Apr

Federal takeover of WC: the problem with occupational diseases

Posted by Joe Paduda on Sunday, April 4th, 2010 | Comments

In the five and a half years I’ve been publishing this blog, I’ve never had a guest post. Today’s post breaks that tradition. (This is NOT a change in policy; please don’t submit guest posts)
Good friend and colleague Peter Rousmaniere is one of the most thoughtful and interested observers of all things related to workers comp; his work appears in many other publications including Risk and Insurance. Peter and I were discussing the issue of the federal government’s role in work comp, he mentioned the history of federal involvement in occupational disease, and was kind enough to agree to write up his thoughts on the issue. I don’t necessarily agree with Peter’s perspective, but his views are well worth consideration.
Here’s Peter’s view.
There is talk about the threat of complete federalization of the workers compensation system without any evidence that the Administration and Congress is giving the idea any thought. However I envision a scenario for a serious effort in the next few years to take over coverage of work-related diseases. I have four points to make.
First, there is a very apt precedent of a federal takeover of about ten years ago. Thousands of nuclear weapon workers employed from the 1940s through the 1970s at private companies contracted by the federal government filed disease claims in state systems. Hardly any were accepted, an indication less of the merits of the claims than of the torturous, glacial pace of disease claims in virtually all state workers compensation systems.
After decades of inaction at the state level, Congress in 2001, in a bipartisan way, and with tacit concurrence by the states, said that the federal government was assuming the task of managing these claims. Thus emerged the Energy Employee Occupational Illness Compensation Program. The Department of Labor has spent several billions of federal tax dollars paying disease claims that were not paid through the workers compensation system.
Second, there is some interesting evidence that most occupational diseases do not enter into the state workers compensation systems. These ill workers go without the protections provided by these systems. The Massachusetts Department of Public Health studied asbestosis-related hospitalizations between 1996 and 2000 and found that among 3,344 hospitalizations, only 15 were paid for by workers compensation insurers.
Using epidemiological methods, and after analyzing state records of disease claims, other researchers estimated that the large majority of disease claims were missed. They went on to estimate that the annual national medical spend outside the workers compensation system for occupational diseases is between $8 and $23 billion.
Third, if the Democrats maintain their control of Congress in November, they are very likely to return to massaging the issue of OSHA undercounts. Congress could well extend its scope to investigate any kind of systemic barrier to protection of workers from the incidence and effects of occupational injury and disease. Congress will have not problem filling a conference room with claimant bar attorneys and medical reseachers.
Fourth, threats of federal takeover actually work. At the time the Nixon Administration created OSHA, it also launched a National Commission on State Workmen’s Compensation Laws. The commission’s report of 1972 is credited with embarrassing and prodding many states to modernize their workers’ compensation systems.

Apr

The work comp picture gets a bit brighter.

Posted by Joe Paduda on Friday, April 2nd, 2010 | Comments

Today’s employment report contains a bit more of the good news workers comp have been hoping for: an increase in manufacturing employment and continued overall growth in industrial production. Overall, the economy generated 190 thousand jobs in March, the highest rate of job creation in three years.
according to Marketwatch,
“Manufacturing payrolls increased by 17,000. Construction employment rose by 15,000. Manufacturing hours increased by half an hour to 41 hours per week, with 3.7 hours of overtime on average.”
The net is positive – more jobs, longer hours, more overtime.
A decline in construction spending tempered the positive employment news, but that could have been significantly affected by the lousy weather experienced by much of the country in February.
The investment income picture isn’t quite as encouraging, with returns for the P&C industry down sharply in 2009 over the prior year, That’s somewhat offset by the jump in the equity markets over the last year. While higher returns would be nice, the silver lining is comp insurers aren’t able to keep premiums low by generating significant investment income, forcing underwriters to price to risk rather than bank on high investment returns covering claims costs.
There are some indications that carriers are beginning to strengthen pricing in selected markets and products. That’s not to say the market is turning, but the bottom may be near.
What does this mean for you?
As employment picks up in manufacturing and the spring brings increased construction activity, claims counts and frequency are also likely to rise. While bad news for the injured, this will be good news for occ medicine clinics, managed care and bill review firms, PBMs, and, most of all, TPAs.

