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Getting More Control Over Workers’ Comp

By MICHAEL WEINPER PT, MPH California employers were hoping for more relief from high workers’ comp insurance premiums by now. They expected rate cuts of at least 20 percent after the passage of the new workers’ comp law (SB899) last April, but so far the average annual premium for workers’ compensation insurance has dropped only between 13.9 percent and 16.6 percent in the last six months, according to the state Department of Insurance. But there’s a light at the end of the tunnel. The California Division of Workers’ Compensation (DWC) has approved new regulations that offer employers more control over medical care than ever before by authorizing them, beginning January 1, 2005 to designate Medical Provider Networks (MPNs) to provide all treatment to injured workers. In the past, employers had control over employee medical care for only 30 days after the injury was reported. The new rules require networks to: >Include a variety of doctors and other providers with both general medical and occupational injury experience. >Follow all medical treatment guidelines established by the DWC. >Provide injured workers with primary and emergency care within 30 minutes or 15 miles of each employee’s residence or workplace. Specialists must be within 60 minutes or 30 miles. >Allow employees a choice of providers in the network after their first visit, and allow second and third opinions if the injured worker disagrees with the diagnosis or treatment offered by the treating physician. Workers injured prior to the establishment of the networks may continue to receive treatment from their existing doctors if the worker is scheduled for surgery, or the worker’s condition is acute, serious and chronic, or terminal. For more information on the regulations, go to the DWC Web site at http://www.dir.ca.gov/dwc. Only networks approved by the DWC will be eligible to treat injured workers. Therefore, choosing the best MPN will be crucial for employers who want to lower their workers’ comp costs, and facilitate a safe and timely return to work for their injured employees. Because rehabilitation care (physical therapy and occupational therapy) is one of the most significant cost drivers for workers’ comp injuries, employers should consider choosing a specialty network for the outpatient rehabilitation portion of their MPNs. Picking an expert to administer rehabilitation services “carving out” physical and occupational therapy services rather than using a single source to provide all medical specialties offers employers the following advantages: Directed patient referrals to a network of highly qualified and credentialed physical and occupational therapists with a proven track record of reasonable and appropriate standards of care. By promptly directing care to such providers, employers can better control costs and also protect themselves against those workers that have potentially fraudulent claims. A case management program in which providers are held accountable to provide the appropriate level of care to match the patient’s needs. One new regulation limits patients to 24 physical therapy visits, and for the vast majority of cases, that is sufficient; however, that cap may encourage some providers to deliver more visits than necessary. An effective case management system monitors utilization of services to ensure that patients receive neither too much nor too little treatment. Ideally, physical therapists should be reviewed by experienced peer case managers rather than nurses or claims managers who lack the training to properly monitor the continued need for a particular type of specialty care. Patient satisfaction measures that deal with the treatment process as well as its outcomes. Quality of care includes the treatment process as well as its outcomes. Do patients have to wait several days to get an appointment? Was enough time spent with the injured worker on how to avoid re-injury? Patients need to feel they’ve received sufficient treatment as well as instruction on how to avoid re-injury, and feel providers are interested in their well-being. A satisfied injured worker is less likely to sue the employer and/or insurer. Independent rehabilitation practitioners who own their own offices. Research has shown that these therapists as opposed to those working in physician- or corporate-owned physical therapy offices do not have conflicts of interest in ownership that can drive up utilization, raise costs and compromise quality of patient care. A study reported in the New England Journal of Medicine found that physical therapy was initiated 2.3 times more often by physicians who referred patients to their own rehabilitation clinics than by physicians who referred patients to independent facilities. Michael Weinper, PT, MPH, is President and CEO of Calabasas-based PTPN, a national network of private practice rehabilitation therapists experienced in treating workers’ compensation injuries. For more information, visit www.ptpn.com.

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