AHCA, CBO, and Workers’ Comp

There’s lots of news out there about the Congressional Budget Office’s scoring of the Republican healthcare reform bill known as AHCA; we’ll narrowly focus on what passage of AHCA would mean for workers’ comp – and highlight what’s missing from every other analysis of the CBO report.

Briefly, I’d expect case-shifting and claims-shifting to workers comp to increase significantly, resulting in higher work comp expenses for employers, and more business for the work comp service industry.

Here’s why.

The expansion of Medicaid and the individual mandate covered about 13 million more workers than pre-ACA; 81% of Medicaid recipients’ families have at least one member working. When workers who have health insurance get hurt, they are less motivated to claim it was on the job. And, if they are hurt on the job, work comp doesn’t have to pay for non-occupational medical conditions (e.g. dealing with hypertension before doing surgery).

The newly insureds are also working in jobs with higher claim frequency than average.

Some argue that the high deductibles and copays common in some insurance plans negates my argument; I respectfully disagree.  That’s because the newly insureds are poorer than average, thus they are much more likely to either:

  • get premium support payments from ACA which also cover deductibles and copays or
  • be covered by Medicaid, which has no cost-sharing (except in Indiana).

Since ACA was fully implemented in 2014 we’ve seen historically-low work comp medical trend rates, a strong indication that ACA is a major factor in lower work comp costs.

The CBO has projected:

  • 14 million will lose health insurance next year
  • 7 million more by 2020
  • another 5 million will lose coverage by 2026
  • most of those losing coverage would be older
  • deductibles and copays would be higher than under ACA

(credit Washington Post)

All of these projections are bad for work comp; older workers’ injuries are more expensive, and the higher deductibles and copays, along with a big drop in Medicaid coverage, would financially motivate workers to “claim shift.”

(credit Washington Post)

So, those losing health insurance would be:

  • much older
  • more likely to be employed in higher-risk jobs
  • more likely to be currently covered by Medicaid

What’s missing

…from all of the press reports and analyses of the CBO report is a discussion of how providers would react to passage of AHCA. That’s in part because the CBO report (full copy here) doesn’t address the issue.

Insurance coverage is just part of the story; doctors, hospitals, pharma and other providers are going to be hugely affected by a big decrease in their customer base.

More on that tomorrow.

What does this mean for you?

For work comp payers, higher claims and higher medical bills.



Are you the frog in the pot?

At some point the frog figures out the water is getting too hot – but by then the heat has sapped so much of its strength that it can’t escape. It’s morbidly funny – except if you’re the frog.

Our economy is changing so rapidly, many businesses, “thought leaders”, regulators, legislators, and other actors are going to be shocked when they find their long-held beliefs – and the businesses based on them – are no longer valid.

More succinctly, ignorance kills, and there’s a LOT of ignorance out there.

How much of your business relies on blue-collar employment? If you are a work comp insurer, case management company, adjusting firm, or loss prevention entity, likely a lot.

If you are a worker in that business, times are changing rapidly indeed.

If you had a job laying communications cables, wireless technology killed it. If you bolted pipes together in an oilfield, a machine can do it faster better cheaper – and with no injury risk. If you inspected pipes to look for possible weak spots, a robot can do that way more effectively and efficiently than you can. If you analyzed data in the field to figure out precisely where to drill to find possible natural gas reserves, a computer is about to replace you.

Oil rigs are increasingly automated. Even if we continue on this disastrous push to increase use of carbon-based energy, it isn’t going to do much to help blue-collar workers. Rigs that used to need 20 workers now do just fine with 5. One Texas oil producer added over 200 new wells – without hiring a single additional worker.

Coal production is falling because natural gas is much cheaper and easier to use – but coal mining jobs are disappearing largely because of automation.  Studies indicate 40% – 80% of mining jobs are at risk due to automation.

I’ve posted before about the coming demise of the long-haul trucker, one of the few blue-collar jobs that still provides something close to middle-class pay and benefits.

And don’t think those workers are going to jump industries and become construction workers.  Even if Congress and the President are able to pass a huge infrastructure bill, there will be fewer jobs than you might expect.  Even construction is being automated…

Think these guys and gals are likely to get hurt?

What does this mean for you?

How far out is your business forecast, exit plan, or “equity event”?



