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BOSTON — Higher fee schedules generally result in cases being shifted from group health coverage to workers compensation, according to preliminary findings by the Workers Compensation Research Institute.
Depending on the injury, decisions about whether an injury is related to work may rely heavily on treating physician assessments, WCRI President and CEO Dr. John Ruser said Thursday during the Cambridge, Massachusetts-based group's 2016 WCRI Annual Issues & Research Conference in Boston.
With factures, contusions and lacerations, for example, it's usually clear whether an injury occurred on the job, Dr. Ruser said of the study of injuries originating between 2008 and 2010. Causation is less obvious for soft tissue injuries such as knee and shoulder strains, giving doctors more discretion, he said.
“It's not about fraud,” Dr. Ruser said. “It's about uncertainty, and financial incentives could influence that decision.”
According to WCRI's preliminary findings on how fee schedules affect case-shifting, increasing workers comp reimbursement rates by 20% for physician services associated with office visits increases the odds that a soft tissue injury will be considered work-related by 6%.
“It doesn't sound like a lot, but it's more than you think,” Dr. Ruser said, adding that the 6% increase in comp-related soft tissue injuries leads to a 1.5% increase in overall workers comp costs.
In Illinois, for example, a 12% greater volume of case-shifting of soft-tissue injury cases from group health to workers comp translated to 3.7% higher workers comp benefit payments, or $85 million, according to the preliminary research.
He said there was no evidence of case-shifting for patients with fractures, lacerations, contusions or traumatic injuries by trauma in all 50 states studied.
Though employers pay for both group health and workers comp, case-shifting leads to higher costs as workers comp typically pays higher prices for medical care, higher workers comp income benefits can cause cases to stay open longer, and income benefit payments often exceed nonoccupational disability insurance payments, which aren't offered to everyone, Dr. Ruser said.
During a question-and-answer session, an attendee noted that case-shifting might also include repeat surgeries and poor outcomes for older workers.
Patient incentives also can come into play, Dr. Ruser said, since there are no copays or deductibles in workers comp.
“Everything else equal, the patient would be happy if a particular case was called work-related,” he said.