After a Thanksgiving hiatus, Health Wonk Review is back with your biweekly view of what the healthcare policy wonk’s have been blogging about. Brad Wright hosts Health Wonk Review: Holiday Shopping Guide at Wright on Health.
Workers Comp Networks – At Managed Care Matters, Joe Paduda has been front and center covering the matter of Aetna’s exit from workers comp and his post today, Aetna part 2. Also related, his post about Where work comp networks are headed.
UBB Report followup – In followup to yesterday’s post, here is a link to the MSHA Upper Big Branch Investigation Report – it’s a detailed account, including transcripts of interviews.
Bloodborne Pathogens – According to the CDC, about 385,000 sharps-related injuries occur annually among health care workers in hospitals, and the average risk of bloodborne infection following one of these injuries is approximately 1.8%. The NIOSH Science Blog posts about needlestick punctures and bloodborne pathogens, highlighting the film Puncture which is about the personal injury case of Vinessa Shaw, a nurse who contracts AIDS after an accidental stick. The post calls attention to the NIOSH injury prevention initiative, The Stop Sticks Campaign. which is aimed at clinical and nonclinical health care workers and health care administrators in hospitals, doctor’s offices, nursing homes, and home health care agencies.
Pole Dancing: – A Georgia Court recently ruled that Pole Dancers are not independent contractors. “The Judge found the club exercised control over the dancers because the amounts charged by the dancers for certain types of dances were set by the club. The club also established what amounts had to be paid by the dancers to the DJ and to other employees of the club each day at the conclusion of their shift. The club could also fine or fire the dancer for not coming to work or being late. The Judge also noted that every other FLSA case brought by exotic dancers from Alaska to Florida had concluded they were ’employees’, and not ‘independent contractors’.” Note: This is not the first pole dancing issue we’ve covered. My colleague posted about another claim with a pole dancing angle last May. This should lead to some interesting search results in our logs – not to mention some disappointed searchers.
Brain Trauma – the New York Times has a 3-part series on 28-year old professional hockey player Derek Boogard’s death due to repeated head trauma, chronic pain and a deadly drug addiction. Read part 1 A Boy learns to Brawl, Part 2 Blood on the Ice and Part 3 A Brain ‘Going Bad’. There is also a related video: An Enforcer’s Story. For a good resource on preventing, treating and living with traumatic brain injury, we point you to Brainline.org.
Related – In doing our rounds, we note that Dave DePaolo has an excellent post on Professional Sports and the Relevancy of Comp.
In the I-guess-it-doesn’t-go-without-saying department – Slightly off track here, but Bob Wilson has a rather unusual warning that we are passing along as a public service: Beware the Door to Door Breast Examiner.
News Briefs
Posts Tagged ‘networks’
Health Wonkery, Networks, TBI, Pole Dancers & other news of notes
Thursday, December 8th, 2011New Hampshire Fee Schedule: Climbing a Mountain in the Fog?
Wednesday, April 6th, 2011Nearly a year ago we blogged the issue of a medical fee schedule in Maine. The legislature mandated the creation of a fee schedule way back in 1991. Twenty years later, there have been a few reports, a few changes in the membership of the committee trying to establish the fee schedule and, to date, no fee schedule. We now wonder whether neighboring New Hampshire will follow Maine’s example, climbing a slippery mountain trail into a deep fog.
New Hampshire, like Maine, has a two tiered system: in the first tier are managed care networks, which negotiate fees with doctors and hospitals. Everyone in the second tier – those outside the networks, the self-insured, smaller carriers, etc. – are stuck with paying the “usual and customary fees.” Medical costs account for 71% of total costs – a truly staggering number when compared to the national average of 58%.
Dr. Gary Woods, an orthopedic surgeon and chair of the NH Workers Comp Advisory Council, thinks that the high percentage of medicals is the result of good medical care, combined with a strong return-to-work focus: in other words, indemnity is relatively low because workers are not out of work very long. Well, doc, show me the numbers. I expect that New Hampshire – ranked 14th highest among states for comp costs – is spending too much on indemnity and way too much on medical services. It’s no bargain for anyone.
