This is a pretty esoteric workers comp post, so if you aren’t so inclined, click on something else now before your eyes glaze over and it’s too late.
In workers comp, employers have the ability to make claimants go to specific physicians or lists of physicians in some states and don’t in other states. The former are “employer direction” states, the latter are “employee choice” states.
Except that’s not really true.
Example. In Florida, an employer direction state, if an injured worker is directed to go to a network provider and does not, the insurer does not have to pay the bill. Pretty strong stuff. Despite that strong stuff, there are many examples of claimants seeking care outside the network, and very few of them got stuck with the bill. Why? The insurer didn’t want to get wrapped up in a legal battle.
In Illinois, injured workers can go to any provider they want. Employers can suggest they go to specific docs, but can’t “force” them to.
So in reality, what’s the difference between employer direction and employee choice states?
Perception and attitude.
Most of the difference lies in the attitudes and business practices of adjusters, case managers, and employers. Because in reality, you can “direct” in Illinois just like you are in Florida. Practically speaking, the two states are the same.
Which begs the question – why aren’t workers comp payers doing a better job of getting injured workers into networks? Most payers see penetration rates in the 60% range, which when you really think about it, is not very good.
What does this mean for you?
Food for thought. And for you WC professionals, stop thinking about how hard it is, and start thinking about how to do it.
Is there any good data out there comparing WC-based PBM penetration rates in employee vs. employer choice states?
Also, in employer-choice states, does an adverse selection perception help control utilization? (i.e. pharmacies assume that non-PBM affiliated workers must be disputed claims and therefore refuse to fill scripts)?