Context?!

Attorney Loren M. Lambert of Arrow Legal Solutions in Utah told WorkCompCentral legal reporter, Sherri Okamoto, that over the past few years he's "been seeing a pendulum swing" in terms of the social and political climate in Utah, such that it seems "society doesn't like people who are injured or disabled" in general.

Lambert was commenting on the Utah Workers' Compensation Commission's propensity to write its own law reflecting its view of how things should be - in this situation inserting a standard that doesn't exist in statute, thereby denying an injured worker of benefits to which he otherwise is entitled.

Lambert represented Socorro Guzman, who had worked for Circle 4 Farms performing animal husbandry work. In August 2008, a large boar rammed him, causing him to fall to the cement floor of the boar pen.

He was able to continue working after this accident, eventually going to see a doctor about his back pain.

Guzman's back worsened with time, and he stopped working in July 2009.

After Guzman filed a claim for Permanent Total Disability benefits in 2011, the Administrative Law Judge referred the case to an independent medical panel.

The panel reported that Guzman had suffered a herniated disc, which limited him to lifting no more than 40 pounds on an occasional basis, and that he could not repeatedly bend, stoop, squat or perform overhead work, but he would be capable of doing light- to medium-duty work.

The vocational rehabilitation consultant on the case opined that Guzman was essentially unemployable because he was in his 70s, with a fourth-grade education, limited English proficiency and no transferrable job skills.

The ALJ awarded PTD benefits to Guzman, but a divided Labor Commission appellate panel reversed last June, writing that while the medical panel had identified a "clear set" of restrictions on Guzman's physical activities, he still retained a "reasonable amount of strength, flexibility and endurance" and so his condition did not "reasonably limit his ability to work in a broad range of jobs."

The Court of Appeals then reversed the commission because there's no "reasonable" in the law.

The governing statute, Section 34A-2-413, requires Guzman to demonstrate only that his work-related injuries "limit (his) ability to do basic work activities," the court said. Thus, by applying "the qualifying term 'reasonably' or 'reasonable' in evaluating Guzman’s limitations, the board improperly imposed a higher burden on Guzman than the statute dictates."

The court went on to say that it was "troubled" that the commission failed to assign much persuasive weight to the vocational assessment report just because the consultant did not testify during the hearing on Guzman's claim.

"This flawed reasoning implies that evidentiary reports only carry value if the author of those reports can be questioned," the court said. Such logic was also inconsistent with the commission's decision to place great weight on the independent medical panel report when there was no evidence that the panel members appeared at the hearing.

The appellate court said the commission decision was "riddled with inconsistencies that call its findings into question."

It seems the commission has been rewriting the law to suit a political agenda for some time. A couple of other cases likewise have been reversed by the Court of Appeals lately, and the employers have asked the state Supreme Court to review.

In addition to the Guzman case, the commission has been reversed on the same grounds in Oliver v. Labor Commission and Quast v. Labor Commission.

Jaceson Maughan, the deputy commissioner and general counsel for the commission, told Okimoto on Tuesday that the commission's imposition of a "reasonableness" element "was an attempt to create context," since commissioners had thought "there needs to be some sort of limitation" as to what is a "limitation" for purposes of Section 34A-2-413(1)(c).

Who asked them to do that? What "context" is missing?

The "context" seems pretty clear: A monolingual, uneducated, elderly Hispanic manual laborer in a conservative, principally white, state got hurt, and can't return to the labor market.

I don't think any further explanation is needed.

The Moving Fulcrum

When I started in the workers' compensation field, medical treatment requests needed only a physician's opinion that it was reasonable and necessary. Virtually anything that a doctor wanted for the injured worker was ...

That led, of course, to abuses, and a long line of injured workers who didn't get better, who didn't return to work, who incurred intractable disability and a few medical providers that benefited from the liberality financially.

Along came guidelines.

Guidelines were first introduced by the general health insurance industry to assist meting out treatment dollars. While efficacy was a paramount concern, the primary consideration for the medical insurance companies was controlling the outflow of dollars - prescriptions, if you will, for what would and wouldn't be paid.

The health carriers provided appeals processes, largely in response to federal mandates, to allow for exceptions where the standard treatment protocol wasn't effective but where a technique or service that hadn't yet been fully vetted could be implemented and investigated. If it worked, super, and if not, on to the next thing.

It took a couple of decades for guidelines to merge into workers' compensation. Now virtually every jurisdiction uses some form of medical guideline to regulate the administration of treatment.

