- What were the recent experiences of physicians treating injured workers within the California WC system?
- What are the characteristics of the Medical Provider Networks (i.e., number of providers, by specialty and geography)?
- What are the trends in the numbers of providers, utilization, and spending from medical claims data?
The California's Workers' Compensation (WC) program provides medical care and indemnity (e.g., wage-replacement) benefits to workers who suffer on-the-job injuries and illnesses. The Division of Workers' Compensation (DWC) is mandated by California's Labor Code Section 5307.2 to assess whether injured workers have adequate access to quality care on an annual basis and authorizes the administrative director (AD) of DWC to make appropriate adjustments in fee schedule amounts if the AD determines there is inadequate access to care.
The California Department of Industrial Relations commissioned RAND researchers to examine annual trends in access to care for injured workers in a three-year effort. This report documents findings from the second year of this effort. This Year 2 report updates the trends examined in the Year 1 report by including an analysis of medical claims data from 2012 to 2015 (which includes injured workers followed for 12 months following initial injury; i.e., into 2016), analysis from a RAND-fielded physician survey, and data from Medical Provider Network listings. Researchers' key objective for this Year 2 report is to describe access to medical care among injured workers in California as mandated by state Labor Code Section 5307.2. This report builds on earlier California WC access reports sponsored by the state.
The physicians survey is nonrepresentative but offers insight into areas for improvement
- The physician survey in spring 2017 yielded a low response rate and a sample of 225 WC providers.
- The most common reasons for limiting new WC patients were (1) issues with authorizations and utilization review (UR) denials (46 percent), (2) paperwork and/or administrative issues (39 percent), and (3) payment levels (23 percent).
- The majority of physicians reported requesting authorization for treatment, but most reported lacking easy access to the medical treatment guidelines.
Medical Provider Networks (MPNs) include many of the same physicians
- An analysis of 146 MPNs participating in the California WC system found an average network size of 6,317 providers in 4,176 locations.
- Provider participation in an MPN does not necessarily increase the underlying supply of providers available to injured workers.
Trends in providers, utilization, and payments remain relatively stable
- The number of providers and the number of total claims filed each year was relatively stable: 69,728 providers and 846,649 medical claims in 2012 relative to 72,790 providers and 843,162 medical claims in 2015.
- Utilization and payments were relatively stable across most provider types, except acupuncturists, occupational medicine physicians, and physical therapists, all of whom experienced statistically significant increases in the number of claims per provider, the number of services per claim, and the total annual WC reimbursements.
- WC bills decreased for prescription drugs, medicine, surgery and durable medical equipment, while the bills for "other or unknown" service types increased.
- Because of the inherent difficulties in obtaining a representative sample of physicians and adequate response rates, researchers recommend that future studies of physicians in the WC system consider alternative approaches to gathering important contextual details and physician perceptions (i.e., qualitative interviews, case studies in areas where there are known issues, or focus groups).
- Further research on the role of MPNs in affecting access for injured workers is necessary.
Table of Contents
Medical Provider Networks
WCIS Claims Analyses
Discussion and Summary
Physician Experience Survey Instrument
WCIS Claims Analysis Supplemental Information
This study was commissioned by the State of California's Department of Industrial Relations (DIR) and conducted by the Justice Policy Program within RAND Social and Economic Well-Being.
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