NY Worker's Compensation Board Proposes New Medical Treatment Guidelines

New York Worker’s Compensation Board’s proposed new medical treatment guidelines that will modify 2010 previously implemented.

1. Adopt the new carpal tunnel syndrome (CTS) medical treatment guidelines (MTG) as the standard of care for the treatment of injured workers with carpal tunnel syndrome;
2. Modify current MTGs to include new maintenance care recommendations; and
3. Implement consensus changes to simplify the process, reduce litigation and speed dispute resolution.

Carpal Tunnel Syndrome (CTS)
The new CTS MTG provide evidence based guidelines for the treatment of carpal tunnel syndrome, the most common occupational disease experienced in the workers’ compensation system. Like the other MTGs, the CTS MTG should improve the quality of care, speed access to the most beneficial treatment, and control the use of ineffective treatment.

Maintenance Care
The original four MTGs primarily address treatment for the acute and sub-acute phases of injury, with limited recommendations for the management of chronic conditions and chronic pain. As part of its effort to develop chronic pain guidelines, the MAC re-evaluated those recommendations that relate to maintenance care, recognizing that in certain situations maintenance care (chiropractic and occupational/physical therapy) should be available. The revised MTGs will authorize an ongoing maintenance program that can include up to 10 visits per year for those who have a previously observed and documented objective deterioration in functional status without the identified treatment. To be eligible for maintenance care, injured workers with chronic pain must have reached maximum medical improvement (MMI), have a permanent disability, and meet the requirements of the maintenance care program. No variance is allowed from the 10 visit annual maximum.

The new recommendations address a major concern of both providers and payers: the high number of variance requests. To date, more than three quarters of the variance requests are for maintenance care for those with chronic pain. Injured workers will now have access to important maintenance care while payers and providers will be relieved from the administrative burden of handling individual variance requests for this care. The remainder of the chronic pain guidelines is expected to be completed by early 2013.

Process Changes
The regulations also include several changes to simplify the process, reduce conflict, and speed dispute resolution. These consensus changes are the result of suggestions from stakeholders. The changes will achieve the following:

• enable parties to more easily choose resolution by the Medical Director’s Office, which provides faster and less costly dispute resolution;
• clarify and simplify transmission requirements that were resulting in rejection of thousands of variance requests for technical violations;
• allow carriers to partially grant variance requests, thereby expediting care and reducing litigation;
• eliminate submission of duplicate variance requests;
• reduce the number of procedures requiring C-4 Authorization, and
• authorize submission of variance requests through a web-based portal or other technology in the future, should it become available.
•  

In addition, several changes to the Forms C-4 AUTH, C-8.1, MG-1 and MG-2 forms that have been agreed upon with stakeholders will be implemented.  Comments on the draft forms may be sent to formsdepartment@wcb.ny.gov and will be considered if received by Monday, November 26, 2012. Final versions of the forms will be posted in early December. The parties will be expected to begin using the new forms after February 1, 2013. Old forms cannot be used to initiate new requests after March 15, 2013.

Complete copies of the proposed regulations, new and revised guidelines, complete description of the process changes, draft versions of the new forms, and other information are available on the Proposed Changes to New York Medical Treatment Guidelines page of the Board’s website. The regulations will be published in the November 21, 2012 State Register.

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Workers' Compensation Jeopardy: Romney and Medical Costs

Mitt Romney

Planned changes by Mitt Romney to Medicare and Medicaid will have a dire effect on the regulations of the future cost of workers’ compensation medical treatment. Proposed changes to the Federal program will indirectly impact the patchwork of workers' compensation programs by removing federally mandated fee regulation embraced under Obamacare.

Directly or indirectly, most workers' compensation programs have medical treatment and pharmaceutical pricing costs that are geared to Federal payment schedules regulated by the Medicare and Medicaid systems. Additionally, the Medicare Secondary Payer Act mandates reimbursement to the Federal, and State administered, and in many instances the Federal costs are less than the customary payments under workers’ compensation systems. Therefore the Federal programs, even if conditionally paid, result in lower payments eventually by employers and workers' compensattion insurance companies who in term are required to reimburse the Federal agency.

Additionally, the elimination of the Federal controls, that put a lid on the cost of benefits, would adversely affect the workers' compensation programs by creating havoc by eliminating the certainty of reduced costs, especially where future costs are concerned, ie. catastrophic care scenarios and latent diseases, ie. asbestosis.

