This morning's story about the Georgia State Workers' Compensation Board studying whether to seek legislative authority to adopt treatment guidelines got me thinking - why is it that different states have different guides?
I learned in school as a child that basically all human beings are biologically the same.
There should be no difference in one's biology if a person is from California, New York or Georgia.
So why is it that the states that do adopt treatment guides all do something different?
For example, California adopted the guides from American College of Occupational and Environmental Medicine (ACOEM) as a part of its 2004 reform, but also has guidelines that supersede ACOEM.
Texas, as a part of its last reform adopted guides, but the state couldn't decide what it wanted so it adopted both ACOEM and those from Work Loss Data Institute (WLDI).
Florida just has its own guides and did not adopt a national standard.
Do doctors receive medical training differently in California than in Texas, or Florida, or Georgia?
Or do the politics of a state determine whether a person's biology is treated differently than another state?
Watching the debate unfold in Georgia, me thinks it's the politics.
John Poole, legislative consultant to the Georgia Self Insurers Association told our reporter that guides are being considered to control medical costs in the workers' compensation system.
Donald J. Palmisano Jr., executive director of the Medical Association of Georgia, wonders why this would be necessary in light of Georgia's utilization review process.
Jason Perkins, a member of the executive committee of the Georgia Trial Lawyers Association, said discussions about the treatment guidelines have centered on increasing medical costs.
Phil LeFevre, senior account executive for the Work Loss Data Institute, said the board is concerned with both costs and outcomes for workers. He said the state board has not decided whether to write its own guidelines or adopt WLDI or ACOEM.
And of course both WLDI or ACOEM stand to gain market share in the guidelines business so there is motivation to push for a guideline standard.
The first objective of any work comp guideline adoption program should be to ensure that injured workers receive quality medical care that results in the return of a worker to productive status.
And each treatment case will be different because though everyone's biology is standard, no one's life experience is standard, so what is effective for one person is not effective for another without some additional accounting for an injured workers' coping tolerances.
We have seen increasing evidence lately that accounting for psychosocial factors is nearly more important than accounting for biological factors in terms of controlling costs - because when you really get down to it, controlling costs is the primary reason treatment guides are adopted or implemented, NOT to ensure the delivery of quality care.
I don't believe that controlling costs and delivering quality care are mutually exclusive though. Indeed they are complimentary if the design has as a primary focus the delivery of VALUE, which means not focusing on procedure costs but looking at the totality of all variables consequentially related to a work injury.
Back to my original question - why does each state have something different? I believe, as I have opined in the past, medical treatment in workers' compensation is more political than scientific.
workers compensation, work comp, injured worker
Thursday, October 20, 2011
Wednesday, October 19, 2011
"Reform" Should Not be Defined by Financial Outcomes
In a webinar presentation yesterday, advocacy groups representing California employers indicated that they are looking for a new "reform" or overhaul of the state's workers' compensation system.
There seems to be consensus from the group in yesterday's presentation that permanent disability indemnity benefits need to be increased.
But the group is unwilling to concede to increases without taking something away from some other cost driver.
Sensible enough given that workers' compensation operates within a defined set of financial parameters - there is only so much money to go around so increasing one thing will require decreasing another.
Jason Schmelzer, chief lobbyist for the California Coalition on Workers' Compensation (CCWC), said in the webinar that business agrees it is necessary to adjust permanent disability (PD) benefits, but there are a lot of questions about how it should be done citing that fact that PD is not defined specifically in either statute or regulation creating the problem of court opinions interfering with the reforms.
"The Almaraz/Guzman and Ogilvie decisions are a testament to the creativity of the Appeals Board," he said. "Most observers think the reforms were pretty clear, but the reflection looking back on the system is when we do the next reform, we need to make it iron-clad."
I disagree with Schmelzer - history is replete with "reforms" being interpreted by the courts and escaping the "intent" of the reformists - there is no possible way to make any law "iron-clad". Laws get written, then cases with specific facts applying those laws are argued by attorneys who are trained to advocate for their clients, be they injured workers or employers/carriers so whatever "reform" is instituted will be challenged and case law will be made. That is how our system works.