Apr

Britain’s NHS to run US Health Insurance Exchange, control costs

Posted by Joe Paduda on Thursday, April 1st, 2010 | Comments

As one who haas heartily criticized the health reform bill for it’s apparent avoidance of any real cost control, I was quite surprised to hear that there are two meaningful – and very significant – cost control mechanisms contained in the new law. Both rely on using proven methodologies to attack administrative and medical costs and both have been widely tested.
I don’t doubt they’ll work as intended, but I have serious doubts about the willingness of physicians and many patients to accept these provisions.
Buried deep within the 2000+ page health reform bill is a paragraph that called for sealed bids from potential vendors interested in managing the national health exchange component of health reform, bids that would have to exceed certain standards in order to be considered. Those standards, when closely examined, are the operating metrics used by Britain’s National Health Service’s External Markets Programme.
As no American company or not for profit organization has the necessary experience required by the law, it certainly appears as if this provision was intended to allow, if not require, HHS Sec. Kathleen Sibelius to award the contract for administering the National Insurance Exchange to the NHS.
This isn’t as far-fetched as it may sound. The NHS was awarded a similar contract two years ago in India, and is currently managing the health systems in the BVIs, Barbados, the Falkland Islands, and most recently is reportedly close to a deal to revamp Iceland’s troubled health system.
Details are scarce; as one might imagine the Administration is loathe to provide any information at a time when refom opponents are in full voice and the media is following reform very closely. Don’t expect to hear anyone in Washington speaking on the record about this anytime before July; with Congress out of session and vacations in full swing any uproar will be kept to a minimum.
As if that wasn’t enough, sources within HHS have confirmed the long-circulating rumors that Dr. Sir James Watson, former head of Britain’s NICE program, will be heading up the federal government’s medical guideline development project. Watson is reknowned for his ability to identify the most cost-effective procedures with minimal data, a talent that will serve him well in the grossly-underfunded new department.
Watson will have to be a quick study, as Americans will be justifiably concerned with the prospect of the architect of Britain’s medical cost control program in such an influential position.
What does this mean for you?
Less work on the part of physicians or patients as HHS will be determining which procedures are, and are not, ‘necessary’.

Mar

Why all the sound and fury about the individual mandate?

Posted by Joe Paduda on Wednesday, March 31st, 2010 | Comments

The objections to the individual mandate are loud, frequent, and hyperbolic. What they are not is credible.
Much of the criticism of the mandate appears to be coming from people and organizations that previously supported a mandate. That’s why it is so difficult to take them seriously.
Here are a couple examples.
– Mitt Romney, who could teach a kite a thing or two about moving with the political winds, signed a bill into law saying it was “a personal responsibility principle”; a bill that was pretty similar to the one he now describes as “an unconscionable abuse of power.”. (and yes, Romney did endorse a Federal mandate)
Romney also said “Some of my libertarian friends balk at what looks like an individual mandate. But remember, someone has to pay for the health care that must, by law, be provided: Either the individual pays or the taxpayers pay. A free ride on government is not libertarian.”
– Sen Orrin Hatch (R UT) cosponsored a bill that required a universal mandate back in 1993. Today, he says:””If they mandate you have to buy insurance, it’ll be the first time in this country that the government can tell you what to buy,” said Hatch, warning the measure could portend even more government control in the future.”
– Newt Gingrich, who backed a mandate back in 2008, and…doesn‘t now.
Many of the loudest objectors were strong supporters of the mandate in the past, including the worthies at the Heritage Foundation. Here’s what they said then (text spacing issues from original):
The second central element-in the Heritage proposal is a two-way commit ment between government and citizen. Under this social contract, the fed eral government would agree to make it financially possible, through refund able tax benefits or in some cases by providing access to public-sector health programs, for every American family to purchase at least a basic package of medic a l care, including catastrophic insurance. In return, government would require, by law every head of household to acquire at least a basic health plan for his or her family.Thus there would be mandated coverage under the Heritage proposal [emphasis added], but the mandate w ould apply to the family head, who is the appropriate person to shoulder the primary responsibility for the familys health needs, rather than employers, who are not.
And here’s what they say now:
This “personal responsibility” provision of the legislation, more accurately known as the “individual mandate” because it commands all individuals to enter into a contractual relationship with a private insurance company, takes congressional power and control to a striking new level. Its defenders have struggled to justify the mandate by analogizing it to existing federal laws and court decisions, but their efforts do not withstand serious scrutiny. An individual mandate to enter into a contract with or buy a particular product from a private party, with tax penalties to enforce it, is unprecedented– not just in scope but in kind–and unconstitutional as a matter of first principles [emphasis added] and under any reasonable reading of judicial precedents.
Which leads to the question – why have Romney, Gingrich, Hatch, and Heritage (amongn others) changed their view? Could it be due to a re-reading of the Constitution? New evidence that the original authors didn’t want universal health care?
Or could it be that no one to the right of center wants to say anything neutral, much less positive, about anything the President and his fellow Democrats advocate?
Why is this? The reform plan, which has more than its share of warts, doesn’t include a public option, has a relatively weak mandate mechanism, relies on private insurers to provide coverage, and doesn’t do anything to manage price or utilization.
One would think all conservatives wouldn’t find that so universally objectionable.
This doesn’t make sense at any level; their flipflopping is patently obvious and readily identified, and all the Dems have to do is advance increasingly centrist ideas and watch while the GOP partisans howl in outrage, backing themselves into a really small corner.
If they don’t wise up, they’ll find themselves a very, very small party.
There’s a lot left to do to truly ‘reform’ health care. Without the contributions of legislators from all parts of the political spectrum we will end up with a system designed by one party. Some will never ‘buy in’ to that system, no matter how moderate and effective the reforms may be.

