The National Pay-As-You-Go Workers Compensation Program. Worker s Compensation: An Introduction

Transcription

1 The National Pay-As-You-Go Workers Compensation Program Worker s Compensation: An Introduction

2 Worker s Compensation IS nation s first social insurance scheme a state responsibility, organized by state a compromise funded by employers through premiums IS NOT a welfare scheme or entitlement program a federal government responsibility a single plan required for all employers, except where state provides tax supported

3 What existed before WC? Crisis during the Industrial Revolution Injured workers had to sue employer Courts deliberately tried to protect employers in interest of increasing employment, wages Legal defenses for employers insurmountable: assumption of risk = worker voluntarily accepts risk of a dangerous job fellow servant doctrine = employer is not responsible if injury due to action of another employee contributory negligence = if any action by injured worker can be construed to have contributed to risk

4 What forced the change? Skyrocketing injury rates created social, political problems Labor unions started using this as an organizing issue As economy settled down, courts became more open to worker-initiated lawsuits Muckraking (e.g. The Jungle) Political climate changed: Progressive movement Model available: Germany, UK

5 The WC Compromise Workers receive care and benefits Medical care Lost wages Death benefit paid to family Administration would be fair and efficient Insurance model (actuarial rating, costs passed to consumers/employers) Intended to allow employers to anticipate costs Rapid, no-fault processing of claims Exclusive remedy: no appeal outside system, no alternative system

6 Early days of WC Huge wave of state legislation from 1911 to 1915 States set up Industrial Accident Commissions Coverage mandatory (except TX) Early attention to injury prevention Few permitted enhanced benefits Every state is different Benefits Payouts

7 Universal: Medical services for injured workers Income replacement Temporary disability Permanent disability Survivor benefits (if fatality) Variable: Services provided by WC Rehabilitation Retraining Amounts for maximum income payout

8 Who is covered? Usual coverage Employees of firms Covered under special systems: Maritime workers Railroad workers Federal employees Usually not covered Who is covered? Agricultural workers Self-employed Business owners Domestic workers Volunteers

9 Permanent disability benefits Two-thirds of WC disability benefits Wide variation in adjudication, criteria Ratings are based on: Impairment assessment (medically discernable injury) Actual wage loss Permanent loss of earnings potential (considering job market) Scheduled awards for specific impairments are trend (since NJ 1911) Covers future wage loss Unjust for injured workers to forgo benefits even if little wage loss at the time

10 How permanent disability is rated Three basic approaches: Impairment model Based on schedules Based on guidelines (e.g. AMA Guides) Wage-loss formula Calculates actual loss of wages due to injury Caps are applied Loss of earnings capacity Loss of future wages based on actuarial model

11 The AMA Guides to the Evaluation of Permanent Impairment Like any tool, needs to be used properly Not a cookbook: often gives a range Achieves some consistency Face validity in terms of relative impairment within functional systems Expert consensus

12 Downside to the AMA Guides No objective validation Often used indiscriminately as a formula for disability Avoids many important types of disability: Chronic pain Mental changes, depression Reversible conditions, such as airways reactivity Dermatitis Stress-related disorders (e.g. irritable colon) Has become a self-perpetuating industry involving complicated revisions, guides to the Guides, training programs and even a certification scheme

13 Carriers have a difficult time profiting on WC Six states have exclusive funds Economic conditions often directly affect claims experience Employers pay insurance premiums Premiums are based on: Industry group Size of enterprise Historical claims experience ( rating ) Carrier rates, territories and class codes Financial realities of WC Administrative expenses are very high (up to 30 to 40% of premiums)

14 Financial realities: Special cases Monopolistic States: ND, OH, WA, WY and Canadian provinces State insurance pools (24 states) intended for residual market and high risk expensive for employers Self insurance allowed in 47 states, not ND, WY company pays out, usually sets up fund only an option for very large companies Partially self-funded usually an option with clients who generate over $500,000 in estimated annual premium, fully funded

15 Financial realities of WC: Benefits Benefits from WC tend to be low Some states cap as a % of average wage in state, typically 2/3 Some states index to wages Only considers wages, not additional direct costs or social costs Costs are shifted from WC to supplemental Social Security and other programs Limbo between denied WC claims and rejected LTD claims injured worker caught in middle Market forces reductions in benefits to reduce costs: Reduced dollar benefits Reduced acceptance rate for claims Reduced impairment ratings Choice of rating system Choice of medical doctor

16 Underreported Underrepresented in claims Latency period Often arises during retirement Difficult to attribute to responsible employer Requirement for objective finding Bad or lacking information Missing data Incomplete differential diagnosis Inadequate exposure history Irrelevant data Occupational disease

17 Sociology of WC Deeply rooted distrust Of workers Of employers Of carriers Abuse of system By injured workers By malingering workers By employers By carriers Fear of consequences of filing a claim Emphasis on moral hazard

18 Sociology of injured workers Filing claim may bring stigmatization Esp. if injury is not obvious Esp. if embarrassing to employee Esp. if highly visible to other workers PD or prolonged rehabilitation Wearing on family Coworkers often turn unsympathetic, even hostile Neighbors, friends get tired, even suspicious of abuse Injured worker gets depressed Depressed people are difficult to be around Intimations of fraud, exaggeration, abuse Evolutional cycle

19 Role of physician Who picks: the right of choice of physician: Worker (half of states and DC) Usually family physician Employer or insurer (half of states, incl. VA) Often on list of approved providers Has given rise to PPO, other managed care models

20 Federal and Special Programs Federal workers Federal Employees Compensation Act DoE Office of Compensation Programs nuclear workers (radiation exposed) nuclear workers (chemical exposure) Federally administered Longshore and Harbor Workers Compensation Act Federal Black Lung Program

21 Occupations not covered by worker s compensation These workers have programs that cover disability whether workrelated or not; worker retains access to tort litigation US Merchant Marine Railroad workers in interstate commerce