One last post on last week’s excellent WCRI conference; Alex Swedlow CEO of CWCI provided a brief but information-rich profile of California – an Altered State.

The good news…

  • Medical trend has flattened
  • Fewer spine surgeries
  • Fewer Opioid scripts
  • $1.3 billion in system wide savings

One problem that seems almost specific to California – cumulative trauma claims. These claims are particularly problematic in the LA county area – and are outliers in terms of disability duration, cost, indemnity payments.  Moreover, cumulative injury cost are driven by LA county AND attorney involvement.

Medical treatment costs have been essentially flat for five years – due in large part to adoption of an RBRVS-based fee schedule.

The FBI’s involvement in tracking down miscreants in the spinal surgery industry may have been helpful in reducing overutilization of that much-criticized procedure.

Opioid spend has declined for the 5th consecutive year – kudos to the work comp PBM and payers who’ve done this. There’s also been a 26% decrease in cumulative MED over the first two years of the average claim.

This is very good news.

But, as Alex noted, we’ve only moved from the disastrous to the miserable, as opioid use is still far too high.

Overall, while a reduction of 8 percent in medical trend is welcome news, this happened before in the previous attempt to reform California work comp.  After an initial similar reduction, costs zoomed up, necessitating more reform.  So, while Alex is hopeful that trends are positive, he is wary indeed.

A few more key data points

Loss Adjustment Expense is just about equal to indemnity payments and is the highest across almost any comparison group.  And, this expense load has increased dramatically over the last couple of years. Medical cost containment expenses are a big part of this; the data presented was preliminary and thus can’t be cited yet but suffice it to say that costs account for a huge portion of overall medical expense.


Rx spend accounts for 12.4% of medical spend but average expense for first 24 months after a claim is incurred is just under $2000 – this has decreased over the last few years.

A formulary is in the offing and it looks like the go-live date of July 1 2017 will happen. While the intent is to improve care and reduce cost, there will have to be strict enforcement for the hoped-for results to actually become real. One of the key issues unresolved is the formulary doesn’t address the difference in the price per pill of identical drugs – the variation can be wide indeed. This is an area that regulators have been focused on, yet none of the current solutions – change in fee schedule or adoption of a formulary – has addressed.

IMR and UR

Only 4.3 percent of medical care sought by treating providers was modified or denied, refuting claims made by other media outlets that there was wholesale rejection and denial of needed care thru the IMR process. Fortunately 99.4% of compound drug rejections were upheld – and over 90% of opioid denials.

What does this mean for you?

Things are getting better in California, but some of the “solutions” offered by regulators are misguided and will actually increase frictional costs. I’m going to dive into this in a post next week.


ACA Deathwatch: Republicans should hope AHCA doesn’t pass

I’ll stipulate to this – ACA needs major fixing. See below, and multiple past posts, for my take on what’s needed.  Unfortunately that doesn’t look likely.  The internecine warfare among Republicans over the American Health Care Act was inevitable, and will not be easily resolved.

That’s because there’s no consensus among Congressional Republicans on what healthcare reform should look like, who should pay for it, or what the priorities should be – access, coverage, cost control, less government intrusion, lower taxes, budget deficits are all in play, and many conflict. There’s also palpable and well-justified fear of the conservative infrastructure, a force including media outlets, think tanks, consultants, donors, and fringe groups that is extremely vocal, very powerful, and critical to the political future of individual Republicans.

Outside the reliably Republican world there is even more danger lurking.

What’s not being reported is this – If AHCA passes, the Republicans are in deep trouble.  10 – 15 million Americans will lose coverage (and loss aversion is powerful indeed).  Insurers will drop out of many markets overnight.  Hospitals, especially in rural America, will get crushed due to lower reimbursement and higher bad debt. Trump voters who believed him when he said he’s lower costs and improve insurance are going to be disappointed indeed. Deficits will go up.

Thus Republicans are in a can’t win situation; they have to deliver on impossible campaign promises, and if they do, voters will blame them for loss of coverage, higher prices, and anything and everything related to healthcare.

While Republicans battle amongst themselves, the medical provider community – AMA, AHA, American Nurses Association – just about every national interest group has come out firmly against AHCA. Insurance companies are warily walking the fence, not willing to provoke a tweetstorm but concerned indeed that AHCA will pass and their risk pools will crater. Seniors are up in arms, outraged that they’d have to pay more (!) for insurance if younger people don’t subsidize their needs.

