Column: Workers' Comp

What’s Old May Be New Again

By: | November 2, 2015

Roberto Ceniceros is a retired senior editor of Risk & Insurance® and the former chair of the National Workers' Compensation and Disability Conference® & Expo. Read more of his columns and features.

Perhaps it’s time to eliminate workers’ compensation medical care and treat injured workers in the more-efficient and lower-expense group-health system.

That’s a potential strategy I’m hearing discussed more often, reminding me of the attempts 20 years ago to do just that.

The “24-hour care” system, which melded workers’ comp medical care into group health, emerged from the idea that group-health plans would treat employees 24/7, no matter where or when an injury or illness occurred.

But why would the strategy succeed this time?

Proponents respond that the Affordable Care Act’s push to hold medical providers accountable by basing their compensation on the treatment outcomes they produce, rather than on a fee-for-service model, will make health care offered under workers’ comp appear even less efficient.

A workers’ comp health care fee-for-service model that encourages more treatments won’t be sustainable, they add.

Employers would be better off treating all injuries in the group health system without regard for causation. — Dr. Bernyce Peplowski, consultant former health care executive

It won’t make sense for employers to pay their group-health doctors under a system holding them accountable while simultaneously compensating doctors to treat injured workers under a system clinging to fee-for-service, said Dr. Bernyce Peplowski.

Peplowski worked for Kaiser Permanente when it operated a 24- hour-care pilot program in Southern California from 1994 to 1997. She has since served in several roles, including as senior VP, national medical strategy and innovation for U.S. HealthWorks Medical Group and as the medical director for California’s State Compensation Insurance Fund.

Under the current workers’ comp system, employers regularly pay for injuries with questionable causation factors. When it’s unclear whether an aging worker’s knee problems resulted from a strenuous job or from their genetic makeup, employers often pay for treatment through the less efficient workers’ comp system, Peplowski said.

So employers would be better off treating all injuries in the group health system without regard for causation, added Peplowski, who is now a consultant and proponent of combining workers’ comp medical care and group health care.

Under Kaiser’s 1990’s pilot, the health plan charged the County of San Diego $330 per employee per month for group health care plus $16 per employee per month for the expense of treating any workers’ comp injuries.

Successful results allowed Kaiser to return $200,000 to the county.

But other 1990s-era 24-hour-care pilots managed differently failed to produce positive results. At the same time, the rapidly increasing workers’ comp insurance pricing that fueled the interest in 24-hour care reversed.

That killed interest in continuing the innovation. Employers were content with cheaper insurance.

But things are different today, proponents of merging workers’ comp care with group health argue.

Today, drivers of ever increasing health expenses are not going away and will continue to place greater strain on employers, the proponents maintain.

There is also evidence that employers are growing increasingly restless with paying more to treat the same type of injury under workers’ comp than they do under their group health plan.

While many entrenched parties would resist a shift to a new workers’ comp treatment model, perhaps it is time for new pilot programs.

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