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News Gram™ November 2004

November 2004 ~ Volume 11, No. 4

It's been a topsy-turvy world since last April when the legislature passed the new comp bill. But what has happened so far is but a prelude to the main act that begins on January 1st. With the New Year comes the full implementation of the law and that means a mega-change. Stress claims are written into the law and the applicant attorneys are lining up at the gate to pursue them.

Will the system work? Will the lower premiums be justified by lower costs, less litigation and faster resolution of claims? When we asked these questions of people on both sides of the fence, we were told, "Lotsa luck, fella." Here's how opinion on the new law breaks down: About a third of the people we spoke with believe it will be business as usual. Another third think the law is not enforceable. And the final third is holding out for some improvement as a result of it.

One of the most significant changes is the introduction of managed care programs into the system. As many readers know by now, this new administrative structure adds many complications to healthcare delivery to injured workers. Aside from the question as to whether or not managed care has reduced medical costs in the overall delivery of medical care across the country, this way of doing things attracted the lawmakers and became law with virtually no public discussion.

When translated into real terms, come 2005, the comp system will be functioning with Medical Provider Networks (MPNs). The employer will control treatment across the board and the discretion previously available to the worker with respect to physician choice will be dramatically reduced. Also, the insurance company had better act fast lest it be on the hook for medical bills up to $10,000 in the first 30 days - whether or not the injury is adjudged to be work-related.

The not-quite-venerable QME report, pale, diminutive and hidden in shadows, has been relegated to a back room somewhere, to be pulled out only when a claimant has seen three other doctors who have turned him or her down. In the same stroke, AME physicians are the new aristocracy, since the law intends that a single physician would eventually decide the majority of intransigent disputes. Through such basic structural changes, the age of dueling docs may be coming to an end.

Even the mainstay of the medical information component of the workers' comp system - the AOE/COE report - will not likely see the light of day. The emphasis is more on treatment these days. Such a shift is not bad, though doctors are already complaining that the discounted reimbursement rates for medical treatment offered by the MPN administrators are, to put it politely, shabby. It appears inevitable that many of the most qualified doctors will leave the system entirely for want of fair payment. They don't sense the urgency to reform the system as the legislators have, nor have they had to confront the governor's wrath.

Physicians on the Medical Provider Networks will provide all treatment. They will confront the same irritating need to contact a network administrator for approval to treat an injured worker with a certain modality of care and for a given length of time. Chiropractic treatment has been reduced to 24 visits per injured worker, which will result in a precipitous plummet from the nearly indefinite number of visits enjoyed by patients prior to the new law.

Gone too is the old apportionment system. Apportionment can now be in terms of causation, which means that a person did not have to have experienced a disabling illness previously in order for a physician to apportion disability to him. The mere occurrence of a relevant condition may be a sufficient basis for apportionment. The net result is that the employer is less likely to incur complete liability for many disabling conditions if a related condition had existed in the patient at some time.

The impact of the new law will be substantial. Whether one perceives it as a good law or a bad one depends on whether that person is a patient, an employer or a physician. What does seem clear is that the freewheeling system now drifting into oblivion is going to be replaced by a more rigid one that promises to rein in the excesses, waste and occasionally criminal abuses of people within.

One attorney declared that the system will simply melt down. No one appears to be enthused about what is to come. Instead, there is a glum sentiment that pervades the professionals involved in providing vital services to injured workers that they won't be able to do their jobs given the severe constraints of the new law. In that case, Sacramento will have proved it doesn't have the magic touch necessary to solve the problem.

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