There is a possible compromise bill, Cassidy Collins does offer some hope as it would likely garner support from both sides of the aisle if it gets any attention – and a lot of modification along the way.  But that is a very big “if”.

While all have different and specific issues, the net is this: AHCA will not lower the cost of care, and will increase the number of Americans without health insurance by at least 10 to 15 million people at the outset.

If AHCA passes, that number will inevitably increase as insurers’ risk pools experience worsens when fewer young people enroll, driving up costs for older folks. The death spiral in the individual markets will accelerate until…something happens.

There’s no question ACA needs fixing.

  • An excellent start would be to re-fund the risk corridor program killed by Sen Rubio in 2015 when he was able to force thru defunding of risk adjustment in the budget agreement.
  • Adding a public option to markets with limited choice would provide an insurance backstop, much like residual markets in workers’ comp.
  • Increasing the penalties for failing to carry insurance is another wise step.
  • Replacing deductibles with co-insurance requirements would help ensure people could afford the care they need while making sure the high-utilizers think long and hard about their medical care.
  • Requiring all to take greater responsibility for personal behaviors that increase health risks should be front and center. Obesity, substance abuse, medication adherence and failure to utilize preventive medicine should all be addressed

The intractable problem is cost. AHCA focuses on insurance markets, subsidies, eligibility, and credits.  It does nothing to address what drives cost – the massive waste due to unnecessary care and inflated prices for drugs, services, devices.

What does this mean for you?

AHCA won’t pass, a fate Republicans should be forever grateful for.



WCRI – What’s happening with medical?

Hospitals are losing work comp share. You would think that’s good news as non-hospital care is much cheaper.  But that may well be wrong. 

The hospital info was the headline from Carol Telles’ kickoff presentation Friday morning at WCRI’s Annual Conference. Workers’ comp patients are using less inpatient hospital care AND care is moving from hospital facilities to ambulatory surgery centers.

This isn’t specific to work comp.  Care has been moving from inpatient to outpatient to non-hospital facilities for decades.  Way back in the eighties – when I started my career in what was then known as “cost containment” – the big effort was to reduce hospital length of stay and admission rates. Over the last thirty (gulp!) years we’ve seen massive shifts in the location of care, as procedures that once HAD to be done on an inpatient basis – think back surgery – moved to outpatient facilities.

The result – outpatient/ambulatory facility use for all payers grew dramatically over the last 30 years, while inpatient admissions actually decreased over that period. This despite the aging and fattening of America.

For work comp patients, this trend persisted across all states – but this did NOT result in lower cost. In fact while the decrease in inpatient admissions was in the low single digits, costs per admit increased on average 24%. This makes sense. As providers and payers have moved patients to outpatient locations, only the sickest and most risky patients have required inpatient treatment. Unlike ambulatory surgery centers, hospitals have a broad array of emergency and life support resources needed.

Not surprisingly, hospitals are pretty unhappy about this. They are losing healthy, easy, well-insured patients to doctor-owned facilities, but get to keep treating the risky, low-health-status Medicaid and uninsured patients. Over the years, hospitals’ patient population has gotten more expensive to care for and less likely to have good outcomes.

What this means for workers’ comp

To fight back, hospitals are getting much better at revenue maximization.

In English, that means they get as much revenue from vulnerable payers as possible to offset lower reimbursement for unprofitable patients. And you, work comp payer, are about as vulnerable as it gets.

While fee schedules in some states (Maryland for example) generally protect work comp payers, most states’ fee schedules ensure work comp is very lucrative indeed for hospitals.

And no, your PPO isn’t helping.

Work comp PPO discounts may look ok, but the actual cost of treatment has been ballooning in many states. Payers THINK they are doing fine when they see the “savings” below fee schedule, but many aren’t focused on the real problem – how much they are paying.

What can you do about this?

Direct care to providers that deliver the best value, defined as cost divided by quality.




ACA Deathwatch – (some) Republicans reveal their bill

Good morning all – it’s going to be a busy day in health reform land – so here’s the latest.

Republicans have released their long-secret healthcare plans; don’t get all excited as it’s going nowhere, mostly because Congressional Republicans aren’t all behind it.

