Geek alert!

For work comp wonks, in this post I’m reporting on what transpired at this morning’s meeting at DOL on Work comp; a summary and perspective will be the subject of a post tomorrow.

OSHA’s Director led off this morning’s presentation at the Department of Labor with a quick summary of the history of work comp, noting the death rate for WC declined from 37 per day to 12 per day over the last 40+ years despite a doubling of the number of people employed.

(note the statements below are paraphrased, some may not be entirely accurate due to lack of transcript available at the time of posting)

The written report is here for download. 

He also stated many injuries are NOT reported, saying workers’ comp is the ONLY element of the social net without federal oversight.  

Key paraphrased quotes:

• Costs are shifted away from employers, and to workers, their families, and other social insurance programs.
• The race to the bottom for workers comp among states has continued.
• Potential policy initiatives are here.

NASI CEO Bill Arnone’s comments included:

• workers’ compensation is a social insurance system that “needs work”
• today’s work place is very different from 1908…
• 3 million injuries and illnesses reported in 2014 – 1/3 represented time away from work
• lack of uniform reporting of state experience
• goal of workers comp- adequate wage replacement and medical care at reasonable cost – balance adequacy and affordability

Social Security’s Commissioner Carolyn Colvin was up next; notable statements follow:

• 9 million disabled workers receive income from Social Security – plus 2 million of their dependents; averaging under $1,200 per month
• for 1/3 of these workers, SS Disability Income (DI) income is their ONLY income.
• if the full cost of workers injuries aren’t covered by workers comp, someone else is paying for those costs
• recent changes in some states’ work comp laws may be shifting costs to SS DI and Medicare

The Commissioner was quite clear that Social Security is very interested in worker disability as shifting of expense to SS DI increases Social Security’s ultimate cost.

Secretary of Labor Tom Perez then took the podium.  Perez gave a detailed and passionate review of the formative years of workers’ compensation.  The Secretary noted that today, just as 80 years ago, state workers’ comp systems vary widely, AND, the Feds have “leverage” at the federal level for other social insurance programs including unemployment insurance.

Perez linked today’s work comp systems with those that led to the National Commission in the last century, starting with Texas opt-out as problematic due to low benefits. The Secretary also said:

• you’ve got to win the geographic lottery to be taken care of due to differences among states
• taxpayers are unfairly subsidizing a workers’ comp system that is not doing enough
• DOL doesn’t have statutory authority to protect workers but we do have the bully pulpit.

A panel discussion began; speakers included John Burton, PhD, Professor Emeritus at Rutgers and former Chair of the Commission; Gary Franklin MD, Medical Director of Washington’s State WC Fund L&I; Christopher McLaren PhD of NASI, Emily Spieler, Professor and Labor Attorney, former Commissioner of WC in West Virginia.

Burton was asked for his views…at which time the broadcast went down for a few minutes. When we were reconnected, Burton provided a background of the Commission’s work, suggesting the standards represented a “floor” for benefits and other aspects of workers comp, and the decline in benefits was largely driven by state’s unfounded fear that employers would leave for more friendly locales.

Burton does not believe there is any chance federal standards will be enacted over the next 20 years, and can’t be developed because the world has changed so much.  Burton believes there is a “race to the bottom” once again, and this has resulted in states reducing benefits.

In a later segment, Burton noted there is a discrepancy between the NASI data and the Bureau of Labor Statistics’ data on employers’ workers’ comp costs; BLS data indicates employer costs are not going up, in contrast to NASI’s findings.

He also panned the AMA Disability Rating Guidelines, claiming among other things that they are completely non-evidence based, and suggesting the Institute of Medicine come up with a disability rating guide…I wholeheartedly disagree w Burton’s assertions about and denigration of the Guides.

Dr McLaren hit the highlights of the new NASI work comp report – copy here. Later, he noted that costs are going up now due in large part to the ongoing recovery from the Great Recession; costs tend to go up before the benefits paid catches up to the new workers’ new injuries. 

Dr Spieler was asked to identify the key problems in state workers’ comp systems. She agreed with John Burton that a major problem is states seeking to compete with other states, and:

• many injured workers don’t apply for benefits and therefore don’t appear in NASI or other reports
• some apply for benefits but don’t get them due to payer contesting the claim due to requirement that workplace was major contributing cause to the impairment.
• are cash benefits adequate – there have been cutbacks in length of time patients can receive benefits, citing Oklahoma
• patients exist in a “Kafka-esque” system, alarmingly complex and stigmatizing.
• there’ve been statutory efforts to “cut back” on medical benefits
• the goal of replacing 2/3 of pre-injury wages was and should remain a goal.
• Oklahoma opt-out was mentioned multiple times

Gary Franklin MD PhD spoke about medical care in the system (note – Gary is a  friend and colleague)

Gary noted that unlike some states, Washington is in a race to the top.  He also said many payers don’t even have senior medical staff to help guide policy. For those who know Dr Franklin, it will come as no surprise that he used the term “evidence-based” multiple times in referring to formularies, lumbar fusion and other surgery, and disability.

