Evaluation FR rely on the WCRI FLASHREPORT. November 20155

Transcription

1 A WCRI FSHREPT Evaluation of the 2015 Professional Fee Schedule Update for Florida Olesya Fomenko November FR ISBN WCRI FSHREPTS are data-based analyses of specificc and highly topical issues that are typically being debated in current public policy debates. They are often done in response to requests for analyses by public officials or stakeholder groups. Since they are based on already-published WCRI dataa and methods, they are not separately subjected to the standard WCRI review process. Typically these reports rely on the WCRI Detailed Benchmark/Evaluation (DBE) Database. WCRI FSHREPTS are published in electronic format and widely distributed at no charge to the workers compensation n community at the time of publication. Subsequent copies can be orderedd at a nominal charge from the WCRI web site at / Workers Compensation Research Institute 955 Massachusetts Avenue Cambridge, (617) WCRI FSHREPT November 2015 FR Page 1 of 13

2 Evaluation of the 2015 Professional Fee Schedule Update for Florida INTRODUION This WCRI FlashReport responds to a request for information from the Florida Division of Workers Compensation. The agency requested information from WCRI since the Florida Legislature will consider ratifying an update to the Florida Workers Compensation Health Care Provider Reimbursement Manual during the 2016 session. Specifically, the agency requested that WCRI update some charts contained in the 2012 WCRI report Designing Workers Compensation Medical Fee Schedules that were reproduced in the recent CompScope Medical Benchmarks for Florida, 16th Edition. This report provides a comparison of the proposed fee schedule rates as published in the draft of Florida Workers Compensation Health Care Provider Reimbursement Fee Schedule, 2015 Edition, and Florida Medicare rates as of 2015 for the same set of procedures. In addition to comparing the 2015 proposed fee schedule rates to 2015 Medicare rates for Florida, we also evaluated how the proposed fee schedule update compares with the 2011 Florida fee schedule levels relative to 2011 Medicare rates and how it impacts Florida s ranking among other fee schedule states. For the purpose of the ranking comparison, we used workers compensation fee schedule percentages above or below Medicare for all fee schedule states as of 2011 that were reported in the previously published WCRI study Designing Workers Compensation Medical Fee Schedules (Fomenko and Liu, 2012). The 2011 fee schedule rates may not accurately reflect the current ranking of some states that had substantial fee schedule changes since July As in the previous study, this study uses a marketbasket approach to ensure interstate comparisons of fee schedules are based on the same mix of procedures in each state. OLI OF J FIINGS The key findings from the evaluation of the proposed 2015 update of the professional workers compensation fee schedules in Florida are briefly summarized below. A more extensive discussion with supportive charts can be found in the next section, Major Findings. The proposed update would result in an increase in the workers compensation fee schedule rates for all types of professional medical services except for pain management injections. However, as a result of this fee schedule increase, Florida would only slightly move up in the ranking among other fee schedule states and would remain in the group of states with workers compensation fee schedules near or below Medicare. In particular, the overall workers compensation fee schedule would increase from 2 percent to 14 percent above Medicare, while the overall workers compensation fee schedule rates in the majority of the states were above the Medicare rates by 30 percent or more. For evaluation and management, Florida workers compensation fee schedules would increase to 10 percent above the Medicare level from 7 percent below Medicare, so Florida would remain in the group of states with workers compensation fee schedules for evaluation and management near or below Medicare. Similarly, the workers compensation fee schedule for physical medicine in Florida would increase from 1 percent below Medicare to 10 percent above Medicare. Hence after the 2015 update, Florida would not change its ranking for physical medicine and would stay among the states with workers compensation fee schedules for physical medicine services near or below Medicare. For major surgeries, the workers compensation fee schedule rate in Florida would increase from 28 percent to 46 percent above the Medicare rate in the state. As a result, Florida s fee schedule rates 1 In September 2011, the Illinois workers compensation fee schedule rates for all types of medical services underwent an across-the-board decrease of 30 percent. Also, effective January 2014, California transitioned to a resource-based relative value scale (RBRVS) based fee schedule. Before this change, California used the Official Medical Fee Schedule (OMFS) to regulate the payment of professional services, and the fee schedule rates in the OMFS remained unchanged since WCRI FSHREPT November 2015 FR Page 2 of 13