I agree with Schmelzer on an important point. He told the webinar audience, "There is no reason for as much to be going in front of the Workers' Compensation Appeals Board as there is. We need to bring down the tension level."
The problem with the thinking of these advocacy groups in my opinion is that they are intent on repeating history - expecting different results with the same inputs. In other words, rather than tackling the underlying raison d'êtree, "reform" is being defined by changing the surface level.
The discussion needs to be about the culture of workers' compensation. The question needs to be about what the ultimate outcome should be.
Do we want to compensate people for being disabled, or do we want to provide incentive that changes the expectations of people that end up in the system?
Do we want to control medical costs on a piecemeal basis, or do we want to reward physicians for returning value to workers' compensation?
Do we want to continue putting money into investigations of employers committing payroll fraud or who provide unsafe working conditions, or do we want to create a culture of mutually shared responsibility and reward?
Creative employers are working within existing systems and are experiencing extraordinary results because they are not using the same old inputs.
Just yesterday I blogged about Safeway experimenting with biopsychosocial treatment, a fancy way of saying they are dealing with the WHOLE injured worker and not just the "injury", and experiencing positive results beyond their wildest imaginations.
I have blogged in the past about employers paying more for medical care during the early parts of a claim and experiencing greatly reduced litigation rates, disability rates and payroll replacement costs.
These are just examples of piece meal solutions working within an existing "broken" system to obtain superior results for both injured workers and employers.
The lesson is that these people thought outside the box, examined the CULTURE of what was going on and created INCENTIVES to drive the culture. They defined what the expected SOCIAL outcome was first. They did NOT define financial outcomes first. These creative people then instituted changes that would drive the social outcomes and then measured the results on a global basis examining costs beyond the incremental, special costs, of just the workers' compensation program.
So, my simple message to the well meaning advocates of "reform" - step back and think first about what the desired social outcome is first, then think of ways to motivate people towards those outcomes. And while the financial issues should be addressed, they should not define "reform".
workers compensation, work comp, injured worker
There seems to be consensus from the group in yesterday's presentation that permanent disability indemnity benefits need to be increased.
But the group is unwilling to concede to increases without taking something away from some other cost driver.
Sensible enough given that workers' compensation operates within a defined set of financial parameters - there is only so much money to go around so increasing one thing will require decreasing another.
Jason Schmelzer, chief lobbyist for the California Coalition on Workers' Compensation (CCWC), said in the webinar that business agrees it is necessary to adjust permanent disability (PD) benefits, but there are a lot of questions about how it should be done citing that fact that PD is not defined specifically in either statute or regulation creating the problem of court opinions interfering with the reforms.
"The Almaraz/Guzman and Ogilvie decisions are a testament to the creativity of the Appeals Board," he said. "Most observers think the reforms were pretty clear, but the reflection looking back on the system is when we do the next reform, we need to make it iron-clad."
I disagree with Schmelzer - history is replete with "reforms" being interpreted by the courts and escaping the "intent" of the reformists - there is no possible way to make any law "iron-clad". Laws get written, then cases with specific facts applying those laws are argued by attorneys who are trained to advocate for their clients, be they injured workers or employers/carriers so whatever "reform" is instituted will be challenged and case law will be made. That is how our system works.
I agree with Schmelzer on an important point. He told the webinar audience, "There is no reason for as much to be going in front of the Workers' Compensation Appeals Board as there is. We need to bring down the tension level."
The problem with the thinking of these advocacy groups in my opinion is that they are intent on repeating history - expecting different results with the same inputs. In other words, rather than tackling the underlying raison d'êtree, "reform" is being defined by changing the surface level.
The discussion needs to be about the culture of workers' compensation. The question needs to be about what the ultimate outcome should be.
Do we want to compensate people for being disabled, or do we want to provide incentive that changes the expectations of people that end up in the system?
Do we want to control medical costs on a piecemeal basis, or do we want to reward physicians for returning value to workers' compensation?
Do we want to continue putting money into investigations of employers committing payroll fraud or who provide unsafe working conditions, or do we want to create a culture of mutually shared responsibility and reward?
Creative employers are working within existing systems and are experiencing extraordinary results because they are not using the same old inputs.