A lot of the contribution to long term disability is due to baad medical care; workers’ comp medical care is among the worst medical care in the country,  Gary cited 32 deaths of workers comp patients who had low back sprains, got opioids, and were dying due to their prescriptions.  WA focuses on preventing disability three ways:

• develop validated methods, tools, and instruments that docs can use to identify patients at risk for extended disability
• using evidence based methods to develop treatment guidelines to prevent them from being injured
• develop delivery systems to reorganize care to allow better care for injured workers, the Centers for Occupational health and Education – 50% of patients are going thru these Centers, which have helped reduce preventable disability by over a third.

Net – paying much more attention to technology assessments, evidence-based clinical guidelines, and preventable disability are all helping workers avoid bad care and prevent extended disability.  Gary talked about the horrible effects of lumbar fusion surgery and opioids – “a huge percentage of injured workers that are now on SSDI are on opioids, and that started in the workers comp system.”

The discussion went on from there, with a discussion of illnesses and how the system doesn’t adequately address occupational injuries, DOL’s views on work comp and the Gig economy, and the need for more research on occ injuries and illnesses sustained by Gig economy workers.

The issue of misclassification, and how states handle independent contractors, problems in the construction industry with labor cheating was raised by Burton – valid points all.

A comment by David Deitz MD on last week’s post is well worth your read.  Referring to ProPublica, Dr Deitz said:

describing the use of guidelines and other evidence-based tools as a cut in benefits is not just misleading, it gets to the root of one of the central problems with much WC care

As Dr Deitz notes, what PP doesn’t grasp is this; evidence-based guidelines promote better medical care, and when work comp patients get sub-standard care, everyone suffers. .

Not just a few patients highlighted in a couple of headline-grabbing stories, but thousands victimized by lousy medical treatment. Today, many states do not allow or support the use of evidence-based clinical guidelines (which PP describes as a “cut in benefits”), and as a result many patients get crappy medical care.

Want evidence?

• Workers’ comp accounts for 1.25% of total US medical spend, but 13% of opioid spend. Opioid prescribing and dispensing is a major contributor to death, extended disability, ruined families, and ruined lives.
• The Drobots and their ilk – carving up workers’ comp patients to implant faulty devices to generate huge profits for a select few doctors.
• Physician dispensing of drugs extends disability, runs up medical costs, and keeps patients from returning to work.
• Physician-owned toxicology labs.

Data and the analysis thereof identifies these issues.

Outcomes data such as return to work, disability duration, functionality, sustained re-employment, re-injury rates differentiates good medical care, and providers who deliver that care, from providers who don’t.

Alerts based on potentially problematic treatment such as prescription of opioids without trauma or surgery, high incidence of surgery for patients with soft-tissue injury diagnoses, physical therapy scripts for patients without musculoskeletal injuries are based on data collection and analysis.

Dull stuff, huh?

Anecdotes are easy to grasp, get lots of attention, generate excitement, start politicians squawking. Data is, well, boring. Thinking based on data requires focus, concentration, effort, and a desire to understand.  Anecdote is quick, easy, and triggers emotions that often lead to simplistic and misguided conclusions.

That’s the briefest explanation I could come up with as to why work comp reform efforts are far too often sidetracked by issues/stories that, while concerning or even troubling, do NOT represent what happens the vast majority of the time.

What does this mean for you?

Make decisions based on data, not on anecdote.

Is set for release at a public meeting in Washington this Wednesday, October 5, at 10 AM. While the content has been closely held, sources indicate topics  include:

• increasing inadequacy of benefits,
• restrictions on medical care for injured workers,
• new procedural processes and hurdles for claimants, and
• the effect these trends have had on Social Security Disability Insurance.

There will also be a discussion of Opt-Out; DoL’s Employee Benefit Security Administration has been looking into opt-out alternative plans and their compliance with ERISA.