This works most of the time for most people.

Some people fall outside the bell curve of guidelines, though. For those people the usual remedy is to find other evidence either not recognized by the guidelines in place or for which the guidelines had not yet been updated and then convincing someone up the appellate process that the evidence sufficiently supports the treatment attempt.

An interesting debate occurring in Oregon demonstrates the forces at work.

The Oregon Workers’ Compensation Division isn’t impressed with platelet-rich plasma injections despite evidence that professional athletes have used the therapy as a way to heal injuries faster and get back on the job sooner.

At least not yet.

WCD and is moving toward renewing a policy that the treatment is not compensable in workers' compensation claims.

Platelet-rich plasma ("PRP") injections take a sample of the patient’s own blood and process it to produce a concentrate of platelets, cells best known for their role in blood clotting. The platelet-rich plasma also contains growth factors that can help with healing, the theory goes. A doctor injects the PRP into the injury site, repeating the treatment every few weeks as needed.

According to an information page posted by the American Academy of Orthopaedic Surgeons, PRP has been found to be most effective in treatment of chronic tendon injuries, such as tennis elbow. Although more evidence is needed regarding the therapy’s effectiveness for other injuries, AAOS says risks of the procedure are about the same as for cortisone injections.

The Medical Advisory Committee subgroup of the Oregon WCD evaluated PRP treatment and proposed a recommendation that platelet-rich plasma injections should not be compensable, at least yet, because there is inadequate published scientific studies supporting its use.

The committee, however, leaves the door open to reevaluating the policy in the future since research on the injections is continuing.

What this really means is that the financial risk of paying for a relatively innocuous medical treatment service outweighs the probability of medical efficacy. Since workers' compensation is a "first dollar" medical benefit system (i.e. the patient in the vast majority of jurisdictions doesn't have a co-pay, deductible or any other financial participatory obligation) the party that actually pays (i.e. the employer/carrier) has a say as to whether or not it is willing to assume the efficacy risk.

Whether this is right or wrong in the privatized public benefit system of work comp can be debated endlessly. It just is the way it is, and is part of the deal.

While PRP holds "great promise," says AAOS, it also notes, "Few insurance plans, including workers' compensation plans, provide even partial reimbursement."

At some point, all of the studies on professional athletes using PRP will have sufficient correlations to determine whether, in fact, it is a beneficial treatment that should be provided via workers' compensation.

Until then, the fiduciary component of workers' compensation - watching where the money goes - will remain conservatively based. There will be some cases where the therapy is approved on an industrial basis when the physicians provide sufficient evidence and argument in favor of approval, and those cases will be studied too.

It's not a perfect system. And some folks will get denied treatment that could help them move on ... or not. 

Balancing the interests of those who pay, and those who receive, is inherently vague. The fulcrum is always moving.

Stop The Fantasy

It was really difficult to keep me away from posting over the holidays - all sorts of interesting things happened in the workers' compensation world: scandal, new rules and laws, studies, court rulings, controversy... some things never change.

And ProPublica published yet another story about workers' compensation, this time taking to task all of the intermediaries that have evolved in the past couple decades under the rubric of "cost containment."

Author Michael Grabell points to the lavish parties and other extravagances at industry conferences as examples that "cost containment" services have run amok. This drew fire, understandably, since most industries have wild parties and indulgent conferences - so why should workers' compensation be different?

Yet, if you see Vons/Safeway/Albertson's VP of Risk, Bill Zachry at any of these conferences, he is always carrying a camera and taking pictures of all of the vendor booths.

I asked him about this one day. He explained that when he gets back to the office he reviews all of the photos and counts up the number of vendors in any particular special service sector - that tells him where all the money is going and where he could potentially see some cost savings.

A brilliant strategy, I think.

Zachry has the luxury of working for, and with, a self insured, self administered (in most jurisdictions) business with the resources to conduct such investigation and implement mitigation strategies to drive the claim dollar where it has the most effect - providing medical care and indemnity to injured workers according to legal obligation.

Most employers don't have that luxury because they delegate the claims decision process to their insurance company.

So an outside observer notes that some of the marketing is over the top, perhaps creating in the least, as we were taught in law school ethics, an appearance of impropriety - not that there actually is any.

There's nothing wrong with promoting your business, even a "cost containment" business. Marketing is a necessary element of business. Without marketing people don't know you exist, much less know of the awesome service and/or products you provide.