This legislation will have to pass the House and Senate.  It will not pass the Senate as is, because four Republican Senators have publicly stated they will not vote for the bill due to concerns over Medicaid coverage.  Three other Republican Senators have expressed concern with the cost of the bill, and appear reluctant to vote in favor.

For the bill to pass, at least 7 Democrats would have to get behind it- which is highly unlikely.

Republicans will not ask CBO to score the bill – thus we don’t know what the impact on federal deficits would be.  There’s also no estimate of how many would gain or lose insurance.

And, Freedom Caucus members in the House are denigrating the bill as “Obamacare Lite”, demanding a “clean repeal” instead of a replacement.

So, this is mostly an academic exercise, but does provide a starting point for the GOP.  Here are the key points from the bills, with my quick take appended:

  • Eliminates subsidies, replacing them with age-based tax credits ranging from $2000 to $4000
    MCM – this does little to help lower-income Americans; the current subsidies haven’t been enough to drive participation, so these lower amounts won’t do much.  Also, these aren’t income-based, so it amounts to a giveaway to wealthier Americans who don’t need the subsidy. UPDATElate change to the bill adds income levels that would change credits.
  • Eliminates premium-support and deductible/copay funding 
    MCM – these subsidies help poorer Americans pay for deductibles; eliminating them is a major concern of insurers, and several insurers have said they will immediately move to end coverage without the subsidies
  • Roll back Medicaid expansion, capping payments to states
    MCM – Anathema to many GOP Governors and several Senators from expansion states.
  • Delays the Cadillac Tax
    MCM – this would reduce tax receipts, leading to higher deficits
  • Ends most of tax provisions of ACA, reducing taxes to wealthiest Americans
    MCM – this will result in higher federal deficits, a key issue with at least three R Senators
  • Eliminates the individual mandate requirement and tax penalties for failure to maintain coverage
    MCM – this would likely reduce the number of young members who subsidize older and sicker people, leading to higher costs for older members.
  • Requires people to maintain coverage or be subject to a 30 percent penalty.
    MCM – Many would likely face this penalty as 24%+ of people 26-64 have a pre-existing condition, and those who lose employer-based coverage would have a tough time paying the entire premium themselves without a job
  • Ends all federal funds to Planned Parenthood
    This troubles some Republicans as PP provides a lot of healthcare to lower-income women.

The legislation is exposing splits among and between Republicans on ACA and health reform.  Republicans opposed ACA, but for diverse reasons; costs too high, mandate, tax provisions, Planned Parenthood.

But there is no unity around a solution.  It’s easy to rally opposition to a complex issue; many Democrats have been pointing out problems with ACA for years. It’s far harder to come up with a new solution because everyone has different priorities and ideologies.

What does this mean for you?

The ACA Deathwatch clock moved forward a bit – but not much…


Several states have seen precipitous decreases in the amount of opioids dispensed per claim.  KY, NY, MD, and MI all saw reductions in excess of 35%.

In every one of the states WCRI studed, at least 30% of patients with opioid scripts also had a script for a central nervous system depressant.  That’s just remarkable; the risk of adverse consequences goes up dramatically when patients take both drugs.  The good news is the percentage of workers who were prescribed this combination declined in most states – but the average decrease was a few percent.  While there can and may well be good reasons for docs to prescribe these drugs for individual patients, the research indicates there are significant risks.

Some have said medical marijuana should be considered an alternative to opioids.  If that’s a valid claim, that’s wonderful news indeed – and not just for growers, marketers, and pizza purveyors.

Dean Hashimoto MD reviewed the National Academies of Science’ report on all literature and evidence concerning the medical use of marijuana. Summary is here.

There’s conclusive support for cannabis’ ability to reduce chronic pain in adults, BUT at great risk of motor vehicle accidents and the development of schizophrenia and other psychoses.  This is a big deal, as most patients using medical marijuana cite chronic pain as the reason for consumption. There’s a lot of evidence that medical marijuana is effective – evidence derived from well-controlled clinical trials.  But little is known about efficacy, dosage, frequency, administration routes, or side effects.

There was moderate support for better sleep outcomes but at the price of impairment of learning and memory and increased dependence on other substances eg tobacco and alcohol.

Interestingly, there isn’t enough data or research to associate non-medical cannabis use with occ injuries or accidents.

There’s more good news.

Two solid studies documented significant decreases in opioid overdose mortality rates and opioid addiction in states that allowed medical marijuana.

