, are more costly than other states because we have allowed them to be by introducing new processes and other micro-management systems over the years.
The truth is that in most instances we have failed to use "best ball."
If the problem is complications resulting in higher costs, the answer is not more complication. The answer is figure out how to get the ball to the hole using the best efforts of everyone involved.
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