How the Affordable Care Act Affects Workers Compensation Part Two

How the Affordable Care Act Affects Workers Compensation Part Two By Mark Noonan Part one of this series examined the potential impact of the Affordable Care Act (ACA) on workers compensation and general healthcare. Specifically, it considered the impact of provider shortages and explored how nurse practitioners (NP) and physician assistants (PA) will provide alternatives to traditional physician provided treatment. Along with those alternative access points to health care, wellness programs and their potential impact on the workforce was presented as a potential solution. Here, we discuss the reality of the aging workforce and how it may impact employers in the workers compensation area as well as disputing some myths about older workers being more injury prone and expensive. We look at cost shifting and how it could impact employers and the Healthcare Industry and provide some final thoughts on what to expect in the next few years. The Impact of an Aging Workforce As noted in Part one, the number of people over the age of 65 will increase 36% by 2020. Compounding the provider shortage issue in workers compensation is the reality that retirement trends (and the resulting withdrawal of older workers from the workforce) have changed drastically in the last decade. Fewer people have defined benefit retirement plans, people tend to move around to different employers much more frequently than prior generations, and the cost of living and availability of an adequate funding of post work life have driven many older Americans to remain in the workforce beyond traditional retirement dates. Where 65 was once the magic age (and 62 the target for many) Social Security has driven that age to 66 (if born before 1957) and to 67 for many more. As workers remain in the workforce longer, they will continue to face risk of injury. Treatment will be necessary and will result in further pressure on providers to maintain sufficient resources to treat older employees with potentially significant injuries. Additionally, the co morbidities that come with age can require more and different types of treatment. The NCCI completed and published a study in 2011 on the aging workforce. Some of the findings underscore the concern that provider demand will continue to grow in workers compensation for treating older workers. In addition to confirming that the share of older workers is increasing, the NCCI examined differences in the components of loss costs frequency (injury rates per worker) and severity across age groups; identified those factors that account for the observed differences in severities between older and younger workers; and compared the combined effects of frequency and severity, or loss costs, per worker. How the Affordable Care Act Affects Workers Compensation Part 2 August 2014 1

Key Findings From the NCCI In terms of loss costs per worker, the major difference in cost occurs between the 25 to 34 and the 35 to 44 age groups. All groups of workers age 35 to 64 appear to have similar costs per worker. These findings offer reassurance that an aging workforce may have a less negative impact on loss costs per worker than originally thought. 1 The long standing tenet that younger workers have much higher injury rates is no longer true. Therefore, differences in loss costs by age in recent years primarily reflect differences in severities since differences in frequency by age have virtually disappeared. 2 Differences in leading types of injuries are a major factor in differences in severity by age. Older workers tend to have more rotator cuff and knee injuries while younger workers have more back and ankle sprains. 3 On the indemnity side, higher wages are a key factor leading to higher costs for older workers. 4 For medical, more treatments per claim are a material factor. 5 Cost Shifting There are a number of reasons that costs can be shifted from non occupational health insurance coverage to workers compensation. Lack of health insurance in the days before the ACA was a frequently cited reason by employees for suggesting a condition was work related. High out of pocket expenses for treatment, including surgery, were also utilized as justification as was long term treatment (PT, etc.) and cost of medications. Sometimes the cost shifting was unintentional. The claims involving fabrications or fraud are easy to identify, but when causation is ambiguous, like an aggravation to a pre existing injury, it is not unreasonable to conclude that the condition was caused by work. Often medical professionals, based on history and background given by their injured patients, would suggest a possible connection to a specific work incident or the overall understanding of the job the patient performed that could produce a finding of causal connection. Will injured workers like these be so quick to conclude that the condition was caused or aggravated by work if there was a collateral source where they could receive treatment? Preliminary information based off of Massachusetts healthcare reforms from earlier in the decade may shed some light on what we can expect in the future under the ACA. These include: 1 Restrepo, Tanya, and Harry Shuford. "Workers Compensation and the Aging Workforce." NCCI. NCCI Holdings Inc., Dec. 2011. Web. 11 June 2014. <https://www.ncci.com/documents/2011_aging_workforce_research_brief.pdf>. 2 Ibid. 3 Ibid. 4 Ibid. 5 Ibid. How the Affordable Care Act Affects Workers Compensation Part 2 August 2014 2

