Poor Coordination Boosts WC Medical Costs
A claims expert spotlighted a problem in the workers compensation system by citing the case of a Florida worker whose simple slip-and-fall claim ended up costing more than $472,000 in the wake of 57 diagnoses and treatments by 74 medical providers.
"Something has gone wrong," commented Dr. Marcia Satlow, vice president and medical director for The Hartford, during a presentation last month in which she advocated closer monitoring of physicians results.
Dr. Satlows remarks came during a panel discussion on claims trends during the recent annual Florida Workers' Compensation Educational Conference in Orlando. The meeting was sponsored by the Florida Workers' Compensation Institute, in partnership on a national track with The National Underwriter Company (which publishes this magazine).
She suggested that workers comp insurers could put a damper on medical costs by using outcome reviews to examine the treatment results of different physicians. "Get the better medical providers," she advised.
The key to the outcome of complex claims, she said, is not the type of initial injury or diagnosis, but rather the doctor's and employers handling of the case.
Dr. Satlow, whose medical training is in neurology, said that a key to cost control lies in building a consensus with medical providers over treatment.
She also advocated creating and implementing medical policies that use the concept of continuing quality improvement.
Dr. Satlow noted that a close look at medical bills can raise flags. She displayed a prototype software she has developed that gives a vivid pictorial look at an individual claim–graphing the cost of care against a backdrop of bars that show types of medical treatment involved in the case.
She displayed a screen showing a back-strain case involving a 38-year-old worker whose diagnosis was over-exertion. A basic flat line of treatment cost suddenly spiked upward after five months and showed a host of treatment providers.
Dr. Satlow said the case had a total cost of $96,000, involved 22 medical providers and had 17 diagnoses. The final diagnosis, she noted, was post lamenectomy syndrome lumbar–or back pain.
Fifteen percent of claims draw 80 percent of the expense dollars, according to George Neale, president of Dennis Insurance Group in Charlotte, N.C.
Mr. Neale said the cost level of catastrophic claims has not been changing, but that there had been a big "degradation" in claims that might be expected to stay within a $25,000 to $100,000 range.
Those lower-level claims "are the ones you have to be diligent on," he said, advising claims personnel to use their expertise to avoid the cases that could degrade–the "big case wannabes."
Vincent Armentano, vice president of claims services for Travelers Property Casualty Corp. in Hartford, suggested that one problem in getting a handle on claims was that physicians evaluating claims dont do as full a work-up as they might, leaving claims-handlers to work from imperfect or incomplete information.
One reason for the limited work by the physician, Mr. Armentano suggested, might be the fact that doctors do not receive much compensation under workers comp fee schedules.
Reproduced from National Underwriter Property & Casualty/Risk & Benefits Management Edition, September 21, 2001. Copyright 2001 by The National Underwriter Company in the serial publication. All rights reserved.Copyright in this article as an independent work may be held by the author.
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