Just yesterday I blogged about Safeway experimenting with biopsychosocial treatment, a fancy way of saying they are dealing with the WHOLE injured worker and not just the "injury", and experiencing positive results beyond their wildest imaginations.
I have blogged in the past about employers paying more for medical care during the early parts of a claim and experiencing greatly reduced litigation rates, disability rates and payroll replacement costs.
These are just examples of piece meal solutions working within an existing "broken" system to obtain superior results for both injured workers and employers.
The lesson is that these people thought outside the box, examined the CULTURE of what was going on and created INCENTIVES to drive the culture. They defined what the expected SOCIAL outcome was first. They did NOT define financial outcomes first. These creative people then instituted changes that would drive the social outcomes and then measured the results on a global basis examining costs beyond the incremental, special costs, of just the workers' compensation program.
So, my simple message to the well meaning advocates of "reform" - step back and think first about what the desired social outcome is first, then think of ways to motivate people towards those outcomes. And while the financial issues should be addressed, they should not define "reform".
workers compensation, work comp, injured worker
Tuesday, October 18, 2011
Setting Expectations Early Lowers Costs
A recent experiment by a large grocery chain in California demonstrates that setting expectations for claimants that they will return to work quickly and with as little disability as possible positively impacts workers' compensation statistics.
William Zachry, vice president of risk management for Safeway Inc. told attendees of the Association of Workers' Compensation Professionals 13th annual Workers' Compensation Conference in Sacramento on Friday that the company started an early intervention program to test whether poor coping skills were responsible for increases in workers' compensation costs despite a reduction in the number of injuries.
77 people who went through the pilot program in Northern California were told up front that the expectation was they would return to work without disability. To their surprise, all 77 returned to work with no litigation and even though one subject received back surgery.
Safeway worked with Kaiser Permanente and Dr. Melvin Belsky, the store's corporate workers' compensation medical director, to developed a questionnaire that helped identify workers who might have poor coping skills examining characteristics such as drug dependency, depression and anxiety to determine which injured workers would become chronic pain patients.
The biggest indicator, according to Belsky, was when the claimed disability was not proportional to the type of injury.
Belksy expected about 10% of the injured workers would become chronic pain claimants accounting for about 75% of medical and indemnity payments. Though the sample is small, it is still significant that none of the test subjects did.
Belsky said a growing body of evidence has found a connection between adult health status and early childhood abuse and household dysfunction. Because people in this group didn't develop necessary skills for dealing with adversity, they need to be treated differently.
Treatment following the biopsychosocial model, that includes a mix of physical therapy, conditioning and cognitive behavioral therapy is sufficient to get these people back on the job, according to Belsky.
Dr. Steven Feinberg, chief medical officer of American Pain Solutions and an adjunct clinical professor at Stanford University School of Medicine, agreed with Belsky, noting that doctors are not taught biopsychosocial treatment skills in medical school.
I might add that our workers' compensation laws are set up to discourage biopsychosocial treatment. We reward on the basis of disability. We pay doctors on a procedure basis. Attorneys are compensated based on how much the injured worker is disabled. Treatment of interdependent psychosocial components risks new "body part" claims.
Safeway has the luxury of self-insurance, so it can engage in experiments such as the one described here. The lesson is that there is an art to claims management that goes well beyond time limits, fee schedules, and AOE/COE.
workers' compensation, work injury
William Zachry, vice president of risk management for Safeway Inc. told attendees of the Association of Workers' Compensation Professionals 13th annual Workers' Compensation Conference in Sacramento on Friday that the company started an early intervention program to test whether poor coping skills were responsible for increases in workers' compensation costs despite a reduction in the number of injuries.
77 people who went through the pilot program in Northern California were told up front that the expectation was they would return to work without disability. To their surprise, all 77 returned to work with no litigation and even though one subject received back surgery.
Safeway worked with Kaiser Permanente and Dr. Melvin Belsky, the store's corporate workers' compensation medical director, to developed a questionnaire that helped identify workers who might have poor coping skills examining characteristics such as drug dependency, depression and anxiety to determine which injured workers would become chronic pain patients.
