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Obamacare and workers’ comp – part 3 of 9

There are (at least) two additional implications of more people and more workers covered by health insurance; cost-shifting, and access to care.  Each is deserving of careful and thorough consideration; for now we’ll touch on the highlights and leave a deeper discussion for another time.

First, the scope.  21 percent of working-age Americans don’t have health insurance.  This varies widely by state, from 31% in Texas to 6 percent in Massachusetts, with several in the high twenties.  That’s more than 40 million people between 18-64.

Access to care

Stands to reason that adding 30 million to the rolls of the insured is going to lead to a lot of demand for primary and specialty care; many of the newly-insured will have foregone routine care – primary and specialty – for years.  They will need check-ups, tests, drugs, evaluation and counseling.  Some will need major procedures; knee replacements, shoulder surgery, stents and cancer treatment.

A lot – best guess is somewhere over half – of primary care in workers comp is delivered by family practice/internal medicine/generalist physicians and physician extenders.  Many injured workers go to their ‘regular’ physician when they get hurt, and we can expect this to continue.  As there is already a relationship in place, those claimants who’ve had coverage are likely going to see some delays in getting into their doc for anything other than emergent care.  The primary care access problem will arise from the newly-insured; these folks likely don’t have existing physician relationships, and will find it tough to get into see a family practice doc post 1/1/2014.  As a result, they’ll head to the local ER, further burdening hospitals short on capacity. Of course, their care will get reimbursed at a pretty nice rate, and smarter health systems will divert WC patients to their in-house occ med departments.

Alas, there are not a lot of “smarter health systems” when it comes to occ med…and payers will face the usual set of problems/challenges encountered when dealing with providers who don’t know much about workers’ comp.

Specialty care is where the big problems are going to be.

Orthopedic surgeons get paid to do orthopedic surgery, and there are going to be millions of newly insured patients with conditions that may justify/require surgery.  Stands to reason that specialty care – particularly for musculo-skeletal conditions – is going to be in high demand.  The “good news” here for workers comp payers is Medicare, and many private insurers, are doing their darndest to reduce utilization and reimbursement for specialty care.  And, as WCRI so ably reported just last month, workers’ comp pays a lot more for specialty care than most, if not all other payers.  While just paying more won’t guarantee priority access, it will certainly help.

So, what’s an insurer/employer to do?

1.  Stop buying care based on a discount below fee schedule; identify good providers and pay them fairly – above the fee schedule if necessary (or in Massachusetts, all the time).

2. Be easy to work with.  Stop bothering the good docs with pointless UR requests; have your case managers help schedule PT and MRIs instead of badgering the doc and her staff.

3.  Pay quickly.

Do this all now.  It’s almost too late, but if you haven’t started reaching out to key docs yet, better late than never.  Let them know you value them, and want to work with them, and make sure your billing and claims departments support that intent with action.

Or, just sit around waiting to see what happens, and then, when your claimants can’t get an ortho consult for six weeks, blame Obamacare.  

I’ll have to deal with cost-shifting tomorrow – too much work to do today.

4 thoughts on “Obamacare and workers’ comp – part 3 of 9”

  1. Excellent comments Joe. I think the insurers/TPAs need to do a better job of educating their employer clients that such options are available to them, i.e., to participate in Preferred Provider Panels in states where direction is an option!

  2. Joe is exactly right regarding specialty care. When I first came to the Washington State fund, many of the othopedic and neurosurgeons were refusing to take workers’ comp cases. Many of them said it was not because of the reimbursment level but the hassles. Working with Dr. Gary Franklin, we were able to get them to come back into the system by dramatically reducing the bureaucracy, speeding payments and when we could not eliminate the extra work that comes with a workers’ comp case, we paid them to do the extra work. It worked like a charm and injured workers got better and faster care.

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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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