Mar

The ethics of clinical guidelines – the payers’ dilemma

Posted by Joe Paduda on Tuesday, March 30th, 2010 | Comments

In preparing for a talk on the ethics of comparative effectiveness I’m to give at the Geisinger Clinic in Danville PA in April, I’ve been interviewing medical directors from several health plans and workers comp insurers, along with physicians – both practicing and managing, in an effort to get their views on guidelines.
I’ve been somewhat surprised at what I’ve learned.
The real problem may not be payers’ efforts to deny medical care, but their willingness to ‘go along to get along’; to avoid making tough coverage decisions, and when in the slightest doubt, to approve the procedure/drug/treatment/therapy rather than run the risk of upsetting someone.
One would think payers would be keenly interested in supporting and using evidence-based clinical guidelines; costs would be reduced and outcomes improved, benefiting both patients and profits. And one might very well be wrong.
Payers operate in a market where public opinion matters a lot; if the payer has a negative image, it will be harder to convince employers and their employees to sign up for their health plan. It may also be harder to convince physicians and other providers to join and stay in their provider networks. And families may well be reluctant to carry an insurance card from a payer known for their tight controls on medical care.
We all know that restricting unnecessary care is not bad or immoral, but to the general public, it can certainly look like a profit-driven effort to cut costs, regardless of the effect on patients. To be sure, payers’ public efforts to terminate patients on the flimsiest of excuses and refuse coverage to anyone who might actually get sick haven’t helped their image. But the sense I get from the medical directors and practitioners I’ve spoken with is they are quite reluctant to deny treatment.
Part of this may be influenced by reality – when claims costs go up, so do premiums, and so does the health plan’s top line. There are few industries where built-in inflation results in near-double-growth same-store growth every year; health insurance is certainly one. This ‘reality’ is closely related to health plans’ motivations. Wall Street demands revenue growth, and for those health plans that are for-profit, their primary obligation is to their stockholders.
Allowing questionable treatments drives up revenues which benefits stockholders.
Of course, it isn’t anywhere near that simple or straightforward in the real world. Health plans’ profits are higher if medical costs are lower – at least over the short term. And most of the health plan execs I know are honestly trying to ensure their members get the care they need, care that they can’t afford if they approve any and all treatments no matter how ineffective.
But there is no question payers face an ethical dilemma, one complicated by patient demand, provider relations, market influences, and the obligation to their owners. (I’m not addressing the not for profits in this post)
A lot of Federal (taxpayer) dollars are going to be spent on comparative effectiveness research over the next few years, and if there’s a better use of my money I’m not aware of it. It is widely acknowledged that much of what we spend is wasted on unnecessary tests, advertising-driven consumer demand, unproven treatments and procedures that benefit device companies, specialists, and facility owners far more than patients.
It’s also equally clear that reining in those costs is going to be incredibly difficult, because much of it occurs in the somewhat grey area between procedures that are clearly useless or harmful, and those that are undeniably appropriate. And that grey area is where hundreds of billions are spent every year.
What does this mean for you?
Perhaps an ethical dilemma.