And I like parties and shows, even though I won't stay up past 9 p.m. for any due to my unfortunate internal alarm clock that forces me awake at 3:30 a.m. every single morning (even on vacation ... ugh).

Why do we care if Grabell points out that there is lavish spending by vendors at big conferences? What's the big deal?

Some injured worker advocates have latched onto the story to express their opinion that all this money is better sent to injured workers and/or pay for their medical care. Maybe they are right, but maybe those are opinions that aren't well founded either - arguments go both ways.

And maybe stories like the latest in ProPublica need greater publicity and distribution, and provide more people with greater insight into workers' compensation - in my mind whether the portrayal is positive or negative is irrelevant; any time workers' compensation is before the public is good for the institution.

Workers' compensation should not be mysterious, should not be hiding, and should be exposed to the public good or bad, because it is for the public - each and every person that works in this country should be afforded reasonable work injury protection. It's good social policy. It's good economic policy.

Each time The Media comes out with a story, an expose, a critique, of workers' compensation is an excellent opportunity for the industry to reflect and look at ourselves: are we really doing as good of a job as we can with the resources we're given?

Every day I'm the recipient of numerous communications from someone that has seen, felt, heard or otherwise experienced something negative with workers' compensation. It could be from an authorized provider still not getting paid on time, or at fee schedule. It could be from an injured worker or his/her attorney describing some of the ludicrous machinations required to access benefits. It could be from an employer disgusted with the misdirection of its premium dollars. It could be from a claims specialist frustrated with relentless collection attempts by a vendor that should have been satisfied. It could be from a medical professional tired of the authorization gauntlet.

Overwhelmingly, though, such communications come from someone who is just doing their job, or in the least, performing the functions described in the "job description," be it attorney, doctor, claims specialist, broker, and yes, even injured worker.

Everyone has their job to do. In workers' compensation, everyone's job description is created in part by law, by regulation, by a company document and also by culture.

Getting upset about some negative portrayal in The Media is natural - after all, someone is taking to task something very close to us: our professional livelihoods in which a huge part of our egos are wrapped. It is absolutely natural to be defensive.

But it's not productive.

Here's the issue with ProPublica's latest story: "cost containment," despite what Robert Hartwig told ProPublica, ARE dirty words. That phrase sends entirely the wrong message. Yes, the category was started to stop the outflow of irresponsible money and, coincidentally, promote smart medicine. Whether it is used to in fact accomplish those goals is debated by physicians, injured workers and their attorneys (and some employers too).

As in any endeavor, particularly where social benefits are at stake, there are those who play well in the sand box, and others who don't.

Cost containment is an apt term if we, as an industry, are willing to accept its definitional reality - that the intent of cost containment is to save money for those who are paying it out.

Let's stop with the fantasy that cost containment is for the benefit of injured workers. It's not. Otherwise it would be called something else. That cost containment paradoxically results in medical treatment that should result in better outcomes is not the paramount reason for these businesses.

We all know that - so let's stop trying to pretend that it is something which it is not.

If the services are intended to benefit injured workers then there should be a better term for those services that should reflect that beneficial treatment,

Maybe we're misunderstood. Maybe our good intentions aren't appreciated.

But maybe cost containment really is an accurate term - and at whose expense?

Hate to say it folks, but we're getting the attention we all deserve.

The old Pogo comic strip is oft quoted because it is all too true, "we have met the enemy, and he is us." (Walt Kelly, 1953)

Next Year!

Good night 2015!

This is my last blog post for 2015. I'm taking the next two weeks off from this part of my job.

What a year this past one was!

I get asked all the time how I can write so profusely on workers' compensation - a post every single business day (except when I went to Italy for a couple weeks). It really is easy - just read the news. There's always something going on that either defies logic, challenges promises, or frankly just reflects plain stupidity.

Workers' compensation is really, really simple. Employers put money into a bucket. Some expenses are paid out to people for custodial services and management. The rest of the money is to go to and for injured workers.

Sometimes people get more than they should (and sometimes getting anything is wrong). Sometimes people get shortchanged.

But otherwise, it's not a difficult process to execute.

Until our own personal interests get in the way - then we make things more complicated than they need to be.

Some employers, for instance, either don't believe in the workers' compensation institution, or are just plain cheaters, and don't pay into the bucket, or don't pay what they should.

Some workers either feel they deserve more than what the law allows, or are just plain cheaters, and collect when they shouldn't.

