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Friday fast facts, catch-up, and debunking

Today we begin with a plea for…research.

Can someone please provide evidence – that’s solid, well-documented, and not just opinion based on…common knowledge that employees file lots of claims under work comp that SHOULD be considered non-occ?

Or that Obamacare will lead to MORE claim-shifting to work comp?

because that’s what two recent analyses of Obamacare’s impact on P&C/work comp say.  One, from Marsh, says “Employers have long been concerned that injuries from non-work-related causes will be shifted to workers’ compensation.”  Why? Is there any basis for this “concern”? Any research? Science? Data?  Not disagreeing with Marsh’s conclusions, rather challenging what passes for “accepted wisdom” in our industry.

Another “analysis” of Obamacare and P&C, by the Insurance Research Council, reads “In some cases, the [workers’ comp] claim may be legitimate, but would have been previously filed as a health-insurance claim…While increased cost-sharing may decrease health insurer outlays, it also may encourage individuals with health insurance to assert coverage for injuries under property-casualty insurance where the opportunity is present to do so.”

Again, since when is idle speculation “research”? And the assertion that there is “increased cost-sharing” is just ludicrous. In fact, there is LESS cost-sharing in many plans due to lower deductibles and co-pays under PPACA plans than employees’ previous health insurance coverage. Research indicates that if the annual out-of-pocket caps had been in place in 2011, the 15 million people who exceeded the cap would have saved $25 billion.

Truth be told, I too “knew” employees abused work comp, until it turned out the research indicated it wasn’t.

Then again, I’m not a “research council”…I am, however, a big believer in credible research and analytics and science.

Narrow networks

A guest post on Monday will dig in to this deeply, so here’s the teaser.  A Kaiser Health Tracking poll just released finds “those who are most likely to be customers in the Affordable Care Act (ACA)’s new insurance exchanges (the uninsured and those who purchase their own coverage) are more likely [54% to 34%] to prefer less costly plans with narrow networks over more expensive plans with broader networks.” (emphasis added).

Not surprising; those who have to pay the entire cost are more price-sensitive than those whose employers’ subsidize their premiums.

Hospital inpatient volume is declining

And has been for five years, due to fewer elective admissions, tighter controls by health plans, more use of outpatient rather than inpatient facilities, and the structural shift towards “fee-for-value away from fee-for-service” due to more emphasis on prevention and practice care.

Sounds good right? Sure, unless you are a P&C payer – as patient census counts from governmental and private insurers declines, those smart hospital execs are going to look for ways to make up that shortfall.

Federal deficit

Then again, it’s not bad news for we taxpayers, as the decline has reduced Medicare spend below projections, which has helped give us the smallest deficit since 2008.

Always good to end on a high note!




5 thoughts on “Friday fast facts, catch-up, and debunking”

  1. Research (a lot of it) says that a very large share of work injuries do not result in WC claims. As a consequence lots of scenarios exist wherein various forces could cause WC claims to rise or fall due to an increase or decrease in claiming behavior and so it may be impossible to attribute a change in claiming to any one factor

  2. Good discussion Joe,

    We need to continue to discuss and differentiate the difference between “claim” shifting and “cost” shifting(I know they are connected). Just by experience and no empirical evidence the degree of cost shifting in the P&C industry seems to be state by state issue which legislation can temper hopefully

  3. Joe, Cost shifting is a product of silo thinking . Whether a person is injured during the work day or at home the solution is the same. They need medical care and modified duty. It is best to remember if we move the mess out of one pocket into another we still own it. When people feel safe in their Job and appreciated they are less likely to file questionable claims. Clear communication up front solves this.

  4. Joe: You ask for evidence that employees file lots of WC claims that should be considered non-occ. How about all the CTS claims filed? Reportedly there are 250,000 CTS surgeries done annually. I feel pretty safe in estimating at least 25,000 of those CTS surgeries each year are done under WC coverage.

    Here are some links to support the argument that the majority of these CTS claims are not work related:

    Your thoughts?

    1. Jeff – thanks for the note. Good point re CTS.

      I’d suggest the overwhelming evidence is that most “diagnosed” CTS is mis-diagnosed. Therefore, the problem is not so much that group health claims are being paid for under work comp, but rather the condition was mis-diagnosed in the first place.

      Secondarily, there appears to be a mis-understanding on the part of the treating docs, as noted in the Canadian study, of the causality of CTS (leaving aside the misdiagnosis). It is not clear from the abstract as to why the respondents believe CTS should be covered under workers comp. Given the different nature of the physician compensation structure in Canada, I don’t think it is attributable to compensation.

      Net is that many of these surgeries should not be done at all, thus the ones that are covered by WC are likely to be not medically necessary. I don’t see this as a claim-shift but rather as too much unnecessary surgery for the wrong reasons.

      That said, for some percentage of the total, there are dollars spent by WC that likely should not be.

Comments are closed.

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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