Do Pricier Treatments Drive Workers Comp Diagnoses?
By: Stephani Goldberg (Business Insurance) March 2016
BOSTON — A course of treatment is sometimes decided before an injured worker is even diagnosed, a speaker said during the Workers Compensation Research Institute’s 2016 Annual Issues and Research Conference in Boston.
State differences in the utilization of services to treat joint injuries are driven more by the treatments for given diagnoses than by the mix of diagnoses, Barry Lipton, practice leader and senior actuary for the National Council on Compensation Insurance Inc., said Friday during a session on geographic variations in health care.
Mr. Lipton shared a November 2015 study by the Boca Raton, Florida-based workers comp ratings and research organization that focused on knee, elbow, shoulder and ankle strains/sprains.
Highlighting three low-utilization states — Maryland, Indiana and Missouri — and three high-utilization states — Kentucky, Colorado and Illinois — Mr. Lipton said “expenditures on surgery and physical medicine distinguish the high utilizations.”
According to the study, “the higher (cost at common fees) for surgery and physical medicine reflect some combination of a greater average number of services per claim and a shift toward more costly treatment.”
“There are, unfortunately, some bad actors in the medical community who will … back into the diagnosis,” Mr. Lipton said. “We do find it’s more of an issue” in knee cases.
The average cost at common fees per case for shoulder injuries “varies considerably over the six selected states, more than doubling from $3,370 in Indiana (a low-utilization state) to $6,841 in Illinois (a higher-utilization state),” the study shows.
However, NCCI found similarity among the states regarding the diagnosis of shoulder injuries, which include rupture of rotator cuff, strain/sprain of rotator cuff, strain/sprain of shoulder or upper arm, joint pain in shoulder, affections of shoulder not elsewhere classified, and other.
It’s fair to wonder if certain members of the medical community are saying, “Gee, for $1,600 I think you’ll be fine healing on your own, but for $6,000 I think you definitely need surgery,” Mr. Lipton said. “So you can’t always say that first (comes) the diagnosis, then the treatment course.”
During the same session, presenter Dr. Jon Lurie, associate professor of medicine and orthopedics at the Lebanon, New Hampshire-based Dartmouth Institute, said that one reason surgery rates vary from place to place is due to the enthusiasm of providers.
“Doctors who really are enthusiastic about the benefit of these things do a lot of them, and the ones who are more circumspect about them do fewer of them,” Dr. Lurie said. “Many people think the thing that drives physician behavior is payments. It certainly has an effect. But many of these people are doing lots of procedures … because they really believe this is the right thing to do.”