The biggest indicator, according to Belsky, was when the claimed disability was not proportional to the type of injury.
Belksy expected about 10% of the injured workers would become chronic pain claimants accounting for about 75% of medical and indemnity payments. Though the sample is small, it is still significant that none of the test subjects did.
Belsky said a growing body of evidence has found a connection between adult health status and early childhood abuse and household dysfunction. Because people in this group didn't develop necessary skills for dealing with adversity, they need to be treated differently.
Treatment following the biopsychosocial model, that includes a mix of physical therapy, conditioning and cognitive behavioral therapy is sufficient to get these people back on the job, according to Belsky.
Dr. Steven Feinberg, chief medical officer of American Pain Solutions and an adjunct clinical professor at Stanford University School of Medicine, agreed with Belsky, noting that doctors are not taught biopsychosocial treatment skills in medical school.
I might add that our workers' compensation laws are set up to discourage biopsychosocial treatment. We reward on the basis of disability. We pay doctors on a procedure basis. Attorneys are compensated based on how much the injured worker is disabled. Treatment of interdependent psychosocial components risks new "body part" claims.
Safeway has the luxury of self-insurance, so it can engage in experiments such as the one described here. The lesson is that there is an art to claims management that goes well beyond time limits, fee schedules, and AOE/COE.
workers' compensation, work injury
Monday, October 17, 2011
Targeting Photocopy Services for Regulation Requires A Balanced Approach
Division of Workers' Compensation Administrative Director Rosa Moran told attendees of the Association of Workers' Compensation Professionals 13th annual Workers' Compensation Conference on Friday that one of nine committees she has formed will be looking at regulating photocopy services.
"I'm going to start with something small, because we've got to get our house in order," she said. "I randomly picked something that kind of annoys me. I picked copy services."
The copy services that Moran is targeting provide services such as photocopying medical records and legal documents and delivering them to case participants.
According to the WorkCompCentral story, the committee will first identify what a copy service should do and then determine an appropriate charge.
"They do everything but shine your shoes nowadays," Moran said. "What is the product people are willing to pay for? Do you want to pay for the annotated index? Do you want to pay for the service they do for (Uninsured Employers Fund) cases?"
There are two sides to the photocopy coin, of course.
One aspect of the business involves procuring records at the request of the insurance/employer/defense community. Those are direct, fee for service, businesses where the "customer" usually has a pre-existing contract for services and pretty much knows what it is going to pay for the service or product up front.
The aspect I suspect that Moran has her eyes on involves fulfilling requests for applicant attorneys, and these services are performed on a lien basis. The applicant attorney will take a case, get a medical history and then have the records procured to ensure either that there aren't any time bombs or booby traps in the medical history or to find evidence to support the case.
Regardless, the fees charged for procuring records for applicant attorneys are generally many times higher than the fees charged for getting the same records for defense customers.
The two sides of the service are not apples for apples because the expenses involved in getting paid after fulfilling applicant attorney record requests are significantly higher than when performing work directly for the defense.
Applicant attorney photocopy services generally wait for well over a year before they can collect on their receivable, many times for several years. They are required to file liens to protect their payment interests. Many times carriers dispute the right to reimbursement or negotiate down the fee, requiring copy services to retain representation to make appearances at hearings.
Yet there needs to remain an independent record procurement availability to the applicant bar because otherwise the control over critical information would become lopsided providing the defense with an unfair advantage in the least, or worse, the ability to completely hide potentially damaging evidence.
Any regulation on the fees that photocopy services charge for records sought by applicant attorneys needs to also provide for more prompt and secure payment for those services.
My suspicion is that the photocopy interests would not have an objection to a fee schedule if regulations also ensured that they would be paid timely, at the specified rate, without objection, and without further need for receivables enforcement.
workers compensation
"I'm going to start with something small, because we've got to get our house in order," she said. "I randomly picked something that kind of annoys me. I picked copy services."
The copy services that Moran is targeting provide services such as photocopying medical records and legal documents and delivering them to case participants.
According to the WorkCompCentral story, the committee will first identify what a copy service should do and then determine an appropriate charge.