Some of the people that are paid for custodial services and management feel the money employers give them is their own money, ignoring their fiduciary responsibilities.

Some of those providing services to and for injured workers get greedy, and sometimes are dangerous, or are just plain cheaters.

There's enough of these characters on a day to day basis that finding something to write about is not much of a challenge.

More of a challenge is finding the stories about workers' compensation done good. General media publications this past year have certainly painted a picture of a benefit system gone awry.

But, the reality is that the American work injury protection scheme hasn't gone awry. For every bad case that gets reported in the news there are likely hundreds that don't get media attention because of the simple fact that they are not remarkable; things worked out the way they were supposed to.

That has been a personal challenge for me these past couple of years - finding the people and their tales that show what workers' compensation is really about, and how it plays an important role in our society and economy.

That's why the WorkCompCentral Comp Laude was invented, and why WorkCompCentral has worked with Pepperdine University to educate and bring new people into this "industry" (I use quotes around the term industry because workers' compensation is much more than an industry - it is an institution).

Over the next couple of weeks I hope to get a little more rest by sleeping past my normal 3 a.m. Pacific Time wake up habit (no, I don't use an alarm clock). I'll read the news fastidiously every morning, and I know I'll feel the compulsion to write.

I'll save it for the New Year though.

In the meantime, think about the good stories. Tell them to me, and tell them to the rest of the world.

Comp Laude 2016 will occur November 4 and 5 in Burbank, CA. We'll start accepting nominations around late February or early March.

I hope those good stories I know you have get turned into nominations.

Happy Holidays!

Subterfuges Are Not Countenanced

Independent contractor status comes up more often as an issue in workers' compensation than we give credit for - and while the industry watches what is happening with the "share economy" companies, cases involving much more mature industries continue to come out of the courts in surprising quantity, and reiterate what we already know about employee versus independent contractor determinations.

Trucking is one of those industries that has gone round and round for years, and even to this day it surprises me that folks haven't learned - it's not what you call the relationship, it's how you treat the relationship.

The First District Court of Appeal for California yesterday released an opinion that, once again, made it clear that the actions, not words, define the employment status.

In Lexington Insurance Co. v. WCAB (Ali), No. A142340, 12/16/2015 (unpublished), Sheik Zahid Ali was seriously injured on July 19, 2006 after driving a tractor-trailer filled with latex paint from Hayward, California to Spokane, Washington.

When Sheik climbed on top of the trailer to unload its contents, a pressurized cap came off and struck him in the head.

The truck was owned by Ali’s Trucking; the trailer was owned by Trimac Transportation Services Western.

Ali's Trucking had a contract agreeing to lease its trucks to Trimac and provide drivers. The contract noted the drivers would be employees of Ali’s Trucking, not Trimac.

Ali’s Trucking entered into a separate contract with Sheik called an “independent contractor agreement.” This contract made no mention of Trimac.

At the time of Sheik's injury, Trimac had a Truckers Occupational Accident Insurance policy with Lexington Insurance Co. Trimac was also covered for workers' compensation by Zurich Insurance Company.

The court's opinion is extensive, and goes over nearly every detail of Sheik's relationships with the companies. The bottom line conclusion - it's not what what people say, but how they act. There is no clear, defining line - the more control a business has over a worker, the more likely the worker will be found an employee for purposes of workers' compensation.

There's nothing magical about the ruling, and there's nothing unusual either. The public policy towards finding an employment relationship despite contractual definitions to the contrary is to ensure that people injured performing services at the direction of another do not become the burden of the state.

As noted by the Lexington court, the seminal case in California (and highly influential in other jurisdictions) is the California Supreme Court opinion in Borello & Sons, Inc. v. Department of Industrial Relations (1989) 48 Cal.3d 341 (Borello).

Borello cites the public policy of liberality in favor of finding an employment relationship, as quoted by the 1st DCA:

"The nature of the work, and the overall arrangement between the parties, must be examined to determine whether they come within the ‘history and fundamental purposes’ of the [workers' compensation] statute” Those purposes are: “(1) to ensure that the cost of industrial injuries will be part of the cost of goods rather than a burden on society[;] (2) to guarantee prompt, limited compensation for an employee’s work injuries, regardless of fault, as an inevitable cost of production[;] (3) to spur increased industrial safety[;] and (4) in return, to insulate the employer from tort liability for his employee’s injuries. [Citations.] [¶] The Act intends comprehensive coverage of injuries in employment. It accomplishes this goal by defining ‘employment’ broadly in terms of ‘service to an employer’ and by including a general presumption that any person ‘in service to another’ is a covered ‘employee.’ ”

Workers' compensation is a privatized social benefit system. Take out "privatized" and you get to the heart of the matter: work comp is a social benefit system.

