Claims Trends

Joint Injury Care Varies Widely Across States

Although joint injuries are better understood than complex injuries, the type of care provided for similar injuries on a state-by-state basis is inconsistent.
By: | January 4, 2016

“There is a wide variation among states in the utilization of services to treat joint cases as measured by the average cost at common fees per case,” according to NCCI. For each cohort of cases, “surgery and physical medicine show the greatest variation in CCF across states.”

The findings are included in a new report that compares state medical services, costs, and treatment patterns related to joint injuries among states.

It looks at the state differences in the treatment of cases by examining differences in mix and quantity of services for injuries involving the knee, shoulder, elbow, and ankle. While previous studies have focused on price differences related to workers’ comp medical fee schedules, the latest focuses on utilization.

“Joint injuries are among the more common workers’ comp claims,” the report explains. “Although the nature of a joint injury is often better understood and the care more standardized than for more complex injuries, the care provided for a joint injury can run the full gamut of specialized medical services — from physical therapy to diagnostic imaging to surgery.”

The information for the report is based on NCCI’s Medical Data Call detail on medical bills processed on or after July 1, 2010, and based on claims with injury dates between July 2010 and Dec. 31, 2011 — allowing for a two-year window of initial care for each claim included in the calculation of the CCF.

Additional research is needed to determine the drivers of the differences in diagnosis and treatment among the states and to analyze the effectiveness of approaches to regulate utilization.

CCF measures the utilization of medical services rather than price differences. It is computed by using a countrywide fee determined from the median amount paid for the service within each state and averaging the state medians. It is what the cost of treatment would be if all services were reimbursed at that fee.

For the study, the authors included a cohort of cases for each joint, including the following types of injuries:

  • Shoulder: selected diagnoses include sprain/strain and rotator cuff injuries.
  • Elbow: diagnoses include tennis elbow (lateral epicondylitis).
  • Knee: diagnoses include sprain/strain and torn ligament.
  • Ankle: diagnoses include sprain/strain and broken ankle.

For each cohort the authors selected three lower and three higher utilization states. They found the average CCF per case was “much higher for the higher utilization states than the lower utilization states, with elbow cases showing the greatest spread,” according to the report. “Utilization differences across our selected states our driven more by differences in the treatment for given diagnoses than to the mix of diagnoses; this finding is strongest for shoulder and elbow cases.”

The authors say additional research is needed to determine the drivers of the differences in diagnosis and treatment among the states and to analyze the effectiveness of approaches to regulate utilization.

“The question is, are there differences between states in diagnosis coding of otherwise comparable injuries, and, if so, are these differences related to state workers’ comp physician fee schedules or treatment guidelines?” the authors noted. “Finding a relationship between utilization and treatment guidelines is challenging due to the lack of data on the claimant’s comorbidities and prior medical history.”

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at [email protected]

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