"They do everything but shine your shoes nowadays," Moran said. "What is the product people are willing to pay for? Do you want to pay for the annotated index? Do you want to pay for the service they do for (Uninsured Employers Fund) cases?"
There are two sides to the photocopy coin, of course.
One aspect of the business involves procuring records at the request of the insurance/employer/defense community. Those are direct, fee for service, businesses where the "customer" usually has a pre-existing contract for services and pretty much knows what it is going to pay for the service or product up front.
The aspect I suspect that Moran has her eyes on involves fulfilling requests for applicant attorneys, and these services are performed on a lien basis. The applicant attorney will take a case, get a medical history and then have the records procured to ensure either that there aren't any time bombs or booby traps in the medical history or to find evidence to support the case.
Regardless, the fees charged for procuring records for applicant attorneys are generally many times higher than the fees charged for getting the same records for defense customers.
The two sides of the service are not apples for apples because the expenses involved in getting paid after fulfilling applicant attorney record requests are significantly higher than when performing work directly for the defense.
Applicant attorney photocopy services generally wait for well over a year before they can collect on their receivable, many times for several years. They are required to file liens to protect their payment interests. Many times carriers dispute the right to reimbursement or negotiate down the fee, requiring copy services to retain representation to make appearances at hearings.
Yet there needs to remain an independent record procurement availability to the applicant bar because otherwise the control over critical information would become lopsided providing the defense with an unfair advantage in the least, or worse, the ability to completely hide potentially damaging evidence.
Any regulation on the fees that photocopy services charge for records sought by applicant attorneys needs to also provide for more prompt and secure payment for those services.
My suspicion is that the photocopy interests would not have an objection to a fee schedule if regulations also ensured that they would be paid timely, at the specified rate, without objection, and without further need for receivables enforcement.
workers compensation
Friday, October 14, 2011
When Negative Legislation has a Silver Lining
Sometimes there are positive unintended consequences to legislation providing in theory win-win situations to constituencies that one would otherwise think to be diametrically opposed.
As an example, California Gov. Jerry Brown last week signed a bill to eliminate the profit motive for prescribing compound drugs, an important legislative victory for the employer community.
But pharmacists say the governor's signature on the bill also demonstrates the state's approval of compound drugs in the workers' compensation system.
AB 378 (Solorio, D-Santa Ana) addresses pharmacy goods, including compound drugs, medical foods, co-packs and durable medical equipment, as well as physician-dispensed over-the-counter medications. The bill adds these pharmacy products to the list of goods for which physician self-referral is prohibited.
The law provides that compound medications must be billed at the ingredient level and reimbursed at the Medi-Cal rate for each ingredient as identified by its national drug code (NDC). Ingredients that do not have an NDC are not reimbursable under the new law. If a physician dispenses a compounded medication, the bill limits reimbursement to 300% of documented paid costs, not to exceed $20.
The employer/carrier community felt that there was a loophole in the pharmaceutical control laws based on evidence such as a report by the California Workers' Compensation Institute in August 2010 which found that compound medications, convenience packs and medical foods accounted for 2.3% of drug costs in the first quarter of 2006, but climbed to 12% of prescription drug costs in the first quarter of 2009. During this same time period, CWCI said the average payment for compound drugs increased from $468 to $591.
Jason Schmelzer, chief lobbyist for the California Coalition on Workers' Compensation, told WorkCompCentral that, "the spike in compounds was clearly related to financial incentives for physicians and facilitated by certain companies that figured out and helped them take advantage of the system." The new law was intended to curb those abuses.
Bruce Curnick, vice president of Landmark Medical Management, told WorkCompCentral that the bill will clean up some abuses of the system, but it largely leaves compounding unaffected and that while the legislation caps reimbursement for medications dispensed by a physician, those limitations will apply only to doctors who do the compounding in their offices because of the definitions of "administer" and "dispense" as found in the California Business and Professions Code.
There is concern with the reimbursement rate being set too low. Jon Roth, chief executive officer of the California Pharmacists Association, said he can appreciate the comment that the bill appears to legitimize the use of compound drugs but felt the Medi-Cal reimbursement rate is too low.