That means its' primary purpose is to provide benefits to society. It does this by taking care of that small minority (thankfully) of workers who have unfortunate things happen to them while contributing to civilization by furthering the economic goals of another.

What's beautiful about this is that the financial burden of Sheik's serious injuries have been spread out amongst many thousands of other companies and businesses, not just Trimac and not just Ali Trucking. Lexington and Zurich took on the fiduciary obligation of ensuring that risks such as Sheik's injury were sufficiently diversified financially.

Lexington and Zurich decided to be in the business of accepting money for the promise that someone like Sheik would be taken care of in case a pressurized cap popped off and hit him in the head. That they argue amongst themselves about who ultimately pays is okay, so long as Sheik's receipt of medical care and wage loss were not impaired while they fiddled around for nearly 9 years (there's indication that Zurich did provide some benefits).

The California Supreme Court said it most succinctly: “The label placed by the parties on their relationship is not dispositive, and subterfuges are not countenanced.” (Borello, supra, 48 Cal.3d at p. 349.)

A Bigger Hammer

My maternal grandfather lived with us when I was growing up.

We called him "Daddy Harry" at his insistence. His legal name was Harry David Bonacci, given to him "by Decree of court from Enrico Davide Bonacci, as part of the Naturalization" according to the testament by Deputy Clerk Martha Stone for Clerk William H. Tallyn.

He was forty seven years old, five foot six and 130 pounds on April 1, 1946. That was thirteen years before I was born when he became an American citizen. He'd immigrated thirty three years earlier, started a trucking company with his five younger brothers, which grew from a single bob tail into the biggest transport company on the East Coast.

Prohibition was in full swing back then, and my grandfather knew that good money could be made, with little risk, by transporting the raw materials needed by the moonshiners.

But his love was mechanics. After getting the business going he handed over management to his brothers so he could run the maintenance shop. Back then the trades were valued, and there was such a thing as a "master diesel mechanic."

That was my Daddy Harry.

Of course he was retired when he came to live with us. He was separated from my maternal grandmother - she lived in Phoenix, AZ. I recall in my teenage years my parents "forcing" the two to live together, and that was a bit acrimonious, and a story for another post.

The glory to my brother and I, though, was Daddy Harry's garage. Well, it was the household garage, but Dad was too busy being a dentist, Mom had no interest in anything in the garage, so it was my brother and I mesmerized by Daddy Harry's meticulously organized and maintained garage.

I still have many of the tools he passed along, and what I don't have my brother does.

As my brother and I grew older we would tease our grandfather about his mechanical skills. He of course was an extraordinary mechanic, and seemingly could fix, or build, anything, even with the most basic of tools.

Which led to a phrase we would attribute to Daddy Harry, but really we made it up as descriptive of his mechanical prowess: "If it doesn't fit ... use a bigger hammer!"

Following that philosophy is dangerous of course. Making things fit by pounding away with a bigger hammer will, in most cases, just ruin whatever is being "fixed." If you're successful in making it fit, generally the fit won't last long, and the collateral damage to the object being "fixed" can be irreversible, or at least more expensive to repair than had finesse and the proper tools been used in the first place.

We seem to use a bigger hammer when it comes to things in workers' compensation.

And the results are predictable.

In California we used a bigger hammer in 2012, and we made things fit pretty well, at least temporarily.

But the problem with that brute force was that the fit tolerances were sloppy. This may be why the Workers' Compensation Insurance Rating Bureau is finding that the first part of 2015 is reflecting an increase in medical costs, running contrary to the first two years that SB 863 hammered those costs down.

Though still well under what the system started out with prior to SB 863, 2015 is showing so far a 4% increase over 2014 - largely due to utilization, or the number of services being provided (as opposed to unit costs).

And utilization is what drives medical inflation in workers' compensation.

What's interesting about this trend is that Independent Medical Review should impact utilization - and for the first two years that's exactly what happened; utilization following SB 863's implementation of IMR dropped significantly.

But the mix of utilization may be changing, causing this reversal in medical inflation. We know, based on recent research by the California Workers' Compensation Institute, that most requests for treatment do not get challenged, and that compliance rate has been growing, which probably reflects adjustments to the environment by medical vendors.