3 relative to Medicare for major surgeries would remain among the lowest. These three service groups represent an overwhelming majority of the total expenditures for the professional services included in the study (see Table 1). More detailed discussion of the fee schedule changes for these and other service groups is presented in the next section. J FIINGS Chart 1 Fee Schedule Rates Lower Than 42-State Median For All Types Of Professional Services State Medicare Rates E&M ER Services -3-1 Minor Radiology 41 Physical Medicine 109 Major Radiology Major Surgery Pain Mgmt. Injections (2011) (2015)* Median Of Other 42 States (2011) Chart 1 shows the workers compensation professional fee schedule rates compared with the state Medicare rates for the same year across major types of professional services in Florida for 2011 and 2015, and the median of the other 42 states with fee schedules in effect as of The Florida 2015 bar reflects the proposed fee schedule rates as published in the draft of Florida Workers Compensation Health Care Provider Reimbursement Fee Schedule, 2015 Edition relative to the 2015 Medicare rates for Florida. The proposed update would result in an increase in the workers compensation fee schedule rates for all types of services except for pain management injections. However, for both editions of fee schedules, Florida workers compensation fee schedule rates relative to the state Medicare rates for the same year were lower than the median of the other 42 states for all types of services. Key: WC: Workers compensation; E&M: Evaluation and management; ER: Emergency; Mgmt.: Management. WCRI FSHREPT November 2015 FR Page 3 of 13

4 Chart 2 Overall FS Rates Near Medicare, While Most State WC FS Above Medicare By 30% Or More * 11 Chart 2 shows the overall workers compensation professional fee schedule rates as of July 2011 as a percentage above or below the 2011 Medicare rate in each state. This chart shows two bars for Florida. One bar (labeled 11) reflects workers compensation fee schedule rates in 2011 (effective since February 2009) relative to 2011 Medicare rates, and the second bar (labeled 15) captures the proposed fee schedule rates in the draft of the Florida Workers Compensation Health Care Provider Reimbursement Fee Schedule, 2015 Edition relative to 2015 Medicare rates. In the majority of the states, the overall workers compensation fee schedule rates were above the Medicare rates by 30 percent or more. In Florida in 2011, the overall workers compensation fee schedule rate for professional services was close to the Medicare rate 2 percent above Medicare. With the proposed update, the overall workers compensation fee schedule would be 14 percent above Medicare in As a result of this update, Florida would only slightly move up in the ranking among the fee schedule states and remain in the group of states with workers compensation fee schedules near or below Medicare. Note: Rhode Island is not included in this chart since it has different billing codes for physical medicine that we are unable to crosswalk to commonly used Current Procedural Terminology (CPT) codes. An overall rate is not established for Rhode Island, as physical medicine is the largest component of the marketbasket and excluding it significantly biases the results. Key: FS: Fee schedule; WC: Workers compensation. WCRI FSHREPT November 2015 FR Page 4 of 13

5 Chart 3 After The 2015 Update, FS Rates For E&M Services Would Remain Near Medicare Levels * RI Chart 3 shows the workers compensation professional fee schedule rates for evaluation and management services as a percentage above or below the Medicare rate in each state, as of July For Florida, we also computed the evaluation and management fee schedule rate relative to the 2015 Medicare level using the proposed fee schedule rates as published in the draft of Florida Workers In Florida, the workers compensation fee schedule rate for evaluation and management was 7 percent below the Medicare rate in According to the proposed update, Florida workers compensation fee schedules for evaluation and management would increase to 10 percent above the Medicare level in 2015, so Florida would remain in the group of states with workers compensation fee schedules for evaluation and management near or below Medicare. Key: FS: Fee schedule; E&M: Evaluation and management; WC: Workers compensation. WCRI FSHREPT November 2015 FR Page 5 of 13