What does this mean for comp?

Well, 22 million Americans used cannabis in the last month. So it’s real, and it’s common. There’s no legal way to use the banking system to pay for medical marijuana, and there’s no guidance on dosage or other prescribing standards.

And there’s conflict between state regulations, case law, and federal law.

We live in interesting times indeed.



Calling out Coburn at WCRI

Some WCRI attendees thought my public criticism of former Republican Sen. Tom Coburn (OK) was inappropriate (many did not).

Here’s why I called him out.

First, in talking about disability, Coburn asserted that SSDI – Social Security Disability Income – participation has exploded due to Democratic policies and politics. He said 25 million Americans are now covered by SSDI.  That is flat-out wrong.

I questioned him publicly about his figure, asking where he got it.  He immediately backtracked, saying it may be 22 or 25 million.  I responded that, according to a quick google search, the actual number was less than 15 million.

Coburn had blamed the opposition party for a huge growth in SSDI that NEVER HAPPENED.  He either made up the number of SSDI beneficiaries, was misled, or lied.

The real number, according to expert Yonatan Benshalom of Mathematica, is 9.8 million. Yonatan’s source is here. [Thanks Yonatan]

Why this matters

If Coburn’s false claim was allowed to stand, many in the audience may have left WCRI believing it.  As policymakers, regulators, and thought leaders in workers comp, they would then have perpetuated the myth.  That would lead to wrong decisions, lousy policy, and “solutions” for problems that don’t exist. For example, lawmakers may have sought legislation requiring an MSA-type allocation to indemnify SSDI for occupational disability from work comp insurers.

A more complex issue involves Coburn’s false assertion that the ACA was rammed thru “without any Republican input.” I noted that:

  • The ACA’s core design came from the conservative Heritage Foundation
  • The Gang of Six – half Dems, half Reps, met multiple times while ACA was being written – the Republicans were Enzi, Snowe, and Grassley, all of whom dropped out of the Gang under pressure from Republican Minority Leader McConnell.
  • As a results of those meetings and other dialogue, multiple components of ACA were added or changed in an effort to garner Republican support including:
    • removal of any public option
    • addition of the Cadillac Tax
    • reduction of the penalty for uninsurance
    • removal of funding requirement for abortion services
    • allowance for “religious” health insurance

Responding to my statements, Coburn said since he “was there”, he knew more about this than I did.  He said was part of the Gang of Six – which he wasn’t.  He WAS involved in a previous version of the “Gang” that dealt with tax reform –– but he was not involved in the Gang’s healthcare discussions. [I was peripherally involved via discussions with Congressional staffers and a meeting with Sen Ron Wyden (D OR) about reform]

There are many sources that refute Coburn’s false statements; here’s one.

For those interested in the real story, an excerpt:

[Senate Finance Committee] Chairman Max Baucus (D MT), in the spring of 2009, signaled his desire to find a bipartisan compromise, working especially closely with Grassley, his dear friend and Republican counterpart, who had been deeply involved in crafting the Republican alternative to Clintoncare. Baucus and Grassley convened an informal group of three Democrats and three Republicans on the committee, which became known as the “Gang of Six.” They covered the parties’ ideological bases; the other GOPers were conservative Mike Enzi of Wyoming and moderate Olympia Snowe of Maine, and the Democrats were liberal Jeff Bingaman of New Mexico and moderate Kent Conrad of North Dakota.

Baucus very deliberately started the talks with a template that was the core of the 1993-4 Republican [health reform] plan, built around an individual mandate and exchanges with private insurers—much to the chagrin of many Democrats and liberals who wanted, if not a single-payer system, at least one with a public insurance option. Through the summer, the Gang of Six engaged in detailed discussions and negotiations to turn a template into a plan. But as the summer wore along, it became clear that something had changed; both Grassley and Enzi began to signal that participation in the talks—and their demands for changes in the evolving plan—would not translate into a bipartisan agreement.What became clear before September, when the talks fell apart, is that Senate Republican Leader Mitch McConnell had warned both Grassley and Enzi that their futures in the Senate would be much dimmer if they moved toward a deal with the Democrats that would produce legislation to be signed by Barack Obama. They both listened to their leader. An early embrace by both of the framework turned to shrill anti-reform rhetoric by Grassley—talking, for example, about death panels that would kill grandma—and statements by Enzi that he was not going to sign on to a deal.

