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Digital EditionNational Comp 2026: What Group Health Can Learn From Comp
Picture a patient with a torn rotator cuff and major depression. Hurt on the job, she gets a claim number, a stack of authorizations and possibly a nurse case manager focused on getting her back to work. Hurt at home, she gets a call from the doctor’s office to schedule an MRI, along with a deductible that may keep her from booking it at all.
Same patient. Two very different systems.
“They’re like distant cousins,” said Dr. Mark Williams, medical director at The Hartford. “They share the same DNA. They probably go to the same family gatherings, but they don’t really agree on how to get things done.”
Williams moderated a panel at National Comp 2026 in Las Vegas that followed that hypothetical patient through both worlds. He was joined by Silvia Sacalis, vice president of clinical services at Healthesystems; Ceil Jung, director of clinical operations at Stubbe Case Management; and Dr. Steven Serra, vice president and global head of clinical operations at Alight.
All three have worked in both systems.
Liability Versus Benefits
Sacalis, who spent more than a decade in group health before moving into workers’ comp, framed the core difference. “Workers’ compensation is much more than a health benefit. It’s a liability-driven benefit,” she said. Payers are accountable not just for medical bills but for claim duration, indemnity exposure and return to work, across a patchwork of state fee schedules and formularies.
Group health, by contrast, revolves around access, coverage and medical spend. Return to work is the piece that’s missing. “Complexity equals opportunity,” Sacalis said.
For Serra, who spent two decades at Aetna, the biggest structural difference is who pays. Workers’ comp offers first-dollar coverage. Most employer health plans carry a high deductible. “With the cost share, coinsurance and deductible, you probably have a $4,000 to $6,000 barrier,” he said. A low-wage worker may skip coverage to avoid the premium, or enroll and still be unable to afford the deductible. “So we see care avoidance in group health probably much more than we do in work comp.”
Jung, a nurse case manager with more than 30 years across comp, group health and disability, said the extra layers in comp can confuse patients used to group health. But they also bring an advocate. Group health patients rarely get “a nurse case manager working with you to help educate you, provide you resources,” she said. “It’s just somebody that’s a go-between to advocate for them to get this stuff moving.”
Paying for Value
Group health has moved aggressively toward value-based payment. Serra said about 70% of commercial payments now include some value-based element. He illustrated with a bundled payment for the rotator cuff patient: a hypothetical flat $2,700 for six months of care, whether the patient gets an injection or a shoulder replacement. “What are they going to do? They’re not going to do the total shoulder replacement,” he said. “The value-based construct reengineers behavior in the provider environment.”
Workers’ comp lags, Sacalis said, partly because defining value is harder when no single party owns the total cost of a claim. But she sees the industry’s rising focus on outcomes as an opening. “All I hear all the time is the actuaries and the accountants, they only care about the money,” she said. “In my opinion as a clinician, if you do the right thing by the patient, the money will follow.”
Jung has seen the comp equivalent in states that allow provider direction. Case managers know which surgeons get rotator cuff patients back to full function. Treatment guidelines help too, she said, but only when someone explains them. Otherwise, injured workers “think that they’re really being denied something that’s going to help them.”
Safety Gaps
Physician dispensing, nearly absent in group health, surprised Sacalis when she arrived in comp. Cost is part of the problem, but not the biggest part.
“Physician dispensing bypasses the pharmacy protocols that are in place that are designed to support patient safety,” she said, including checks for drug interactions and contraindications.
Jung sees the gap firsthand. Medications from the pharmacy benefit manager show up in one place, while physician-dispensed drugs arrive as separate bills.
“When I look at the whole prescription history, they’re in two different places,” she said, “and so things get missed.”
The Whole Person
Depression complicates the hypothetical patient’s recovery in either system, but comp adds a wrinkle. Jung said claims teams are often wary of adding a mental health diagnosis because it raises new compensability and treatment questions. Case managers must also be careful about what they ask and who they share it with. She has steered workers toward employee assistance programs and credits motivational interviewing training for claims staff.
“Being more empathetic, listening to them, let them know you care can go a long way,” she said.
Sacalis called health literacy the industry’s missed opportunity. Injured workers suddenly have to understand medications, imaging, therapy and the claims process “all during the most difficult and stressful period” of their lives, she said.
“We need to meet them where they’re at, understanding that they’re confused, they’re frustrated, they’re in pain.”
Technology Across the Divide
Group health has years of experience with digital health. Serra cited two Aetna studies. In one, members who regularly met their Apple Watch activity goals had about $10 per member per month lower health care costs. In the other, a digital blood pressure program called Hello Heart was associated with a 19-point drop in systolic blood pressure over three years. “These things work,” he said.
Sacalis sees room for wearables and prescribed digital therapeutics in comp, but trust has to come first. Injured workers will want to know whether the data will be used in claim decisions, or “to monitor and penalize them,” she said. Reimbursement is another hurdle, because no fee schedules cover digital therapeutics yet. “We can’t sit and wait for the reimbursement models,” she said.
What Comp Gets Right
Serra offered comp a compliment its audiences rarely hear. For two decades, he said, group health medical cost trend has run at roughly double general inflation, at 6% to 8% a year and climbing toward 9%. Workers’ comp has averaged 2% to 4%.
“You have something very simple,” he said.
“You have fee schedules, and we don’t.”
Jung confirmed it from experience. Before Minnesota adopted outpatient fee schedules, she said, a payer reimbursing at a percentage of billed charges might see one facility charge $18,000 and another several times that for the same minor procedure. A neighboring state without a fee schedule, she added, saw workers’ comp costs about 9% higher.
Williams suggested the two cousins are growing closer, facing the same provider shortages, aging populations and chronic illness. “Maybe the question isn’t how they’re different,” he said. &
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