The Fix is (Not Quite)) In
The New Hampshire legislature is contemplating SB 71, which would impose a fee schedule on medical services. The bill proposes that hospitals be reimbursed at a uniform conversion rate of up to 150% of Medicare rates. While somewhat on the high side for such linked payments, it would probably bring down the overall costs of medical services in the state.
SB 71 is going nowhere, at least for the moment. The bill will remain in committee while the lawmakers appoint a study group to review the proposal and make further recommendations.
Ultimately, the details of the fee schedule will be in the hands of the comp advisory council, of which Dr. Woods is the chair. Hmm. This brings to mind the stalemate in Maine, where Dr. Paul Dionne was for a long time chair of the committee responsible for implementing the fee schedule. The group just couldn’t come up with a number that would satisfy the doctors. (How would a doctor define a fair fee schedule? “Usual and customary.” ) Last June, facing allegations of a conflict of interest, Dr. Dionne finally stepped aside.
Perhaps the good folks in New Hampshire could speed up the fee schedule project by asking Dr. Woods to step aside. No doctor is going to embrace a cut in reimbursement rates. Dr. Woods would have a choice: he could sit on the sidelines and watch the committee hash out the details, or, with his health and well-being in mind, he could put on his hiking boots and climb one of the Presidentials. I recommend the latter, even if the peak is momentarily obscured by the fog.
Thanks to Work Comp Central for the heads up on this issue (subscription required).
Taking the cookie-cutter to workers’ comp medical networks – Why that doesn’t work
Thursday, August 28th, 2008Yesterday, at Managed Care Matters, our good friend Joe Paduda published an excellent “how-to primer” for starting a workers’ compensation medical network. Essentially, Joe’s advice for would-be network creators is:
- Bring the right physicians into the network – board-certified occupational health specialists, for example, as well as primary care and specialist physicians who understand workers’ compensation;
- Exclude physicians who don’t know anything about the subject;
- Pay the physicians a reasonable rate; and,
- Support the network physicians by sending them patients.
If the network is formed in that way it should be of gold standard caliber. But that’s easier said than done.
We’re all familiar with the super-large networks that include anyone with a medical degree – as long as “anyone” agrees to see network patients for a discounted fee, which the network can then tout as “savings” for employers regardless of the quality of care. Most of these networks and the doctors in them came from the group health arena where modified duty, transitional duty, early return to work, the buzzwords of workers’ compensation professionals, are foreign concepts. And why should that be surprising? After all, workers’ compensation is only one, tiny room in the American health care house that Jack built.
What workers’ compensation professionals sometimes forget is that most doctors, whether in or out of these networks, went to medical school because they wanted to devote their lives to healing the sick, not to becoming some company’s external medical personnel director. Many, perhaps most, physicians in networks that have physician directories the size of New York City’s phone book understand “injuries,” but not workers’ compensation, and that is not their fault. It is ours. We have not educated them sufficiently regarding workers’ compensation, nor have we cohesively partnered with them to help injured workers transition at the right pace back to full duty, which, in my 25-year Lynch Ryan experience, is where injured workers really want to be.
Consider this. Most doctors have small practices that turn them into small business owners. I’ve never met one who liked that, the business end of medicine. Most are not technologically facile, and workers’ compensation injuries comprise a minor share of their “business.” Their responsibility focuses totally on their patients and what’s wrong with them. They don’t see a real need to be overly interested in the workplace; in fact, they most often don’t even know what or where that is. On the assembly line that has become American health care, where insurers force physicians to cycle through patients in fifteen minute intervals, who has time to probe deeply about the workplace and what goes on there? When some claims adjuster or nurse case manager wants to pin them down about physical restrictions or a date when their patient can return to work, they err on the side of humongous caution in order, in their minds, to “do no harm.” This leaves workers’ compensation professionals and employers befuddled, scratching their heads and wondering what is wrong with the doctor. They think, “Why can’t the doctor see what’s really going on here?” They don’t understand the doctors and the doctors don’t understand them.
