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Should workers’ comp pay more for medical care than group health?

That is the question I’m left with after reading WCRI’s latest reports.

One compares group health’s payments for outpatient hospital services to work comp’s; the other discusses the use of group health payments as the basis for a work comp provider fee schedule.  There is a wealth of insight in both studies; generally, states with fee schedules had lower work comp medical costs than those without

The latter is the subject of today’s post; it “focuses on the median nonhospital price paid for five common surgeries and four common established patient office visits in 22 large states for services delivered in 2009.”; it compares group payments to comp.  By focusing on actual prices paid, the analysis factors in network and other discounts taken, increasing the “validity” of the data.

I’ve long thought providers should get paid more for care delivered to workers comp patients than for group, medicare, or medicaid.  Comp involves disability management and all the communications, reporting, and complications inherent in considering disability in delivering care, and as we expect physicians and other care givers to take an active role in that process, by rights we should expect to pay them for that additional work.

That said, the dichotomy between pricing differentials for office visits vs. surgeries reported by WCRI strikes me as precisely the opposite of what should be.  Specifically, the prices paid for office visits under group and comp were typically within 30 percent, with a range of 15 percent in about half of the states studied; in several states comp paid significantly less than group for office visits. Office visits are where and when the “disability management’ stuff occurs as the physician discusses the return to work plan, engages with the field case manager (if one is involved), talks with the claimant about the claimant’s job functions, physical capabilities and limitations, and other factors affecting disability.  This takes time, thought, documentation, expertise.

Conversely, reimbursement for surgeries was generally much higher when the payer was workers’ comp than when a health plan was on the hook. Remember, the payment is specific to the surgical procedure; it does not include visits pre- and post-surgery. A knee arthroscopy is a knee arthroscopy; yes, there may be a little different documentation for WC surgeries, but the surgical notes should consider functionality, rehab plans, and prognosis regardless of who the payer is. Yet in only one state – Michigan – was the reimbursement essentially identical, while in the other 21 states, the reimbursement was higher for comp – in seven states comp reimbursed at least twice as much as group health. 

Surgeons may argue that the higher reimbursement is necessary to ensure access; that argument, should it be made, is easily addressed by noting physicians are willing to accept much lower reimbursement for the identical procedure for most of their patients; there’s no access problem for group health patients despite the lower reimbursement.

In contrast, reimbursement for office visits should be higher for workers’ comp, for the reasons noted above.  If not for the office visit code itself, than perhaps states should institute a different code for disability management (some payers already do this).

What does this mean for you?

From here, this looks like another example of under-valuing primary care and patient – physician interaction, while over-valuing procedures; doing stuff TO patients.  

3 thoughts on “Should workers’ comp pay more for medical care than group health?”

  1. Joe,

    My last post talked about the first WCRI report, and I agree with you regarding the fact that a knee surgery is a knee surgery (I used shoulder surgery, as that is what used as an example).

    And even though the second report, which I did not comment on in my blog, showed lower payments with fee schedules, I would still argue that if medical tourism was allowed to be implemented, there would be considerably more savings realized in such destinations, beyond what the fee schedules allow.

    Only stubbornness, xenophobia, maybe even arrogance, is preventing the workers’ compensation industry from implementation of medical tourism. To be sure there are legal and regulatory barriers, as I have written about, but with the will to try this alternative, from insurance companies and employers, regulators and legislators will have to yield and allow it. It is already happening on one level or another in border states like CA and Florida, and WA and OR allow it in their statutes, so it should become more available throughout the other forty-six states.

  2. Joe, I agree with the last paragraph of your entry. The fact is that a medical procedure is a medical procedure irrespective of who pays the bill! The difference between work comp and group medical is the “social insurance” aspect of the comp system, i.e., whether the consequence of the work-related injury, and subsequent medical treatment, impacts or will impact on the patient’s ability to return-to-work. That distinction has never warranted the additional reimbursement that the provider community has been able to extract from the “jurisdictions”. A medical evaluation, required by the “jurisdictions”, has a separate reimbursement value not related to the medical treatment or surgical procedure rendered. To this observer, the provider community has been far more skillful and effective in making the argument for additional reimbursement and the work comp payers have simply been out-lobbyed!

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Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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