Employee Perspective Needs More Consideration in the Workers’ Comp System
Workers’ comp has been more focused on insurers and employers. It needs to focus more on the worker himself for better outcomes.
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Workers’ compensation claims are considered after a thorough medical records review that can help establish the injury sustained and the subsequent disability the worker experiences. The workers’ comp system has been focusing on managing costs for employers for many decades now, and recently workers’ compensation experts were exhorted to turn their attention more to the needs of injured workers and be more involved in redressing the grievances of workers with disabilities. This was stressed at the WCRI (Workers’ Compensation Research Institute) conference held in Boston in early March this year. Injured workers are in real need of a credible system especially now when options such as employer-funded pensions, job security and health insurance are being weakened. The need of the day is also to more clearly define the responsibilities workers’ comp professionals and public policy makers have towards a group that is outside the system – older workers with long-term disabilities and chronic illnesses, undocumented immigrant labourers, and sharing or gig economy workers. Does the Workers’ Comp System Really Meet Its Objectives? There is a common concern that the workers’ comp system is not fully meeting its commitment of taking care of injured workers for giving up their right to sue their employer over the injury. Many injured workers have failed to receive the benefits due to them, and costs of workplace injuries are primarily met by injured workers, their families, and taxpayers’ support of the social safety net. There have been many issues such as the following. •
There is intense scrutiny of workers’ compensation now.
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States have raised the bar of compensability. Work needs to be a predominant or major contributing cause of an injury.
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Employers are given greater authority to direct medical treatment. As a result, networks and panels were created, along with utilization review protocols, treatment protocols, evidence-based medicine and so on.
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The “opt-out” movement being introduced in some US states is a growing problem. The opt-out option is an issue because many employers just abandon the system and set up their own system, which could be damaging to workers.
Why the Workers’ Perspective Is Important The need of the day is to obtain the workers’ point of view regarding the system so that the necessary reforms can be introduced. The real issue is the group of workers who are not getting what is due to them, such as aging people, and the many workers who develop chronic work-associated illnesses but never apply for workers’ compensation. There are other employees such as temporary workers, non-documented immigrants,
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workers in trades and others who remain outside the system. These workers know that they have the right to receive benefits, but never apply for the same. A recent story in nbcbayarea.com focused on injured workers in California who said that the workers’ comp system is dragging out or denying the medical care needed to get them back to work. Many of them feel trapped in the red tape of the system, and fighting with insurance companies instead of getting well. Both injured workers and their doctors say that denials of medical treatment are at an all-time high. However, it is difficult to study how the system is working because the Department of Industrial Relations that administers workers’ comp does not publish data regarding the number of treatment requests that are ultimately approved or denied. The data and reports related to workers’ comp are published by the CWCI (California Workers’ Compensation Institute), a private organization of insurance companies. This data is voluntarily submitted by its members and therefore it is impossible to evaluate whether that sample represents the entire system. It is estimated that workers who suffer a straightforward workplace injury may find that the system works fine. However, it is not so for those suffering from complex and prolonged injuries because it is this group that faces a number of denials and delays. This leads to the deterioration of their health, in addition to having to suffer mental trauma. The Problem Posed by Utilization Review Many workers find that the main issue is the process of utilization review, in which doctors appointed by insurance companies and employers review the medical treatment requests made by an injured worker’s physician. This review is mainly done to determine if the treatments are medically necessary for the injured worker and aims to contain costs and fight medical fraud. On the basis of a standard set of guidelines, the doctors approve or deny treatment. However, workers and their treating physicians say that reviewing doctors work in favour of the insurance company that is employing them, not the patient. These doctors do not even examine the patient, but make their decision on the basis of a partial medical records review. The doctor who does the UR may even be in another state because there is no law requiring them to have a license to practice medicine in California. A survey of doctors done by the California Medical Association in 2014 found that 67% of physicians reported difficulties in obtaining authorization for treatment through the UR process since the 2013 workers’ comp reforms.
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The greatest problem was the inappropriate denial of medically necessary tests, procedures or services.
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Official records show that in the year 2013 alone, there were around 1,100 complaints about utilization review that were filed by more than 400 injured workers, workers’ comp attorneys, and doctors treating injured workers.
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The CWCI however, says that the data provided by its members comprising insurance companies and employers reveal that 96% of workers’ comp treatment requests are ultimately approved. This data is not made public though.
Application of Evidence-based Medicine Not Appropriate The California Utilization Review program focuses on evidence-based medicine, which uses medical guidelines to determine if a procedure/service is medically necessary. Evidence-based medicine is expected to ensure better care, better health outcomes and fewer wasted resources. However, the criticism is that evidence-based medicine is not being properly applied. According to Steve Cattolica, director of government relations for the California Society of Industrial Medicine and Surgery, the concept of evidence-based medicine has been twisted by the insurance industry with a view to reduce costs and deny care. He points out that a reviewing doctor should consider three factors equally: •
Medical treatment guidelines based on established research and science
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Expertise of the treating doctor
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Expectations of the injured worker.
Unfortunately, reviewing doctors often consider only the treatment guidelines, especially the MTUS (medical treatment utilization schedule). Denying treatment and care on the basis of guidelines alone, without taking into account the specific needs of each patient and their physician’s recommendations is not advisable. Though the concept of evidencebased medicine is good in theory, lawmakers do not have a proper understanding of how it is actually being applied. New Hope for Workers? In this scenario, conference sessions such as “What do injured workers really think about workers’ compensation” held at the RIMS 2017 Annual Conference & Exhibition will help to bring forth the injured workers’ viewpoint regarding the workers’ compensation system. This session presented WCRI’s findings on predictors of injured worker outcomes, and highlighted how employers like Walt Disney are using research and data to improve the likelihood of an injured worker returning to work. By carefully examining some of the predictors of injured worker outcomes, policymakers, employers and other
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stakeholders in the system can have a better understanding of factors that are associated with better and worse outcomes. The WCRI’s research data is derived from interviews conducted with injured workers with regard to significant outcomes such as recovery of health and functioning, return to work, recovery of wages, and access to and satisfaction with the healthcare services provided. The data presented can also be used to understand factors that may influence an injured worker’s access to medical care and also identify some of the reasons why those workers who have recovered from their injuries and could return to work, do not go back to work. Programs and events such as these provide research-driven insight that can be used by employers, insurers and claim professionals to help develop programs that are focused on improving claim development and creating a better understanding of workers’ experiences while negotiating the workers’ compensation system.
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