That’s the scenario in which workers’ compensation professionals very often find themselves. At Lynch Ryan, the only way we have ever found to deal with it successfully is one doctor at a time, sitting face to face and finding common ground. Occupational health specialist or not, an educated physician is a powerful weapon for good in the little world of workers’ compensation.
In my next post I’ll describe the step-by-step process my colleagues and I went through to build the first workers’ compensation medical network in Massachusetts once upon a time. Here’s a teaser: It was a thing of beauty, profoundly successful for everyone involved, and would not be legal today.
Health Wonk Review, NCCI, networks, Missouri, and more
Thursday, May 15th, 2008Jason Shafrin of Healthcare Economist hosts this week’s edition of Health Wonk Review in newspaper style – it’s lean and clean, and packed with interesting pointers to the latest news.
NCCI conference – Peter Rousmaniere attended the annual NCCI Conference this year and reports back on his findings, posted at Joe’s place.
When less is more – Joe Paduda of Managed Care Matters beats a drum that needs beating. Why do buyers use unit cost reductions rather than total cost reductions as a metric of savings in measuring network performance? It’s a perverse incentive that encourages utilization.
You-Don’t-Say Department – a recent survey of small businesses shows that many are spending work comp dollars without knowing what they’re buying. About one out of every seven couldn’t name their insurer and don’t understand their coverage. In a related survey, almost one in five respondents who had just switched to a new insurer weren’t able to name that insurer. Our experience has been that small employers often learn about workers comp the hard way – it would be great if as an industry, we did a better job communicating what workers’ comp is and how it benefits both employers and employees.
Missouri gets tough – Missouri employers who try to cut corners by not carrying workers comp should think twice – the Supreme Court recently upheld a felony conviction for an employer that failed to carry workers comp coverage for his employees. The conviction includes one year in prison and $30,000 in fines and penalties. (More about the Court’s proceedings.)
Useful resource – 101 little known scholarship sources for nurses – a good reference list for both undergraduates and graduates.
And the winner is… – In an interesting bit of insurance trivia, Fireman’s Fund Insurance names the riskiest film of 2007.
News Roundup” Cavalcade of Risk, networks, docs & drugs, scandal watch & more
Friday, May 11th, 2007Carnival time – Cavalcade of Risk #25 is posted at Getting Green. Among other fine entries, we note there are two posts about data security. In one case, the Transportion Security Office lost the records of 100,000 workers – great, that speaks well to their ability to protect us! And in another item, we learn that Chase is careless in disposing of sensitive client materials – and they are obviously not the only ones. Not good. Is your agent, insurer or TPA properly disposing of any claim-related data and records for your organization? You may want to add this item to things you check for in renewals or RFPs.
WC networks – Joe Paduda has some thoughts on the future of workers compensation networks. After meeting with several network executives at the recent RIMS meeting, he sees a definite continuation of the trend away from the national broad-based, discount-oriented networks to regional hybrid networks. Not sure what a Hybrid network is? Joe offers a good explanation in his post. His expert analysis on these matters is worth your attention.
Docs & Drugs – Those free drug samples that physicians hand out may not be such a good idea after all, or so says a recent article in the New York Times. Critics see these as just another example of the close ties between physicians and drug companies, and say that ” … they may actually drive up the cost of health care in the long run, because the drugs being promoted are the most expensive brand-name medications.” We’ve talked about docs and drugs a few times before. (Thanks to HealthLawProf Blog for the pointer to the article)
Scandal watch – We’ve written quite a bit about the Ohio Bureau of Workers Compensation Coingate scandal. Today we learn that the BWC’s former CFO faces 5 years in prison. His sentence was reduced based on cooperation with authorities, so there is the potential for further shoes to drop. There have been 16 public officials and money managers convicted of various offenses thus far. In other state news, trouble is brewing in the North Dakota workers comp system too.
