It’s been a question in CompLand ever since President Obama introduced the Affordable Care Act (ACA) in 2009. Would the law, enacted in 2010, lead to case shifting from health insurance to workers’ compensation?
Case shifting is nothing new. It often arises from gray area claims where the cause of injury might be related to work. An insurance entity does not want to pay bills that another should be paying so naturally, there has been effort to reduce case shifting.
But the ACA puts a new wrinkle on case shifting by encouraging Accountable Care Organizations (ACO) to adopt the age-old managed care capitated spending approach to reduce costs. Understand that this approach puts a lid on annual medical care spending per person (insured). Workers’ compensation, however, provides first dollar coverage, pays on a per-visit basis and limits medical spending by necessity.
Naturally, doctors don’t want to make less money, especially given other pressures such as reductions in Medicare payments. Critics don’t like it either, especially for workers’ compensation, because it can adversely affect quality of care and recovery, which can unnecessarily elongate payment of wage replacement benefits.
So the question is, if you were a medical provider with a “gray area” patient diagnosis, would you rather bill an Obama Care ACO or workers’ comp?
It appears that there is a greater likelihood of filing the patient’s claim under workers’ comp, according to evidence in the Workers Compensation Research Institute’s (WCRI) study, Will the Affordable Care Act Shift Claims to Workers’ Compensation Payors? As a result, hundreds of millions of dollars could be shifted to workers’ comp.
“It appears that there is a greater likelihood of filing the patient’s claim
under workers’ comp.”
Specifically, the study found that a back injury was 30 percent more likely to be called “work-related” in a state where the patient’s group health insurance was capitated rather than fee for service, according to a WCRI news release issued today.
In fact, the study found, case shifting was “more likely in states where a higher percentage of workers were covered by capitated group health plans,” the release said. In one state where at least 22 percent of workers had capitated group health plans, the odds of a soft tissue case being work-related was 31 percent higher.
In comparison to states where capitation was less common, there was no evidence of case shifting. “It also appears that when capitation was infrequent, the providers were less aware of the financial incentives,” the release said.
I always find WCRI’s research to be top notch. If you are concerned about workers’ compensation medical spending, you should check out their site at www.wcrinet.org.