6 Chart 4 After 2015 Update, Would Not Change Its Ranking For Physical Medicine FS Rates * 11 Chart 4 shows the workers compensation professional fee schedule rates for physical medicine services as a percentage above or below the Medicare rate for similar services in each state, as of July For Florida, we also computed the physical medicine fee schedule rate relative to the 2015 Medicare level using the proposed fee schedule rates as published in the draft of Florida Workers Compensation Health Care Provider Reimbursement Fee Schedule, 2015 Edition. In the majority of the states, the workers compensation fee schedule rates for physical medicine were above the Medicare rates by 30 percent or more. With the proposed update, the workers compensation fee schedule for physical medicine in Florida would increase from 1 percent below Medicare to 10 percent above Medicare in Hence after the 2015 update, Florida would not change its ranking for physical medicine and would stay among the states with workers compensation fee schedules for physical medicine services near or below Medicare. Note: Rhode Island is not included in this chart since it has different billing codes for physical medicine that we are unable to crosswalk to commonly used Current Procedural Terminology (CPT) codes. Key: FS: Fee schedule; WC: Workers compensation. WCRI FSHREPT November 2015 FR Page 6 of 13

7 Chart 5 After 2015 Update, FS Rates For Major Surgery Would Remain Among The Lowest * RI Chart 5 shows the workers compensation professional fee schedule rates for major surgery as a percentage above or below the Medicare rate in each state, as of July For Florida, we also computed the major surgery fee schedule rate relative to the 2015 Medicare level using the proposed fee schedule rates as published in the draft of Florida Workers Compensation Health Care Provider Reimbursement Fee Schedule, 2015 Edition. In 70 percent of the states, the workers compensation fee schedule rates for major surgery were at least double the Medicare level. Moreover, about one-quarter of the fee schedule states established their fees for major surgery to be at least triple the Medicare rates in each state. In Florida, the workers compensation fee schedule rate for major surgeries would increase from 28 percent (2011 rate) to 46 percent (2015 proposed rate) above the Medicare rate in the state. As a result of the proposed update, Florida would only slightly move up in the ranking of the states with respect to fee schedule rates for major surgery, and its fee schedule rates for major surgery would remain among the lowest. Key: FS: Fee schedule; WC: Workers compensation. WCRI FSHREPT November 2015 FR Page 7 of 13

8 Chart 6 After 2015 Update, FS Rates For Major Radiology Would Remain One Of The lowest * RI Chart 6 shows the workers compensation professional fee schedule rates for major radiology as a percentage above or below the Medicare rate in each state, as of July For Florida, we also computed the major radiology fee schedule rate relative to the 2015 Medicare level using the proposed fee schedule rates as published in the draft of Florida Workers Compensation Health Care Provider Reimbursement Fee Schedule, 2015 Edition. In the majority of the states, the workers compensation fee schedule rates for major radiology were at least double the Medicare rates in the state. In 2011, the workers compensation fee schedule rate for major radiology in Florida was close to the Medicare rate. With the proposed update, the workers compensation fee schedule would increase to 12 percent above the Medicare rate in After the 2015 update, Florida fee schedule rates for major radiology would remain among the lowest. Key: FS: Fee schedule; WC: Workers compensation. WCRI FSHREPT November 2015 FR Page 8 of 13

9 Chart 7 After 2015 Update, FS Rates For Minor Radiology Would Remain Near Medicare * RI Chart 7 shows the workers compensation professional fee schedule rates for minor radiology services as a percentage above or below the Medicare rate in each state, as of July For Florida, we also computed the minor radiology fee schedule rate relative to the 2015 Medicare level using the proposed fee schedule rates as published in the draft of Florida Workers Compensation Health Care Provider Reimbursement Fee Schedule, 2015 Edition. For minor radiology, the workers compensation fee schedule rates were more than double Medicare in 20 states. In Florida, the workers compensation fee schedule rate for minor radiology was 3 percent below the Medicare rate in According to the proposed update, workers compensation fee schedules for minor radiology would increase to 12 percent above the Medicare level in 2015, so Florida would remain among the states with the lowest workers compensation fee schedule rates. Key: FS: Fee schedule; WC: Workers compensation. WCRI FSHREPT November 2015 FR Page 9 of 13

