It’s COMPlicated – Little Things Mean a Lot

A 2021 Harvard Business School newsletter encouraged business leaders to take the long -term view rather than concentrating on quick returns. This is sound advice for several aspects of the medical component of workers’ compensation, three of which are discussed below.

First. Medical care is a major component of the total cost of workers’ compensation. Policymakers have accepted that medical fee schedules help reduce medical costs in workers’ compensation and are necessary to be good stewards of workers’ compensation dollars. Fee schedules usually include language that limits the liability of the employer to the maximum allowable fee in the state’s medical fee schedule. They may also allow an employer to pay less than the maximum allowable amount if they are able to negotiate lower fees, typically through PPOs and silent PPOs. But it is the rare state that allows for payments greater than the maximum allowable fee.

For most claims, medical fee schedule maximums do not impair access to quality medical care. But for injured workers who need medical care in certain specialties such as neurology, pulmonology, or psychiatry, the maximum fee can pose a hurdle to the care they need. Lack of access to an appropriate specialist can result in longer recoveries, increased impairment and permanent benefits, longer periods of temporary total disability, and higher legal fees when the injured worker goes to court to obtain the appropriate medical care.

The long view would provide some type of mechanism, such as a waiver to the state fee schedule. This could ensure that patients can access physicians who can help them attain recovery as quickly and successfully as possible, offsetting the increased cost of the higher physician fees.

Second. Every state in the continental United States shares at least one boundary with another state. Maine only shares one border, and at the other extreme Tennessee shares a border with eight states. Most states require physicians who provide medical care to workers’ compensation claimants to be licensed to practice medicine in their state.

These provisions are understandable from one perspective, but they can impede rapid access to quality medical care. The long view would allow for greater flexibility, if significant numbers of their citizens are closer to medical care in another state, and they experience access problems if the right medical provider is across the state line and no close medical providers are available in their own state.

Third. Another aspect of this issue has emerged in the wake of COVID-19. Telemedicine has grown exponentially in the past two years. Telemedicine not only made medical care available without exposure to the virus, but it also made experts in medical care available to patients without consideration of borders, unless the state requires the telemedicine provider to be licensed in the state. Again, the long view would look to use telemedicine more often in appropriate cases and with adequate safeguards.

Looking Ahead. These are but three “little things” that could improve the care of workers’ compensation patients and reduce costs through more complete recoveries and shorter periods of incapacity.

They are not the only changes that could be made without a major reform. Among the other possibilities are:

  • Return-to-work coaches/coordinators
  • Drug formularies
  • Increased use physician extenders such as physician assistants and nurse practitioners
  • Increased involvement of the patient in the selection of physicians
  • Use of alternative treatment such as acupuncture, yoga, or massage therapy.

Let’s get the conversation going on improving medical care outcomes and the workers’ compensation system. What changes would you recommend to improve medical care?