My Daddy Harry used to nap in the television room every afternoon in his recliner. He would snore "like nobody's business" (a phrase, by the way, that he used to use often), mouth wide open, facing the ceiling, lower jaw moving rhythmically to inhales and exhales. I recall vividly the beautiful dental work Dad had executed so nicely displayed to all the world...

The challenge for my brother and I was to input an index finger into his mouth while open, and withdrawing it just in time before being "bitten." The game was to see how long we could pull off this stunt before waking our grandfather.

And when he woke he would yell at us, "Why you little monkeys!"

Of course we snickered, and took on the challenge another day during another nap. It never got old. We just couldn't resist the bait of Daddy Harry's undulating orifice, the rattle of his sinus cavity and the eventual interruption of his snoring when he sensed a foreign digit in his mouth.

Kind of like the workers' compensation medical game. The challenge of not getting an index finger bit is just part of the fun. How long it can go is another part of the dare.

And eventually a big hammer is brought out to try and fix things, and when that doesn't seen to work an even bigger hammer is used until all has been forced back into place.

Daddy Harry never really told us to use a bigger hammer. That was a fiction my brother and I concocted because it was fun.

So was the finger game.

Paper Irrelevancy

On Friday I quoted blogger and principal of Health Strategy Associates, Joe Paduda, about physician's reticence to complete paperwork.

Paduda opined that physicians would be loath to move claims from general health to work comp because of the extra paper work, stating, "documentation that is perceived by physicians as irrelevant to patient care is the discontent of doctors - seems to me that's the definition of workers' comp."

The latest Texas biennial Performance Based Oversight (PBO) report seems to bear that out - that report showed an alarming minority, up to 25%, of workers' compensation treating physicians surveyed failed to complete or filed required work status reports timely or accurately.

Work status reports and back-to-work documentation are two of four categories under which doctors are assessed through the biennial PBO process for health care providers. Other categories are timeliness in filing medical evaluation forms and filing documents supporting their use of magnetic resonance imaging. Doctors file both forms with insurance carriers and the state Division of Workers' Compensation.

“The measurements that physicians perform the worst on are the administrative requirements of the DWC, rather than the clinical measurements, which physicians score quite well on,” Warren Cooper, the Texas Medical Association's director of health care delivery services, told WorkCompCentral.

83 health care providers were reviewed in the latest PBO report, published Monday, for the timeliness of their medical evaluation reports (DWC Form-069). 61 were high performers, 18 were average performers and four were poor performers.

High, average and poor are defined by regulation.

But, of the 124 health care providers reviewed for the completeness of the work status report (DWC Form-073), 55 were high performers, 38 were average performers and 31 had scores placing them in the poor-performer tier.

The DWC checked the records of those same 124 health care providers to see whether they had proper documentation of the reasons injured employees couldn't return to work.

Of those 124, 62 were high performers, 41 were average performers and 21 were poor performers.

Of the 33 health care providers reviewed for whether they had proper supporting documents for the usage of magnetic resonance imaging for spinal injuries less than 21 days after an injury occurred, 21 were high performers, eight were average performers and four were poor performers.

DWC says it deliberately expanded the number of physicians subject to audit from the last report, nearly doubling the number reviewed for for work-status forms.

To discourage further physician participation in workers' compensation cases, in addition to paperwork they don't want to complete, poor performers are subject to further review and potentially penalties.

I'm being sarcastic of course, and DWC has good intentions - like much in government oversight though, motivation is provided via punitive measures rather than positive incentives.

The other day the Workers' Compensation Research Institute sponsored a webinar debate between retiring president/CEO, Richard Victor, and Paduda - the theme was cost shifting from general health to workers' compensation.

Victor said their data showed it happening. Paduda challenged the premise and the data, and suggested that just as much shift to work comp was also occurring in the opposite direction, providing the quote at the top of this post.

Regardless, it seems to me that Texas would be a great place to do further research on this topic, starting with the physicians that were surveyed in this latest PBO to see how discouraging work comp paperwork, and subsequent discipline assuming poor ratings, motivated a shift to general health if the circumstances permitted.

Even better would be research on how government could meet its need for data while stimulating physicians to provide that information without resorting to de-motivating measures. It would start by formulating forms that physicians would perceive as adding to patient care, rather than the obviously current perception of irrelevancy.