Medical Care Provided Under California's Workers' Compensation Program

Effects of the Reforms and Additional Opportunities to Improve the Quality and Efficiency of Care

by Barbara O. Wynn, Justin W. Timbie, Melony E. Sorbero

Download

Download eBook for Free

Full Document

FormatFile SizeNotes
PDF file 1 MB

Use Adobe Acrobat Reader version 10 or higher for the best experience.

Summary Only

FormatFile SizeNotes
PDF file 0.2 MB

Use Adobe Acrobat Reader version 10 or higher for the best experience.

Appendixes

The appendixes are available for download only. They are not included in the printed version of this report.

FormatFile SizeNotes
PDF file 0.4 MB

Use Adobe Acrobat Reader version 10 or higher for the best experience.

Purchase

Purchase Print Copy

 FormatList Price Price
Add to Cart Paperback122 pages $37.50 $30.00 20% Web Discount

Since 2004, significant changes have been made to the California workers' compensation (WC) system. The Commission on Health and Safety and Workers' Compensation (CHSWC) asked the RAND Corporation to examine the impact that these changes have on the medical care provided to injured workers. This monograph synthesizes findings from interviews and available information regarding the implementation of the changes affecting WC medical care and identifies areas in which additional changes might increase the quality and efficiency of care delivered under the WC system. To improve incentives for efficiently providing medically appropriate care, California should revise its fee schedule allowances for services provided by hospitals to inpatients, freestanding ambulatory surgery centers, and physicians, create nonmonetary incentives for providing medically appropriate care in the medical provider network (MPN) context through more-selective contracting with providers and reducing medical review requirements for high-performing physicians; reduce incentives for inappropriate prescribing practices by curtailing in-office physician dispensing; and implement pharmacy benefit network regulations. To increase accountability for performance, California should revise the MPN certification process to place accountability for meeting MPN standards on the entity contracting with the physician network; strengthen Division of Workers' Compensation (DWC) authorities to provide intermediate sanctions for failure to comply with MPN requirements; and modify the Labor Code to remove payers and MPNs from the definition of individually identifiable data so that performance on key measures can be publicly available. To facilitate monitoring and oversight, California should provide DWC with more flexibility to add needed data elements to medical data reporting and provide penalties for a claim administrator failing to comply with the data-reporting requirements; require that medical cost-containment expenses be reported by category of cost; compile information on the types of medical services that are subject to UR denials and expedited hearings; and expand ongoing monitoring of system performance. Finally, to increase administrative efficiency, California should use an external medical review organization to review medical-necessity determinations, and it should explore best practices of other WC programs and health programs in carrying out medical cost-containment activities.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    An Overview of Workers' Compensation Medical Expenditures

  • Chapter Three

    Payments for Medical Services Provided to Injured Workers

  • Chapter Four

    Medical Provider Networks

  • Chapter Five

    Medical Cost-Containment Expenses and Activities

  • Chapter Six

    Monitoring System Performance

  • Chapter Seven

    Increasing the Value of Workers' Compensation Medical Care

This research was prepared for the Commission on Health and Safety and Workers' Compensation and was conducted under the auspices of the Center for Health and Safety in the Workplace.

This report is part of the RAND Corporation monograph series. RAND monographs present major research findings that address the challenges facing the public and private sectors. All RAND monographs undergo rigorous peer review to ensure high standards for research quality and objectivity.

Permission is given to duplicate this electronic document for personal use only, as long as it is unaltered and complete. Copies may not be duplicated for commercial purposes. Unauthorized posting of RAND PDFs to a non-RAND Web site is prohibited. RAND PDFs are protected under copyright law. For information on reprint and linking permissions, please visit the RAND Permissions page.

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.