But AB 378 provides that the administrative director of the Division of Workers' Compensation has the authority to make regulatory changes to prevent a reduction when the methodology for determining reimbursement rates in Medi-Cal changes from the average wholesale price to the average acquisition cost. This may help out the pharmacy sector from rates that make it difficult to provide medications in the work comp system.
I'm an optimist by nature, but occasionally even I am surprised when an interest group sees a positive benefit from a legal change that would otherwise be deemed negative. The world continues to surprise me!
workers compensation
As an example, California Gov. Jerry Brown last week signed a bill to eliminate the profit motive for prescribing compound drugs, an important legislative victory for the employer community.
But pharmacists say the governor's signature on the bill also demonstrates the state's approval of compound drugs in the workers' compensation system.
AB 378 (Solorio, D-Santa Ana) addresses pharmacy goods, including compound drugs, medical foods, co-packs and durable medical equipment, as well as physician-dispensed over-the-counter medications. The bill adds these pharmacy products to the list of goods for which physician self-referral is prohibited.
The law provides that compound medications must be billed at the ingredient level and reimbursed at the Medi-Cal rate for each ingredient as identified by its national drug code (NDC). Ingredients that do not have an NDC are not reimbursable under the new law. If a physician dispenses a compounded medication, the bill limits reimbursement to 300% of documented paid costs, not to exceed $20.
The employer/carrier community felt that there was a loophole in the pharmaceutical control laws based on evidence such as a report by the California Workers' Compensation Institute in August 2010 which found that compound medications, convenience packs and medical foods accounted for 2.3% of drug costs in the first quarter of 2006, but climbed to 12% of prescription drug costs in the first quarter of 2009. During this same time period, CWCI said the average payment for compound drugs increased from $468 to $591.
Jason Schmelzer, chief lobbyist for the California Coalition on Workers' Compensation, told WorkCompCentral that, "the spike in compounds was clearly related to financial incentives for physicians and facilitated by certain companies that figured out and helped them take advantage of the system." The new law was intended to curb those abuses.
Bruce Curnick, vice president of Landmark Medical Management, told WorkCompCentral that the bill will clean up some abuses of the system, but it largely leaves compounding unaffected and that while the legislation caps reimbursement for medications dispensed by a physician, those limitations will apply only to doctors who do the compounding in their offices because of the definitions of "administer" and "dispense" as found in the California Business and Professions Code.
There is concern with the reimbursement rate being set too low. Jon Roth, chief executive officer of the California Pharmacists Association, said he can appreciate the comment that the bill appears to legitimize the use of compound drugs but felt the Medi-Cal reimbursement rate is too low.
But AB 378 provides that the administrative director of the Division of Workers' Compensation has the authority to make regulatory changes to prevent a reduction when the methodology for determining reimbursement rates in Medi-Cal changes from the average wholesale price to the average acquisition cost. This may help out the pharmacy sector from rates that make it difficult to provide medications in the work comp system.
I'm an optimist by nature, but occasionally even I am surprised when an interest group sees a positive benefit from a legal change that would otherwise be deemed negative. The world continues to surprise me!
workers compensation
Thursday, October 13, 2011
FL Judges Shown Politics Controls Judiciary
In most states the workers' compensation adjudication system begins with an administrative process and the judges are administrative law judges (ALJ) that have limited judicial powers and are bound by judicial canons of ethics and conduct.
In most states ALJs are hired by the state agency and are not the subject of executive appointment.
Florida is unique in that its ALJs are appointed by the Governor. This makes the workers' compensation adjudication process in Florida subject to politicization.
Apparently that is what is going on in Florida.
Veteran Judge of Compensation Claims (JCC) Paul T. Terlizzese is losing his job because the Statewide Nominating Commission for Judges of Compensation Claims in August failed to reach a majority vote on Terlizzese.
Terlizzese, of Melbourne, was appointed by former Gov. Jeb Bush as one of the state's 32 judges of compensation claims (JCCs) on Nov. 1, 1999. His term expires on Oct. 22.
From what was reported in WorkCompCentral this morning on the matter, Terlizzese had his enemies but he had never been counseled for unethical behavior or bias.
But there was a group of lawyers that had filed complaints against Terlizzese claiming that he demonstrated bias against injured workers.