Mar

Flip flopping on the mandate – Gingrich’s hypocrisy

Posted by Joe Paduda on Monday, March 29th, 2010 | Comments

There are enough problems with reform – big, obvious, scary problems – that make lying about reform unnecessary. Yet opponents continue to resort to ludicrous, unsupportable, and completely false claims about the bill, with some of the leading detractors choosing to rewrite history in an effort to scare voters and score political points.
It is NOT socialized medicine, socialized healthcare, government-controlled health care, a violation of the US Constitution, or any of the other ridiculous charges leveled by people who should be more responsible. The reform law is:
– pretty centrist – no public option, utilizing private, for-profit insurers to deliver insurance
– without price controls on providers or insurers, and with no utilization controls to speak of
– based on a very weak mandate that is more accurately described as a fine for those who decide to forgo coverage
Among the demagogues who know better is Newt Gingrich the former House Speaker is outraged, outraged I say, at the Democrats’ passage of the insurance mandate. He’s obviously had a change of heart, as a few short years ago he not only called for an enforceable mandate in a speech, he did it in two of the books he wrote.
Newt’s flip-floppery came about just yesterday, when the following dialogue took place on that fair and balanced network:
HANNITY: Do you think any of these constitutional challenges that are out there about the employer mandate, individual mandate, or any of the other challenges — do you think as they work their way through the courts, that any of that will be effective?
[…]
GINGRICH: Then you have to appeal the president’s ruling and they’d probably lose that fight. But what my sense is — first of all, I’m glad to see that some 13 attorneys general around the country —
HANNITY: Are going to sue.
GINGRICH: Have sued. Based on a 1992 Supreme Court decision which said that the federal government cannot punish you for failure to do something, I think that there’s an outside chance the suit will hold up. And that that will stop the individual mandate at the federal level.
Hmmm, seems pretty unequivocal.
here’s what Newt said just two years ago: “According to a June 11, 2008 Associated Press article (accessed from the Nexis database), which ran under the headline, “Gingrich suggests insurance mandate for those who can afford,” Gingrich reportedly “outlined his strategy to combat rising health care costs a plan of attack that includes insurance mandates for people who earn more than $75,000 a year” at a visit to a Nebraska health system. The article went on to report that “Gingrich called it ‘fundamentally immoral’ for a person who can afford insurance to save money by going without, then show up at an emergency room and demand free care. He said those who can afford insurance and choose not to buy it should be required to post bonds to pay for care they may someday need… Gingrich said everyone should have insurance, but not provided by the federal government.” [emphasis added]
(from MediaMatters)
Is he so ignorant, or so ballsy, that he doesn’t think anyone will pay attention to what he said, or wrote, a few short months ago? Or is Gingrich so driven, so insanely desperate for power, that he’ll be blown by political winds like a feather in a gale? Gingrich’s patently false statements are prima facie evidence of the depths to which right-wing opponents will descend in pursuit of power and popularity.
It’s disgusting and abhorrent behavior, and ill serves the nation.
What does this mean for you?
The new law of the land is nowhere close to perfect, or even very good; as I’ve said repeatedly I’m deeply concerned about the law’s all-but-complete failure to address costs. There’s so much misinformation circulating about health reform it is impossible to keep track of it all, much less debunk it.
When you hear Romney, or Boehner, or McConnell, or their fellow wingnuts proclaim the end of America as we know it, ignore them, or better, marvel at the lengths they will go in pursuit of the votes of the ignorant.

Mar

Workers comp will not be ‘Federalized’. Period.