Paul Krugman (NYTimes) points out, “But one thing is clear: If he [Romney] wins, Medicaid — which now covers more than 50 million Americans, and which President Obama would expand further as part of his health reform — will face savage cuts. Estimates suggest that a Romney victory would deny health insurance to about 45 million people who would have coverage if he lost, with two-thirds of that difference due to the assault on Medicaid.”

The Romney agenda to dismantle the present medical benefit program will only further jeopardize the economic stability of the nation’s workers’ compensation system. 

....
Jon L.Gelman of Wayne NJ is the author NJ Workers’ Compensation Law (West-Thompson) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thompson). 
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Workers Compensation: A Cash Cow For Medical Providers

Guest Blog

by Julius Young of the California Bar

Are medical treatment recommendations sometimes driven by profit motive?

In my whole career I've met very few injured workers who expressed concern that the treatment recommendations of their doctor were influenced by physician income considerations.

Americans tend to trust their doctors. Some of us grew up watching Dr. Kildare, Ben Casey, or the MASH doctors. Others cut their teeth on ER or General Hospital.

Nothing pisses off an injured worker as much as having an outside, non-examining utilization reviewer doctor challenge the recommendations of their doctor.

But the reality is that sometimes medicine and economics are intertwined. Just as insurers want to limit costs, there are some doctors who are happy to push procedures and tests for profit.

In a prior post, "Upcoding", I noted recent investigative reporting by California Watch that documented unusually high rates of billings for "cardiac failure" in some California hospitals:
http://workerscompzone.com/index.php?m=11&y=11

So it was no surprise to see today's article in the Wall Street Journal which documents high rates of spinal surgery procedures in some California hospitals. The article, "In Small California Hospitals, the Marketing of Back Surgery", was written by John Carreyrou, Tom McGinty and Joel Millman.

The article focuses on spinal surgery at Tri-City Regional Medical Center in the city of Hawaiian Gardens which is in southeast Los Angeles County near Long Beach.

According to the Wall Street Journal investigative reporters:

"For an operation known as spinal fusion, which joins two or more vertebrae, the small hospital billed workers' compensation insurers $65 million in 2010, up from less than $3 million three years earlier, state hospital discharge data show.Helping spur the business was Paul Richard Randall, a consultant to whom Tri-City has paid millions of dollars in marketing fees. According to people familiar with his role, it was twofold: bringing surgery cases to the hospital by recruiting surgeons to operate there, and supplying metal implants for the surgeries through distributorships he owned."

The article notes that Randall has been the subject of a federal investigation although charges have apparently not been filed nor have illegal acts been proven.

According to the Journal, many small hospitals are doing lots of workers' comp spinal surgeries, noting that "California employers paid $7.1 billion in insurance premiums to cover their workers' compensation liability in 2010. Spinal-fusion surgery is a growing part of the care these premiums pay for. It accounted for 40% of inpatient hospital charges to the state workers' compensation system in 2010, up from 30% in 2001, a Journal analysis of hospital discharge data shows."

Hospitals that did a large amount of spinal surgeries included university-based hospitals such as UCSF, well known treatment centers such as Cedars Sinai and Scripps La Jolla but also a number of small hospitals around the state.

While it would be unfair to assume that some of the hospitals mentioned in the article are encouraging spinal surgery cases as a "cash cow", the article raises a number of questions worthy of further looks by policymakers.

Spinal hardware costs have already been addressed in a RAND study prepared for CHSWC, "Payment for Hardware Used in Complex Spinal Procedures Under California's Official Medical Fee Schedule", by Barbara O. Wynn and Giacomo Bergamo:
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Julius Young is a partner at Boxer & Gerson LLC and has practiced workers' compensation and social security disability law since 1979 advocating for injured workers and their families.. He is the founder, writer, and editor of an award winning blog on workers’ compensation and wider more far ranging and always engaging political issues, http://www.workerscompzone.com/. The blog has twice been selected as winner or co-winner of the top workers’ comp blog in the US by Lexis/Nexis. He was a Board member of the California State Bar Executive Committee in Workers' Compensation from 2007 to 2010. Julius has acted as a training consultant for the US Hastings Employment Law Center Workers’ Compensation Clinic, has acted as an advisor to Worksafe on workers’ compensation and safety issues, and is currently serving on an Advisory Committee re Rand Institute studies at the request of the California Commission on Health, Safety, and Workers’ Compensation.