Those six complaints were investigated by David Langham, deputy chief judge of the Office of Judges of Compensation Claims who found no evidence of that Terlizzese had violated the Florida Code of Judicial Conduct.
A few days before the nominating commission met last April, the Workers' Compensation Section of the Florida Bar released the results of its 2011 survey of judges and gave Terlizzese low marks.
On a scale of one to five, he got a rating of 2.5 for courteousness to counsel, witnesses and parties; a score of 2.3 for patience and willingness to listen, and a score of 2.6 for impartiality. The three ratings were the lowest given to the state's 32 JCCs. We don't know who participated in the survey, how many participated, and whether there was a "bias" in the survey (i.e. whether more participated in the survey regarding Terlizzese than other judges).
Florida's JCC decisions are not reviewed, like many states, by an administrative review system, but go straight into the appellate courts, with the First District Court of Appeal have exclusive jurisdiction over workers' compensation appeals.
Terlizzese's record on appeal is good: Langham said Terlizzese has been affirmed at a rate of between 83.5% and 87.3% in appeals of his orders.
Workers' compensation is a product of the political process, which is the reason in part why we never have a "complete" solution to system issues.
But placing ALJs in the political cross hairs threatens the independence of the judiciary.
I don't know Terlizzese, and I don't know his court room demeanor, but the actions of the nominating committee and the Governor's office don't pass my "smell" test. From our story there were only six complaints, one by a politically powerful person (former Rockledge, Fla., Police Chief John Shockey).
In addition, the nominating commission, which is supposed to be composed of 15 members, only had 8 present to vote on Terlizzese because of vacancies on the commission and the fact that a Jewish holiday had begun on the date of the vote.
The complaints against Terlizzese were about bias. It appears to me that the actions against Terlizzese are ironically biased.
In most states ALJs are hired by the state agency and are not the subject of executive appointment.
Florida is unique in that its ALJs are appointed by the Governor. This makes the workers' compensation adjudication process in Florida subject to politicization.
Apparently that is what is going on in Florida.
Veteran Judge of Compensation Claims (JCC) Paul T. Terlizzese is losing his job because the Statewide Nominating Commission for Judges of Compensation Claims in August failed to reach a majority vote on Terlizzese.
Terlizzese, of Melbourne, was appointed by former Gov. Jeb Bush as one of the state's 32 judges of compensation claims (JCCs) on Nov. 1, 1999. His term expires on Oct. 22.
From what was reported in WorkCompCentral this morning on the matter, Terlizzese had his enemies but he had never been counseled for unethical behavior or bias.
But there was a group of lawyers that had filed complaints against Terlizzese claiming that he demonstrated bias against injured workers.
Those six complaints were investigated by David Langham, deputy chief judge of the Office of Judges of Compensation Claims who found no evidence of that Terlizzese had violated the Florida Code of Judicial Conduct.
A few days before the nominating commission met last April, the Workers' Compensation Section of the Florida Bar released the results of its 2011 survey of judges and gave Terlizzese low marks.
On a scale of one to five, he got a rating of 2.5 for courteousness to counsel, witnesses and parties; a score of 2.3 for patience and willingness to listen, and a score of 2.6 for impartiality. The three ratings were the lowest given to the state's 32 JCCs. We don't know who participated in the survey, how many participated, and whether there was a "bias" in the survey (i.e. whether more participated in the survey regarding Terlizzese than other judges).
Florida's JCC decisions are not reviewed, like many states, by an administrative review system, but go straight into the appellate courts, with the First District Court of Appeal have exclusive jurisdiction over workers' compensation appeals.
Terlizzese's record on appeal is good: Langham said Terlizzese has been affirmed at a rate of between 83.5% and 87.3% in appeals of his orders.
Workers' compensation is a product of the political process, which is the reason in part why we never have a "complete" solution to system issues.
But placing ALJs in the political cross hairs threatens the independence of the judiciary.
I don't know Terlizzese, and I don't know his court room demeanor, but the actions of the nominating committee and the Governor's office don't pass my "smell" test. From our story there were only six complaints, one by a politically powerful person (former Rockledge, Fla., Police Chief John Shockey).
