Access to Medical Treatment for Injured Workers in California

The California workers' compensation (WC) program provides medical care and indemnity (e.g., wage-replacement) benefits to workers who incur injuries or illnesses arising from or during the course of employment. Section 5307.2 of the California Labor Code (2009) mandates the California Division of Workers' Compensation (DWC) to assess annually whether injured workers have adequate access to quality care, and the law authorizes the DWC's administrative director to make appropriate adjustments in fee-schedule amounts if he or she determines that there is inadequate access to care. The RAND Corporation was commissioned for a three-year effort to examine annual trends in access to care for injured workers. This article documents findings from the third year of this effort.

The key objective of this study is to describe access to medical care among injured workers in California, as mandated by Section 5307.2 of the California Labor Code. This study includes analysis of medical billing data from Version 2.0 of the Workers' Compensation Information System (WCIS), which was rolled out starting in April 2016. There were several significant changes underlying data infrastructure in Version 2.0, and this study offers a first examination of the new version of these data.¹ Although the sample that we analyze in this study is not exactly comparable to the Year 1 and Year 2 sample, we highlight differences throughout this study. In particular, in previous analyses, the sample excluded medical bills with missing or incorrect information that was a part of the so-called orphanage. In Version 2.0 of the data, claims are rejected if information is incorrect or missing.² We also used a provider identifier in this report that was different from what we used in previous reports, which yielded a larger sample of unique providers.

Because of the differences in data samples drawn from Version 1.0 and Version 2.0 of the system, our primary focus in this study is on providing a snapshot of the state of access in California's WC system rather than on analyzing trends. When analyzing claims that exclude care received out of state, we found the following:

• There were 76,950 unique WC providers in 2016, and the most common specialties were internal medicine (n = 8,206), physical therapist (n = 6,567), physician assistant/nurse practitioner (n = 5,428), emergency medicine (n = 5,361), and family medicine/general practice (n = 4,879).
• On average, providers had 29.4 claims each during 2016, but this varied across specialties, with a high of 316 among occupational medicine physicians and a low of 2.4 among dental providers.
• On average, providers delivered 208.1 medical services per claim across all specialties. This also varied across specialties, with a high of 1,895 medical services per claim among occupational medicine physicians and a low of 14.3 medical services per claim among ophthalmologists.
• On average, the total annual payment per provider was $24,440, and the payment per claim was $1,306 across all specialties. This also varied across specialties, with occupational medicine physicians and orthopaedic surgeons having the highest average total payments per year, at $131,166 and $118,975, respectively. The specialties with the highest average payment per claim in 2016, however, were other surgery and dental providers, at $3,830 and $3,017, respectively. Pathology had the lowest total annual payment per provider and the lowest average payment per claim, at $1,074 and $123, respectively.
• There was significant variation by region and county across all measures.
• Ninety-four percent of claims included some type of evaluation and management (E&M) service. The second most common types of service were radiology and medicine, which were included in 56 percent and 55 percent of claims, respectively.
• The average payment per E&M office or other outpatient services claim was $565, and the next-highest average payment per claim was for physical medicine and rehabilitation evaluations, at $370.
• The median time between injury and first E&M visit was 2 days. The median time between injury and first E&M visit with a primary care provider in a non–emergency department setting was 6 days. Only 13 percent of injured workers saw more than one primary care provider in the year following their injuries.

Overall, our estimates using the new data for 2016 were relatively similar to those presented in the Year 2 study, although we did not test for statistical differences due to differences in the samples. Nonetheless, estimates using Version 2.0 of the WCIS Medical Bill data suggest stability or slight improvements in most measures when compared with the Year 2 estimates.