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Recent study addresses workers comp dilemma Who should choose a worker's health care provider—worker or employer? By Phil Zinkewicz
In many states, the workers compensation system is in shambles, primarily due to the high cost of medical care, according to most industry observers. Finding ways to control those medical costs has become of paramount importance to businesses in general and the insurance industry in particular. Consequently, a debate is currently underway in the workers compensation insurance arena over who should choose the health care provider when a worker is injured on the job. Workers and their advocates have argued that the choice of the treating doctor or provider should be left to the worker. They say workers should be treated by physicians they trust and whose interests align with the workers’—i.e., interests that encourage prompt return to work, but only as medically indicated. Employer advocates, however, believe the choice of provider should be made by the employer. They argue that employer choice ensures that incentives exist for keeping the costs of care reasonable and appropriate, that employer choice helps avoid excessive services and treatments, and that employer choice expedites return to work. The Workers Compensation Research Institute (WCRI) and the Public Policy Institute of California (PPIC) recently released a study on this very subject. One of the authors of the study, Richard Victor, executive director of the WCRI, says that this study differs from previous ones in four ways. First, it utilizes data taken from employee interviews conducted in 2002 and 2003 in four states—California, Texas, Massachusetts and Pennsylvania—where workers were asked to identify who selected their health care providers. “In contrast,” writes Victor, “previous studies classify provider choice based on state statutory provisions, despite the fact that the statutory provisions are imperfectly related to actual choice of provider exercised by a worker.” Second, he says that this study focuses on the primary provider of medical care, who is often different from the initial provider playing a subsidiary role. “Third, we link the data from the interviews to claims data supplied by the claims payers, providing information on factors that include medical and indemnity costs, medical treatments and employer attributes, among others. A more complete picture of the claim from the vantage point of both the worker and the employer should help to better establish the consequences of provider choice.” Fourth, says Victor, the existing studies are limited to estimating the effects of provider choice on cost, whereas this study looks at a wider set of outcomes of concern to policymakers and stakeholders. Finally, the interview data also indicate whether the primary provider had previously treated the worker for an unrelated condition. The following are some of the findings of this study, according to Victor: • Comparing cases in which the worker selected the primary provider with otherwise similar cases in which the employer selected the provider, the study found that costs were generally higher and return-to-work outcomes poorer when the worker selected the provider. Workers reported higher rates of satisfaction with overall care, however. • Compared with cases in which the employer selected the provider, those cases in which the worker selected one who had not treated him or her previously (new provider) had much higher costs and poorer return-to-work outcomes, generally no difference in physical recovery and higher levels of satisfaction with overall care. • Comparing cases in which the employee selected a prior provider with similar cases in which the employee chose a new provider, the study found that the worker treated by a new provider was less likely to return to work, returned to work more slowly if he or she did return, had lower levels of satisfaction with overall care, and experienced no better physical recovery. Medical costs were similar in both cases, but indemnity costs per claim were higher for a worker treated by a new provider, although this evidence was not as strong statistically as the other results. Victor described the significance of these results this way: “First, we found that when the worker chose the provider, costs were higher, recovery of health outcomes was not better, and return-to-work outcomes were often worse than when the employer selected the provider. This finding suggests that employers, on average, may be well positioned to select good-quality, lower-cost providers—or at least [were] better positioned than many workers. The finding also suggests that employers, in practice, are not generally selecting inferior-quality providers; although there may be exceptions, they do not appear to be frequent enough to affect the overall results. “Second,” according to Victor, “we found that when workers select new providers—those they had not been treated by previously—costs were higher and return-to-work outcomes were poorer. This evidence suggests that state laws that grant employers greater influence over the choice of provider should lead to lower costs and better return-to-work outcomes than laws that allow workers to select providers whom they have not seen previously. “Third, we found that when workers selected providers with whom they had a pre-existing clinical relationship, the costs and most outcomes were not dramatically different than when the employer selected the provider. “However, when workers selected providers—either prior or new—they expressed higher levels of satisfaction with care. We are not surprised by this finding regarding workers choosing prior providers, because a key issue is the likelihood that a worker will be seen by a provider who has the appropriate training and skills, is trusted by the worker, and delivers appropriate care. More surprising, though, is that workers also expressed greater satisfaction when they selected new providers (relative to employers choosing). We explored whether this greater satisfaction appeared to be relative to dimensions of physical recovery not captured in our data or assistance in remaining out of work beyond the necessary time following an injury, but we were able to rule out such explanations. There may, however, be alternative explanations related to empowerment, trust, or the process of care that leaves workers more satisfied with their new-provider choices, even though costs and return-to-work outcomes appear to be worse and physical recovery no better.” Victor said the results for California paralleled those for the larger sample in providing some evidence suggesting that the costs were higher and return-to-work outcomes were worse when workers selected providers with whom they had no prior relationship. This suggests that the recent legislative changes in California—which significantly expanded the limits on worker choice of provider but retain an exception where there is a pre-existing provider relationship—may have struck an appropriate balance. The pre-designation exception to the worker’s choice of provider among an employer-designated network of providers bears some resemblance to the prior-provider category that we analyze. However, this prior-provider category is broader than the California requirements for pre-designation—for example, the prior provider has to be the personal physician of the worker under a non-occupational group health insurance plan offered by the employer. Thus, the results are potentially quite informative about the likely effects of the changes in provider choice recently enacted in California, but they do not provide a direct test of the impact of the reforms. Such a direct test will not be possible until some time after the reforms are implemented, probably at least a couple of years from now, says Victor. * |
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