The false narrative that Democrats rammed thru ACA without any Republican involvement has become accepted fact by many who haven’t read anything but headlines. Coburn’s false statements perpetuated that nonsense, and he deserved to be called out publicly for them.

There’s a bigger problem here – ideological blinders worn by some make it seemingly impossible for those individuals to accept facts. Fact-free discussions, or, even worse, decisions based on beliefs that are the opposite of reality lead to bad public policy.

What does this mean for you?

The people who attend WCRI are enormously influential in our little industry.   They will determine the future of workers’ comp, how employees are treated and who will pay for that treatment.

They deserve to hear the truth.

PS – to the several anonymous commenters – as I’ve stated here numerous times, I don’t publish anonymous comments from cowards afraid to identify themselves.


WCRI – Does the “Grand Bargain” exist? Should it continue to?

WCRI CEO John Ruser PhD led the final panel discussing the status and future of workers’ comp as the Grand Bargain between employees and employers.

Bruce Wood and Emily Spieler PhD sparred over who pays for workers’ comp and tort issues in workers’ comp, specifically negligence and the burden of proof.  Spieler suggested we need to consider costs, how those costs are distributed, and who pays those costs.

David Deitz MD PhD jumped into causation, noting this was a “particularly thorny issue in the 21st century.”  Home-based employment, diseases of life, and other factors make it very difficult indeed to establish who is “responsible” for 50% of the cause of an injury.  The issue – people need care, and we should be talking about how to get them the best care and not argue about who pays.

Editorial note – That, dear reader, is a critically underappreciated point.  We are fighting over who pays, and we should be focusing on optimal care.

David Michaels PhD discussed the challenges of occupational disease – attribution/causation, long-term loss of wages and compensation therefore, cost shifting to SSDI, and harm caused to undocumented workers. Bruce Wood asserted that the undocumented worker issue was not work comp related, but rather a failure to enforce immigration laws.

Spieler asserted that she doesn’t think WC was ever set up to pay for long-term wage loss, or permanent and total (PTD) disability.  She noted research indicated 20% – 40% of workers who suffered amputations didn’t file work comp claims – even if it was clear it the injury was work related.

Ruser asked Deitz about the level and quality of medical care given to work com patients. Uniformly, it isn’t as good as that delivered under group health. But, he argued that work comp is diverging away from where group health is headed, towards value-based care.  That divergence is highly problematic.  FFS – the ONLY reimbursement system existing in workers comp – rewards doing more to get paid more regardless of quality. That’s inherently in conflict with a drive towards quality which is happening in the real world outside work comp.

Deitz would roll work comp medical into group health if he was convinced anyone injured in the workplace could access care.  As not all employees have coverage, that world does not yet exist.

Michaels argued that we’ve really dropped the ball on injury prevention, especially when compared to Germany where there remains a strong focus on prevention.  I hear that, but given the steady decrease in claim frequency over the past three decades, I’m not sure there’s an economic argument to be made around that level of prevention. Tied to Michaels’ argument is an OSHA prevention program that links safety to profits and financial results.

In contrast Wood opined that most employers invest in safety and loss prevention, leading to a to-and-fro between Wood and Michaels on involving public health officials to intervene with employers who don’t adequately address loss prevention.

My takeaway – a bit too much in the weeds, and not enough discussion of where work comp is going given the dramatic changes occurring in our workforce today and tomorrow. I’d have liked to see a bit more on historical perspective; work comp laws and systems were set up 100 years ago when most work was heavy manual labor leading to trauma.  Today, it’s diseases of life, of aging, of comorbidities and cumulative trauma, which are inadequately addressed at best.

Thanks to IAIABC’s Jennifer Wolf-Horejsh for asking about the 50+ million workers who are in non-traditional employment arrangements (my words not her’s).  Spieler asked if we need a national non-employment linked disability program to help address this issue going forward.

Kudos to Spieler for noting that wage replacement adequacy is a major problem; Indiana just raised their very-low indemnity payment basis and few in the audience supported that increase in a show of hands.

Jim Hudak of Paradigm addressed this in a very good question summarizing how employment has changed drastically from days of pensions, good health benefits, and life-long careers with the same employer.  Work comp has NOT adapted, as the social safety net has deteriorated. and employment-based benefit system has all but disappeared