Posted by Joe Paduda on Friday, March 26th, 2010 | Comments

There are some folks in the greater ‘workers comp’ world who are speculating that the ‘Feds’ are going to take over workers comp, or words to that effect.
This is idle speculation based on connecting unconnectable dots, reading unreadable tea leaves, seeing patterns where no patterns exist, some of it on the LinkedIn Workers Comp Forum group founded by Mark Walls (this is in no way a criticism of Mark; the Forum is an open discussion group where anyone can participate).
For the umpteenth time, there is NO interest on Capitol Hill in workers comp. And CMS can’t ‘take over workers comp’ without passage of a bill by Congress As I said last summer:
“we all know that comp was originally part of the Clinton reform package, known as Title Ten. What you may not know (and I didn’t until Bob Laszewski told me) is exactly one (1) person in DC wanted Title Ten. Bill Clinton. No one else, not Ira Magaziner or Jay Rockefeller or Hillary gave two hoots about WC, but the big dog did.
What is also little known is that the person who deleted Title Ten was none other than Ted Kennedy. And the Senator has not had a change of heart.
Could this change? No.
As Sen. Ron Wyden told me several months ago, when it comes to health reform, no one wants to pick a fight with anyone they don’t have to.”
To those who are engaging in this idle speculation, I ask why do you think anyone in Congress has any interest at all in taking on workers comp?
And if they did, which they don’t, where exactly would this fit on the priority list? Above the education reform bill? Just below immigration reform? Senior to the budget bill, or not? more, or less, important than the nuclear non-proliferation treaty? somewhat less significant than the Israeli West Bank settlement issue, or more? more critical than the energy bill, or no? If Congressman X has to spend time thinking about comp, or Afghanistan, or the Iraqi election, or Iran, or China’s refusal to adjust its currency valuation, or bank regulation, what do you think he will do?
As to any interest at CMS in taking over WC, wouldn’t you think they have enough to do what with expanding Medicaid by a third, revising hospital reimbursement, drastically changing physician compensation, completely redo-ing Part D, developing and implementing over a dozen pilots and trial programs, and revamping Medicare Advantage?
Get real, people. Workers comp is a tiny, all-but-insignificant industry that accounts for less than two percent of total US medical spend. Hell, workers comp amounts to only 11% of the P&C industry, and no one’s talking about nationalizing airplane hull insurance, or fire insurance, or GL or auto or…
What does this mean for you?
Anyone who thinks anyone inside the Beltway spends more than two seconds a year thinking about workers comp is not thinking.
To join Mark’s Forum, click here.

Mar

Blunt’s prosecutor under fire

Posted by Joe Paduda on Thursday, March 25th, 2010 | Comments

Let’s take a quick break from the ‘reform impact on work comp’ to return for a brief moment to North Dakota. You’ll recall when last we visited NoDak, we were wondering why the state Supreme Court had yet to issue a ruling in Sandy Blunt’s year-and-counting appeal.
Things have gotten even more interesting in the last few days.
Cynthia Feland, the Burleigh County Assistant State’s Attorney in charge of the state’s case against former WSI CEO Sandy Blunt, is starting to understand what it feels like to be on the other side of the table.
Sources in North Dakota indicated late last week that Feland is not only under investigation by the City of Bismarck’s police department for potential prosecutorial misconduct, but the state Bar Association has also determined Feland’s actions during the Blunt trial merit investigation.
(To which snarky bloggers might say “really? You don’t say!”.)
Bill Kidd at WorkCompCentral reported:
Bismark Police Chief Keith Witt confirmed Thursday that his department is investigating a complaint lodged against the Burleigh County State’s Attorney’s Office by Steve Cates, a Bismarck news blogger and supporter of Blunt. Witt said the investigation is “really preliminary at this point.”…A statement released at a March 9 “informational conference” by Bismarck Police Department Sergeant Mark Buschena said that Cates reported “he believes that the prosecutors of the Burleigh County State’s Attorney’s Office committed criminal violations in the prosecution of Charles (Sandy) Blunt which occurred in 2008.”
“He (Cates) also alleges that a prosecution witness committed perjury during trial and was involved in a conspiracy with the State’s Attorney’s Office concerning the prosecution,” the statement said.
The statement reported the “offenses named” were criminal conspiracy, perjury, false statement and misapplication of entrusted property during the period from Nov. 3, 2008, through Dec. 19, 2008.”
This may cause Feland a bit of difficulty in her campaign for district judge. That is, if the media in North Dakota sees fit to actually report the investigations, and, when they conclude, the results thereof. For some reason the media has yet to pay much attention to the charges faced by Feland…
Meanwhile, the State Supreme Court is still sitting on Blunt’s appeal, using their time to reach decisions on over a dozen cases filed – and heard – after Blunt’s.
Here’s hoping the State Supreme Court renders a judgment soon and the investigation of Feland moves quickly. Blunt has twisted in the wind long enough and it’s time for Feland to be brought to justice.