The RAND Institute found a cost shift from workers compensation to health insurance occurred after the implementation of mandatory Romneycare medical insurance. 6 By reviewing hospital billing to workers compensation claims, the RAND study found that billed charges and treatment volume per workers compensation claimant did not change noticeably. However, the total volume of workers compensation billings fell by 5% to 10%. 7 While a lower overall number of claims may seem like the answer to handling provider shortages, it must also be noted that in Massachusetts there has not been an impact on reducing litigation and costs, just the number of claims. 8 There should also be a decrease in co morbidities as an increased number of people seeing their doctor leads to a healthier overall state. 9 An additional shift will be seen with the creation of the Pre existing Condition Insurance Plan, meaning that people who initially claimed a pre existing condition was aggravated by work in an attempt to get coverage for it will now be covered for their injury under the ACA. With the increase in coverage, changes in Medicare payment rates, and provider integration/global payment models, the workers compensation projected costs for 2016 are $65 billion, ($34 billion for medical costs, $31 billion for indemnity compensation), which is a total reduction in workers compensation costs of 1.4% ($880m) https://www.ncci.com/documents/ais2014 Auerbach ACA.pdf. According to Liberty Mutual Research Institute, which released their Workplace Safety Index in 2013, overexertion was the leading cause of disabling injury in 2011, costing approximately $14.2 billion in direct costs. 10 It is believed that certain health and wellness programs specializing in preventative measures within the scope of work will decrease the number of workplace injuries. However, these wellness programs could also lead to a potential increase in the number of workplace injuries due to the increased amount of exertion and workout in the workplace. 11 Some jurisdictions allow injuries from employer provided facilities to be deemed compensable, especially if working out onsite allows the employer to access the employee during a period of time not normally viewed as work time. 6 Heaton, Paul. The Impact of Health Care Reform on Workers Compensation Medical Care. Rep. RAND Institute for Civil Justice, 2012. Web. 11 June 2014. <http://www.rand.org/content/dam/rand/pubs/technical_reports/2012/rand_tr1216.pdf>. 7 Ibid. 8 Ibid. 9 Luzuriaga."The Potential Ramifications of the Patient Protection and Affordable Care Act (ACA) on Workers' 10 "2013 Liberty Mutual Workplace Safety Index." Liberty Mutual Research Institute for Safety. Liberty Mutual Group, 2013. Web. 25 June 2014. 11 Luzuriaga."The Potential Ramifications of the Patient Protection and Affordable Care Act (ACA) on Workers' How the Affordable Care Act Affects Workers Compensation Part 2 August 2014 3