We do not yet know what the report will say about these topics, however a close reading of OSHA’s March 2015 report provides some clues.  Actually, the title alone may be predictive:

ADDING INEQUALITY TO INJURY: THE COSTS OF FAILING TO PROTECT WORKERS ON THE JOB

A paragraph from the report’s Executive Summary follows:

The costs of workplace injuries are borne primarily by injured workers, their families, and taxpayer-supported components of the social safety net. Changes in state-based workers’ compensation insurance programs have made it increasingly difficult for injured workers to receive the full benefits (including adequate wage replacement payments and coverage for medical expenses) to which they are entitled. Employers now provide only a small percentage (about 20%) of the overall financial cost of workplace injuries and illnesses through workers’ compensation. This cost-shift has forced injured workers, their families and taxpayers to subsidize the vast majority of the lost income and medical care costs generated by these conditions. [emphasis added]

Another paragraph speaks to under-reporting of workplace injuries and illnesses:

While the estimate of three million serious work-related injuries each year may seem extremely high, it is undoubtedly only a fraction of the true number. Numerous studies provide documentation that many, and perhaps the majority, of work-related injuries are not recorded by employers, and that the actual number of workers injured each year is likely to be far higher than the BLS estimate

The meeting, entitled the State Workers’ Compensation Forum (you can attend or sign up for the video feed by registering here) will include representatives from the National Academy of Social Insurance and the Social Security Administration (I am a member of NASI but have had no involvement with this initiative).

Suggestions and observations. 

1. Remain calm.
2. It’s important to read the entire report.
3. Have an open mind.
4. Under-reporting of claims is good news for the workers’ comp “industry” as it creates:
   1. more incentive for safety and loss prevention,
   2. more opportunities for vendors,
   3. more premium for workers’ comp insurers, and
   4. likely better outcomes due to professional management of injuries and illnesses by work comp payers.

 

 

ProPublica’s unethical “reporting” is being used in a PR effort to distort and demonize the workers’ comp industry.

An ethical journalistic organization would have sent a reporter to this week’s IAIABC conference, where they would have found 300 people all focused on improving a system that works quite well for the vast majority of patients and employers.

Instead PP’s “research” has been put into an “infographic“‘ that, by some unfathomable logic, attempts to link states’ occupational fatalities to a contrived, wholly inaccurate, and totally misleading “cut in benefits.”  (more on that here) What one has to do with the other escapes me.

PP defines “cut in benefits” as including, among other things:

• adoption of utilization review and/or evidence-based clinical guidelines (can you IMAGINE!)
• employer direction of care (to avoid patients going to pill mills and purveyors of fake surgical implants)
• using outside medical reviewers to assess medical care
• considering a patient’s pre-existing conditions in determining if an injury should be allocated to a specific employer

The mis-infographic is here, hosted on a law firm’s website.

Allow me to describe what a PP reporter would have seen if they’d bothered to attend IAIABC, the conference that, more than any other, digs into the issues PP seems most concerned about – how injured workers are treated by the work comp system.

They would have heard a terrific presentation by three physicians on improving the quality of medical care delivered to workers comp patients, followed by much discussion among regulators on how to increase the quality of care in their states and provinces.

They would have watched over a hundred regulators and other stakeholders work for four hours to develop an agenda for continued improvements in worker outcomes, safety, medical care, and satisfaction.

They would have heard countless hallway conversations about what this state or that state is doing to speed delivery of benefits, facilitate return to work, reduce friction in the system, and what other states might be able to learn from those efforts.

They would have heard a lengthy and detailed discussion about medical treatment guidelines, and a passionate debate about how evidence-based guidelines can improve the medical care delivered to patients.

They would have heard about an industry that is working every day to reduce the volume and potency of opioids prescribed and dispensed to patients – and having a LOT of success. (cue the totally false, dishonest, and self-serving BS from self-described “injured worker advocates” about how this is adding to suffering).

They would have heard a claims exec talking about his company’s policy on paying workers; NOT waiting to make absolutely sure a claim’s been accepted, but cutting checks to pay workers’ lost wages as soon as they think the worker will be out of work for more than a couple of days.

Nope.

Why try to get the facts when it’s easier to gain pageviews by vilifying individuals who are doing their damndest to make things better?

It’s long past time each and every one of us stood up to this BS.  You – yes, YOU – need to promote, emphasize, publicize your successes.

The patient you helped find a new job.

The house you built to accommodate the paraplegic with a family.

The calls you made to that doctor to get them to change the script from Fentanyl to ibuprofen and physical therapy.

The visit to the plant to figure out why there’s been several recent shoulder injuries.

The time spent talking with state legislators about the importance of prescribers checking Prescription Drug Databases.

The multiple calls with the injured worker’s spouse, helping them understand and navigate the work comp system while listening to their fears and assuring them the check’s been cut.

What does this mean for you?

Sure, you can follow the usual insurance company playbook – don’t say ANYTHING because someone could misconstrue it.

THAT’s worked really well, hasn’t it?