Mar

Health reform’s implications for work comp, part 3

Posted by Joe Paduda on Wednesday, March 24th, 2010 | Comments

Yesterday and Monday we reviewed the macro and micro impacts of health reform on work comp.
Today we’re going to focus on how reform will impact the comp network business.
There are two types of comp networks, those based on group health network contracts and comp-specific PPOs. The comp-specific PPOs include HFN, Rockport, CompPartners; they are contracted specifically for work comp although they may include some rental network agreements. These networks are likely to come thru the next few years relatively unaffected by reform.
Not so the group health-based ‘work comp’ networks.
To understand their future, consider how reform affects health plans. It’s all good; despite their complaints about government interference and regulation, execs are gleefully rubbing their hands in anticipation of tens of millions of new members.
But these very same plans will no longer be able to compete by being better at risk selection; instead they’ll have to get a whole lot better at managing cost and care.
This will require a lot more focus on provider assesment and partnership, development of new and innovative provider-payer relationships and contracts and reimbursement mechanisms and communication.
Health plan staff will be working flat out on these initiatives with precious little te for anything else.
Now let’s think about work comp. Total medical spend in comp is less than two percent of national helth care spend. Coventry, which dominates the work comp network business, gets about 9% of revenues from comp, and probably no more than two percent from network revenues. Aetna, which actually provides the networks for Coventry in 18 states +/-, may get 0.1% of total revenues from work comp networks.
So. You’re a health plan exec with limited resources. Are you going to spend any time, devote any resources, focus any provider relations, IT, or compliance staff on work comp?
Didn’t think so.

Mar

Reform’s impact on workers comp; Part 2

Posted by Joe Paduda on Tuesday, March 23rd, 2010 | Comments

Yesterday I highlighted four main ways health reform will impact workers comp. Today we’ll focus on the less-noticeable ways reform will change the comp industry. But we’ll start by addressing one of the common misconceptions; people without health insurance are more likely to file comp claims.
The research indicates the opposite is the case. As I’ve reported previously here (can’t link to the post cause I’m posting from my iPhone), a recent study documented the opposite; those with health insurance were more likely to file a comp claim than those without coverage. That appears to be more of a statistical than a causal link. There are other factors – e.g. the way the employer treats their workers, the workers’ pay level and immigration status, that appear to have more influence on filing than does coverage.
So don’t expect to see a decline in frequency due to broader health insurance coverage.
Medical devices
While the reform bill does include excise taxes on certain medical devices, it also promises to dramatically increase the number of potential customers for those devices. There has been some concern that manufacturers would raise prices to offset the new taxes; this remains a distinct possibility as there is little price elasticity in the device market. For comp
payers, there is the distinct possibility that device usage will increase driven by suppliers’ enthusiasm for new customers, a potential negative that may be offset by the suppliers’ focus on the much bigger employer and CMS (Medicare and Medicaid) health markets.
Medical management
What passes for medical management in the group and CMS world, while mostly ineffective, is nonetheless far more robust than what passes for med
management in work comp.
That isn’t likely to change anytime soon, but within the next couple of years I fully expect group insurers and health plans will invest heavily in medical management, data mining, analytics, chronic disease management, and electronic health record technology. This will help comp payers in two ways: as comp trails about a decade behind group, these new and improved med management tools will find their way into comp; and the improvements in patient health will reduce the need for comp payers to fix non-work-related medical conditions that complicate treatment of the comp injury.
Healthier claimants
Which brings us to what may well be the moat significant long-term impact of reform; the likelihood that workers will be healthier, their underlying conditions and comorbidities will be at least addressed by their health plan, and therefore comp payers won’t have to pay for treatment of those conditions in order to resolve the work injury. Think diabetes and surgery, spinal stenosis, and hypertension.
Degenerative conditions
Finally, for some diagnoses, identifying the cause of the injury is becoming increasingly problematic. It is often difficult for a physician to determine the ’cause’ of back pain or dysfunction; it may, or may not be wholly or partially related to a work injury and different physicians often reach different conclusions about the cause of injury. While reform won’t clear up those medical mysteries overnight, it will reduce the need for comp payers to pay for what are clearly non-work-related conditions.
What does this mean for you?
Opportunities for observant payers that quickly adopt innovations, and more need for COB expertise for claims staff.
Tomorrow – what’s coming next…how ‘fixing’ physician reimbursement will affect work comp.
Posted via iPhone.

Author: Joe Paduda