10 Chart 8 After 2015 Update, Pain Mgmt. Inj. FS Rates Would Decrease But Remain Above Medicare * 11 RI Chart 8 shows the workers compensation professional fee schedule rates for pain management injections as a percentage above or below the Medicare rate in each state, as of July For Florida, we also computed the pain management injections fee schedule rate relative to the 2015 Medicare level using the proposed fee schedule rates as published in the draft of Florida Workers Compensation Health Care Provider Reimbursement Fee Schedule, 2015 Edition. With the proposed update, the workers compensation fee schedule would decrease from 52 percent to 28 percent above the Medicare rate. Key: Pain Mgmt. Inj.: Pain management injections; FS: Fee schedule; WC: Workers compensation. WCRI FSHREPT November 2015 FR Page 10 of 13

11 Chart 9 After 2015 Update, FS Rates For ER Services Would Remain Near Medicare Level * RI Chart 9 shows the workers compensation professional fee schedule rates for emergency services as a percentage above or below the Medicare rate in each state, as of July For Florida, we also computed the emergency services fee schedule rate relative to the 2015 Medicare level using the proposed fee schedule rates as published in the draft of Florida Workers Compensation Health Care Provider Reimbursement Fee Schedule, 2015 Edition. Following the 2015 update, the workers compensation fee schedule rate for emergency services would increase from 3 percent to 9 percent above the Medicare rate, so Florida would still have one of the lowest workers compensation fee schedules for emergency services. Note: Ohio does not establish rates for the emergency services included in the marketbasket. Therefore, Ohio is excluded from this chart. Key: FS: Fee schedule; ER: Emergency; WC: Workers compensation. WCRI FSHREPT November 2015 FR Page 11 of 13

12 THOD A DATA Method To facilitate the comparisons of the 2015 proposed fee schedule rates and the 2015 Medicare rates, we computed the percentage of the Florida workers compensation fee schedule above or below Medicare in the state for the most common groups of services and the overall state level. In doing so, we closely followed the methodology used in WCRI s Designing Workers Compensation Medical Fee Schedules (Fomenko and Liu, 2012). To further evaluate the change in the Florida workers compensation fee schedules, we compared the proposed rates with the 2011 fee schedule rates in Florida and other fee schedule states. For the 2011 workers compensation levels, we computed the percentages of workers compensation fee schedules above or below Medicare for all fee schedule states as of In selecting the collection of common medical procedures (or marketbasket), we focused on seven service groups, including emergency, evaluation and management, physical medicine, both major and minor radiology, major surgery, and pain management injections. 2 Designing Workers Compensation Medical Fee Schedules also included the neurological/neuromuscular testing service group. However, in 2013, Medicare implemented a fundamental change in the coding for nerve conduction studies that affected the most commonly billed procedures in the neurological/neuromuscular testing service group. Given that there is no direct crosswalk between the old and new codes, we were not able to select a common set of codes to characterize the neurological/neuromuscular testing service group for 2011 and 2015 and to accommodate a comparison of the 2015 proposed update to Florida fee schedules with 2011 numbers for the rest of the states. However, after excluding the neurological/neuromuscular testing service group from the computation of the overall fee schedule rates, the state ranking for all fee schedule states remained largely unchanged because this group only accounts for 2.4 percent of all expenditures. The codes within each service group included in the report cover between 81 and 97 percent of total expenditures in each service group except major surgery (see Table 1). While 39 codes were included in the major surgery group, only 67 percent of total expenditures were represented, because each additional code contributed only a trivial percentage of payments. Since comparisons of Florida workers compensation fee schedule rates with the state s Medicare fee schedule rates were conducted at the service group and state levels, we used the marketbasket approach to aggregate procedure-level fee schedule rates. To aggregate from the procedure-level rates to the service-group level, procedure-level frequency weights were utilized. The procedure-level frequency weights for the selected codes captured relative frequency of utilization of each procedure within the corresponding service group. The same set of weights was used to compute the service-group aggregate rates for workers compensation and Medicare across all states. To further aggregate servicegroup level rates to the state level, we applied service-group frequency weights. Further details on the computation of frequency weights and aggregate rates can be found in Designing Workers Compensation Medical Fee Schedules (Fomenko and Liu, 2012). The use of the marketbasket approach ensures that interstate comparisons of fee schedules are based on the same mix of procedures in each state. 2 Evaluation and management services are office visits. Physical medicine includes physical and occupational therapies and chiropractic care. Major radiology includes services such as computed tomography () scans and magnetic resonance imaging (MRIs), while minor radiology includes services such as X rays and ultrasounds. Major surgery is typically invasive surgical procedures such as arthroscopic surgeries and laminotomies. The pain management injections category includes injection procedures commonly used for pain management, such as epidural or steroid injections on nerve roots and muscles for lumbar, sacral, cervical, or thoracic areas. Neurological/neuromuscular testing includes neuromuscular testing and services such as F-wave studies. Table TA.1 in Fomenko and Liu (2012) lists the Current Procedural Terminology (CPT) codes included in the analysis, organized by service group, with a brief description of each code. WCRI FSHREPT November 2015 FR Page 12 of 13