Geek safety – 25 Free health Tips for Computer nerds This blog may focus on work-related risks, but play can be dangerous too – In 2005, a 28-year-old South Korean man who played computer games for straight 50 hours died of heart failure. Pass this article on to your IT folks and the bloggers in your life. Via Ergonomics In the News
Notes from the Blogosphere – Congratulations to Michael Fitzgibbon at Thoughts from a Management Lawyer ob his 4-year Blogiversary. Michael is a Toronto-base attorney and professor who keeps us informed about the employment-related goings on in our neighbor to the North. And speaking of Canadian bloggers, we told you that rawblogXport had announced the blog was winding down, but we are happy to note that items are still being posted daily.
Don’t let medical providers “discount” your injured workers
Wednesday, August 24th, 2005We talked a bit about “framing” on Monday – the depersonalization that can occur when people are lumped into broad categories or stereotypes, and how that pigeonholing can set the trajectory for future behaviors and events. Thus, an injured worker can make the leap from being your best employee to a rather suspicious “claimant” in one fell swoop. So it was of some interest when, in doing our weekly medical blog rounds, we came upon a post that related to the transformation and depersonalization that often occurs when one becomes “a patient.”
Rita Schwab at MSSPNexus points us to a story in The New York Times about the degrading shift from person to patient* that often occurs when one crosses the threshold into a hospital. Rita comments that, often, ” … the courtesies that help lubricate and dignify civil society are neglected precisely when they are needed most, when people are feeling acutely cut off from others and betrayed by their own bodies.”
She excerpts this incident from the article:
“Mary Duffy was lying in bed half-asleep on the morning after her breast cancer surgery in February when a group of white-coated strangers filed into her hospital room.
Without a word, one of them – a man – leaned over Ms. Duffy, pulled back her blanket, and stripped her nightgown from her shoulders.
Weak from the surgery, Ms. Duffy, 55, still managed to exclaim, “Well, good morning,” a quiver of sarcasm in her voice.
But the doctor ignored her. He talked about carcinomas and circled her bed like a presenter at a lawnmower trade show, while his audience, a half-dozen medical students in their 20’s, stared at Ms. Duffy’s naked body with detached curiosity, she said. “
If you or a family member has been hospitalized recently, you may identify with some of the stories and issues discussed in the article. It made me recall The Doctor, an old film in which William Hurt played a successful but brusque surgeon who learned what it feels like to have the tables turned after he gets cancer.
(* If the NYT article is archived, you may be able to access it from here with free registration.)
What happens when your injured workers visit the doctor?
Employers need to give some thought to what happens when their injured workers become patients. As Rita points out, this is a very vulnerable point for your employee and the medical milieu can be a highly confusing and frustrating labyrinth. In addition to all the regular depersonalization inherent in encounters with the medical world, employees who seek care under the banner of workers comp can be made to feel like they are somehow less worthy, second-class patients. And in a sense, they are – workers comp rates are generally discounted by fee schedules and network negotiations; further, some providers are reluctant to be involved in what they see as a potentially contentious case.
Employers that truly care about the recovery of their injured workers would do well to assume the role of patient advocate. This entails advance planning by seeking out and meeting the quality medical providers near your facilities and making these doctors familiar with your organization and your return-to-work programs. In representing your work force, you have more buying power and more influence to ensure timely service and priority care than any one individual walking in off the street would. If an employee is experiencing frustration or confusion during the course of treatment, you want to know that and be in a position to help resolve those issues whenever possible. If you don’t pay attention to those frustrations, an attorney would be glad to!
