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Obamacare and workers’ comp – Part 6 of 9; quality of care

Quality of care – will it increase or decrease as a result of Obamacare?

That is a major concerns among those work comp professionals tuned in to health reform, as well it should be.

For quality of care, it depends on what care you’re talking about, and how it is measured.  Compensation for primary care activities – spending time with patients discussing their condition, health status, medical options and the like is going to be compensated more richly – in some states, MUCH more richly (e.g. California). The thinking behind this is it is far better to have an educated patient aware of their treatment and prevention options, potential issues, and thereby engaged in their treatment than a clueless patient treated as a lab specimen. And educated patients may well view their care as “better” as they understand what’s happening and why; they also have better outcomes in general.

Moreover, with more covered, the health status of the population will improve (research indicates insured people are healthier than those without insurance).  If they get injured, they will recover faster with fewer complications, reducing indemnity expense as well as medical costs associated with more and longer treatment.

Quality of care for specialty services is more ambiguous.  With a reduction in Medicare (and in some states Medicaid) reimbursement for surgeries, imaging, and other procedures, providers may seek to deliver more services to work comp patients to make up for lost income.  Thus we may see more surgeries and related hospital/facility care, more scans, more tests and injections and implants and pumps.  This will lead to more expense for comp payers, and will likely be a reduction in the quality of care: delivering services that are not needed, even if they are performed at a high standard, reduces the overall quality of care.

Perhaps the most significant , and least recognized, contribution to quality of care under Obamacare is the requirement that insurers cover everyone with standardized benefit plans.

The impact of this cannot be overstated; it changes the competitive dynamic from selling insurance to healthy people who won’t have claims to managing the health risks and outcomes of everyone insured.  Insurers will have little ability to pick and choose who they cover, and their success will be based on delivering the best outcomes to their entire population.  This will force them to:

  • partner with providers on health improvement initiatives (ACOs)
  • research and implement – quickly – quality improvement initiatives
  • identify and change behaviors of unhealthy insureds

If they don’t, they are out of business.

I’ve run out of time, and likely so have you.  We’ll look into the outcomes research funded by Obamacare next…

What does this mean for you?

This is a complex and multi-faceted issue, one successful comp payers will have to monitor carefully if they are to avoid very unpleasant surprises.  

3 thoughts on “Obamacare and workers’ comp – Part 6 of 9; quality of care”

  1. Don’t you think that utilization review and treatment guidelines will keep the over prescribing of surgery, injections, etc somewhat in check in WC?

  2. Joe, thanks for the link to the above article. People with insurance may be healthier than those without. But it is difficult to make comparisons between these two large groups because they may be inherently heterogenous (income, education and baseline health may be very disparate). In a revealing article in the New England Journal of Medicine (May 2, 2013: The Oregon Experiment–Effects of Medicaid on Clinical Outcomes), people without insurance were randomized to two groups: one group received Medicaid, the other did not. After two years “there were no significant improvements in measured physical health outcomes” (They primarily looked at blood pressure, cholesterol and a measure of long term blood glucose). The researchers did find that the insured used more HC services, had increased rates of diabetes detection and management (but, see above, their glucose control did not improve, as a whole), had lower rates of depression and reduced financial strain. These latter things are good but they do not lead me to be optimistic that providing insurance to a new large cohort will make that population healthier (and, consequently, decrease WC costs).

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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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