13 Table 1 Description of Marketbasket Contents Service Group Number of Codes % Expenditures Captured by Marketbasket Codes % Expenditures in Population Emergency 5 97% 2.3% Evaluation and management 10 95% 22.0% Major radiology 15 89% 9.4% Minor radiology 38 81% 4.7% Neurological/neuromuscular testing 13 93% 2.4% Physical medicine 20 86% 32.0% Pain management injections 18 97% 3.1% Major surgery 39 67% 24.0% Total % 100.0% Notes: The numbers in this table reflect the average expenditures of 24 states from January 2008 to December 2009 used to select the marketbasket. This FlashReport excludes the neurological/neuromuscular testing service group from the evaluation of the fee schedule update. In 2013, Medicare implemented a fundamental change in the coding for nerve conduction studies with no direct crosswalk between the old and new codes, which made a comparison of the 2015 proposed update to Florida fee schedules with 2011 numbers for the rest of the states not feasible. Source: Reprinted from Designing Workers Compensation Medical Fee Schedules (Fomenko and Liu, 2012). Data The data for this report come from workers compensation professional fee schedules for commonly used professional medical services in workers compensation. Forty-three states have workers compensation professional fee schedules. 3 The 2011 workers compensation fee schedule rates, current as of July 2011, were acquired from Ingenix (Optum). The 2015 proposed fee schedule rates for Florida come from the draft of Florida Workers Compensation Health Care Provider Reimbursement Fee Schedule, 2015 Edition. Additionally, the 2011 Medicare fee schedules for all fee schedule states as well as the 2015 Medicare fee schedules for Florida were used in the comparison and obtained from the Centers for Medicare & Medicaid Services. 4 VEAT A LITATION To evaluate Florida s fee schedule ranking among other fee schedule states after the 2015 proposed update, we compared the proposed fee schedule rates with workers compensation fee schedule rates for other fee schedule states current as of July The 2011 fee schedule rates may not accurately reflect the current ranking of some states that had substantial fee schedule changes since July For example, in September 2011, the Illinois workers compensation fee schedule rates for all types of medical services underwent an across-the-board decrease of 30 percent. Also, effective January 2014, California transitioned to a resource-based relative value scale (RBRVS) based fee schedule. Before this change, California used the Official Medical Fee Schedule (OMFS) to regulate the payment of professional services, and the fee schedule rates in the OMFS remained unchanged since The District of Columbia was not included in the analysis. In addition to the District of Columbia, we excluded Wisconsin from the analysis because that state uses certified databases based on charges, which are not considered a traditional workers compensation fee schedule. 4 For 2011, retrieved from Payment/PhysicianFeeSched/PFS-Carrier-Specific-Files.html (accessed May 18, 2012). For 2015, retrieved from Items/CY2015-CarrierFiles.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending (accessed September 15, 2015). WCRI FSHREPT November 2015 FR Page 13 of 13