Hands-on advocacy
Often, employers think that managing the relationship with providers is the job of the insurer or the contracted network, but we would argue that this is not a relationship that can be “outsourced” on the day-to-day managerial level. Employers need to be an active participant in this relationship, and to ensure that injured employees get top quality care and service. And we would add that a good place to begin is to be more concerned with quality than with discounts when seeking out a network or a doctor — in fact, we often encourage employers to pay more to ensure good service. Cheap medical care is no bargain; a few extra dollars spent early might be the best bargain of all.
A Few Thoughts on Comp Medical Networks
Tuesday, May 24th, 2005Workers comp is about injuries and injuries require medical attention. Our colleague Joe Paduda blogs the problem of finding good medical care under the comp system. Back in the 90’s, there seemed to be a proliferation of occupation medical practices: from hospital based occ clinics to the “doc in a box” walk-in clinics, there were a lot of options for treating injured workers. These options have diminished dramatically over the past few years. Why? It’s pretty simple: a combination of not enough volume (injury rates are declining) and suppressed rates of reimbursement (rate schedules for medical services under comp tend to be low). In addition, you need to consider the context: total health care in this country costs $1.4 trillion, while the comp portion of this is only $30 billion. Comp, in other words, is chump change in comparison to medical care in general.
Paduda’s blog shows that the prevalent trend is away from networks specializing in work related injury and toward bringing injured workers into conventional health networks — in other words, family practices. This is far from an ideal situation. Occupational medicine brings a unique and essential focus to work injury: the goal is always to keep people as productive as possible; to help them heal faster by returning them to work as soon as possible, often through the prudent use of temporary modified duty. I’m not sure that traditional family practices view injuries the same way. Family doctors are perhaps more sensitive to the pressures and issues outside of work. I suspect they are more inclined to give the injured work time away from work, especially when they know that any lost wages will be covered by indemnity payments. They are not used to communicating directly with their patient’s employer. Indeed, if the patient doesn’t like his or her job, the doctor may be inclined to separate the goal of getting the patient better from returning him or her to work.
Paduda highlights one exception to this trend: the recently announced merging of The Hartford’s workers comp business with Aetna’s workers comp specialty network, which is available in Pennsylvania, New Jersey, Connecticut, Texas and Virginia. Aetna’s network includes 130,000 physicians, hospitals and other health care providers. Aetna, along with Corvel, HealthFirst, Concentra and Focus, and a few others, continue to offer occupational services for injured workers.
Preferred Provider Networks that Really Work
I have long been intrigued with the issue of medical care in the workers comp system. I’m not sure that anyone has got it quite right. In the ideal system, doctors explicitly buy into the notion that a rapid return to work is the optimum result. They are committed to a “sports medicine” approach. They limit office visits and therapy to what is truly needed. They prescribe the necessary medications, but are careful to use generics where appropriate (even though the patient doesn’t really care, because there is no co-pay). These doctors are able to resist the raucous pitch of drug companies to experiment with off-line use of branded medications. And they communicate readily with their patients, the employer and the insurance carrier.
In exchange for all this good work, occupational doctors should be paid reasonable rates — which in many states means paying well above scheduled rates. Too often, the established rates (and the rates within many of the formal medical provider networks) are ferociously suppressed, which can lead doctors to make up the difference by over-utilization; in other words, suppressed rates do not necessarily produce lower costs. In addition to paying occ docs above rate schedules, they should also be reimbursed for certain key activities that usually are provided for free — such as filling out return-to-work status reports. If you don’t pay for such reports, the message to the doctor is that the reports are not important. In the comp system, there is no more important communication than the doctor’s take on medically necessary restrictions — what the employee can and cannot do.
We recommend that employers with any significant volume of injuries develop a relationship with their local providers, whether or not they are in a formal provider network. Make sure that the provider understands your commitment to modified duty. And let your carrier or TPA know that you are not interested in saving a few pennies by forcing your medical provider into a punitive rate schedule. Rather, you want to pay a little extra, in order to secure the level and quality of service that ensures success in workers comp cost control.