In addition, the nominating commission, which is supposed to be composed of 15 members, only had 8 present to vote on Terlizzese because of vacancies on the commission and the fact that a Jewish holiday had begun on the date of the vote.
The complaints against Terlizzese were about bias. It appears to me that the actions against Terlizzese are ironically biased.
Wednesday, October 12, 2011
Tying Work Comp to Other Systems Can Cause Chaos
Tying workers' compensation systems to other systems, which often seems logical, can cause chaos occasionally.
This is becoming evident in California where a change in how prescription drug reimbursement rates are calculated for the Medi-Cal database may cause billing problems in workers' compensation and might also require regulatory changes for consistency in how medications are reimbursed.
California Labor Code Section 9789.40 requires reimbursement rates for prescription drugs in the workers' compensation system to be 100% of the rate paid by Medi-Cal.
The Department of Health Care Services (DHCS) maintains the Medi-Cal database, which until Sept. 28 was based on average wholesale price information provided by First DataBank. First DataBank stopped publishing average wholesale price information at the end of September because of several lawsuits in which it was accused of inflating the prices.
DHCS is changing from average wholesale price to average acquisition cost. Average acquisition cost will be based on survey data showing what pharmacies actually pay for drugs, according to the Division of Workers' Compensation (DWC).
There seems to be consensus that average acquisition cost is a better costing methodology, at least by those interviewed by WorkCompCentral in this morning's story.
But DHCS is also changing its fiscal intermediary from Hewlett-Packard to Affiliated Computer Services, and as a result, Medi-Cal pricing information has not been updated since Sept. 28, and new data will not be available until the end of October, according to the DWC.
Consequently those affected will need to review every pharmacy bill from Sept. 30 until the updated file is available, creating considerable duplicate work loads and, of course, unintended system costs.
Another interesting twist that may not have been contemplated was pointed out by Steve Cattolica, vice president of government affairs for the California Society of Industrial Medicine and Surgery (CSIMS).
Cattolica questioned in the WorkCompCentral story whether average acquisition cost accounts for the differences paid by bulk purchasers, compared to those who buy in smaller amounts which may result in reimbursement rates that are inadequate for some smaller operators.
The Medi-Cal transition will be completed in March or February, according to DWC. In the meantime, the Medi-Cal database will continue to be based on average wholesale prices.
workers compensation
This is becoming evident in California where a change in how prescription drug reimbursement rates are calculated for the Medi-Cal database may cause billing problems in workers' compensation and might also require regulatory changes for consistency in how medications are reimbursed.
California Labor Code Section 9789.40 requires reimbursement rates for prescription drugs in the workers' compensation system to be 100% of the rate paid by Medi-Cal.
The Department of Health Care Services (DHCS) maintains the Medi-Cal database, which until Sept. 28 was based on average wholesale price information provided by First DataBank. First DataBank stopped publishing average wholesale price information at the end of September because of several lawsuits in which it was accused of inflating the prices.
DHCS is changing from average wholesale price to average acquisition cost. Average acquisition cost will be based on survey data showing what pharmacies actually pay for drugs, according to the Division of Workers' Compensation (DWC).
There seems to be consensus that average acquisition cost is a better costing methodology, at least by those interviewed by WorkCompCentral in this morning's story.
But DHCS is also changing its fiscal intermediary from Hewlett-Packard to Affiliated Computer Services, and as a result, Medi-Cal pricing information has not been updated since Sept. 28, and new data will not be available until the end of October, according to the DWC.
Consequently those affected will need to review every pharmacy bill from Sept. 30 until the updated file is available, creating considerable duplicate work loads and, of course, unintended system costs.
Another interesting twist that may not have been contemplated was pointed out by Steve Cattolica, vice president of government affairs for the California Society of Industrial Medicine and Surgery (CSIMS).
Cattolica questioned in the WorkCompCentral story whether average acquisition cost accounts for the differences paid by bulk purchasers, compared to those who buy in smaller amounts which may result in reimbursement rates that are inadequate for some smaller operators.
The Medi-Cal transition will be completed in March or February, according to DWC. In the meantime, the Medi-Cal database will continue to be based on average wholesale prices.
workers compensation
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