A study funded by the National Institute of Health (NIH) found that the median charge for outpatient conditions in the emergency department (ED) was $1233, with a high degree of charge variability. 12 The aggregate charges of the top 10 most frequent reasons for ED visits revealed that uninsured patients were charged the lowest median price ($1178) and those covered under Medicaid were charged the most ($1305). Those with private insurance were charged on average $1245. 13 For Massachusetts, these costs are slightly lower. An ED visit for adults was roughly $580 $700. For a doctor s office visit, the average cost is $130 $180 for adults and $115 160 for children. 14 The most common reasons for an ED visit include chest pain, fainting, headaches, injuries, respiratory problems, stomach pain, and urinary tract infections. Adult office visits in a doctor s office for illness and injury are commonly due to lower back pain, sinus infections, sore throat, and upper respiratory infections due to a cold or other virus. 15 The costs of maintaining an ED is driven by the need for addressing acute illness/injury with staff and equipment able to meet the needs of the patients as presented. Workers compensation injuries can have acute needs but most are minor and can be treated in a doctor s office/clinic. Securing the appropriate level of care for the injury/illness will result in better care at a more cost effective price. Fee reimbursement rates for workers compensation will also most likely be affected; to what extent remains to be seen. Workers compensation complaints generally deal with lower fee reimbursement rates for the healthcare provider. To compound the low fee reimbursement levels, many state workers compensation fee schedules are a divisor of the Medicare reimbursement levels. 16 Part of the ACA mandates that the CMS authorized reimbursement levels will be modified, reducing payments to providers and Medicare Advantage plans of approximately $500 billion over 10 years. 17 Since workers compensation fee schedules often follow Medicare reimbursement levels, this may act as a further deterrent to drive additional healthcare providers out of the workers compensation system as it becomes less economically sound. The ACA is designed to force healthcare facilities to be more efficient and cost effective in order to reduce the cost of Medicare and Medicaid expenditures by the government. Being successful will result in quicker payment by the government. It will also act to reduce workers compensation reimbursements in those states (38 at present) who use Medicaid rates as the basis of their reimbursement levels. Being more efficient may drive down the reimbursement rate on workers compensation claims beyond rates which many feel are already artificially low. If the states utilizing Medicaid reimbursement levels as the basis for their rate schedules do not 12 Caldwell N, Srebotnjak T, Wang T, Hsia R (2013) How Much Will I Get Charged for This? Patient Charges for Top Ten Diagnoses in the Emergency Department. PLoS ONE. 13 Ibid. 14 Typical Costs for Common Medical Services. Blue Cross and Blue Shield of Massachusetts, Inc. 2009. http://www.bluecrossma.com/blue iq/pdfs/typicalcosts_89717_042709.pdf 15 Ibid. 16 Luzuriaga."The Potential Ramifications of the Patient Protection and Affordable Care Act (ACA) on Workers' 17 Douglas L. Wood, M.D., Why Healthcare Costs Are Higher than Necessary and the Implications of the ACA, NCCI Conference (May 2013). How the Affordable Care Act Affects Workers Compensation Part 2 August 2014 4

take this potential reduction in payments into consideration as they re assess rate schedules, there is a potential that physicians and clinics may, where law allows, opt out of treatment for work related injuries. Conclusion The ACA will have a long term impact on the Healthcare Industry for both businesses and employers. The need of healthcare providers to keep highly skilled and experienced people active in their professions is paramount. Healthcare will remain on the cutting edge of Wellness initiatives and will utilize specialty expertise, like sports medicine, to provide unique and progressive solutions for work related injuries. The challenge is to provide these services while continuing to innovate and maintain state of the art facilities and equipment when the ACA and workers compensation demand lower costs. Improving outcomes through wellness programs so that workers are healthier and have less disability caused by co morbid conditions is one solution. Use of more cost effective solutions such as industrial clinics rather than ED, use of NPs or PAs on a larger percentage of claimants in the workers compensation arena (as well as general healthcare) is another. Utilizing shared resources (such as physical therapy facilities and diagnostic testing) will allow Healthcare entities to be more efficient and cost effective. Measuring the impact of the ACA on workers compensation will continue over the next few years and adjustments will be recommended to improve the overall experience of patients. Those facilities that utilize efficient, cost effective solutions will become a magnet for workers compensation payors to direct treatment which, in turn could result in additional patient flow as employees access facilities for general medicine issues for themselves and their families. For More Information Integro is an insurance brokerage and risk management firm focused primarily on serving organizations with complex risks. Clients credit Integro s superior technical abilities and creative, collaborative work style for securing superior program results and pricing. The firm's acknowledged capabilities in brokerage, risk analytics and claims are rewriting industry standards for service and quality. Launched in 2005, Integro and its family of specialty insurance and reinsurance companies, some having served clients for more than 150 years, operate from offices in the United States, Canada, Bermuda and the United Kingdom. Its U.S. headquarter office is located at 1 State Street Plaza, 9th Floor, New York, NY 10004. 1 877 688 8701. www.integrogroup.com For assistance or more information on any of the workers' compensation issues discussed, please contact: Mark Noonan, Managing Principal, phone: 617.531.6855, email: mark.noonan@integrogroup.com; or James Bacon, Managing Principal, phone: 415.365.4230, email: jim.bacon@integrogroup.com. Acknowledgements: Special thanks to Mary Bell for her contributions to the development of this paper. Integro USA Inc. 2014 How the Affordable Care Act Affects Workers Compensation Part 2 August 2014 5