Paduda: The Reality That Is Workers' Comp

As one who came into workers’ comp from the larger managed care world, I’m often struck at how insular and, frankly, ignorant many workers’ comp folks are about the world in which we operate. I’m talking about the entire US healthcare world, a $3.7 trillion industry that employs more than 16 million people and is 1/6^th of the US economy.

At a grand total of $32 billion, workers’ comp medical spend amounts to less than 1 percent of US medical spend. We are the proverbial flea on the tail of the elephant, whipped around by that noble beast as it charges hither and yon, no more able to influence healthcare than the flea is to influence the direction and speed of the elephant.

Yet for some reason policymakers seem to think that doctors who see perhaps one work comp patient a week will study up on, know, and implement clinical guidelines.  That pharmacists who may see one work comp patient every few days will memorize formularies and prior auth requirements, knowing that step therapy is required for drug A but not drug B. That small employers with one work comp claim a year will know about employee direction, injury reporting, and documentation requirements. That emergency department staff will remember that workers’ comp guidelines allow this kind of opioid but not that one.

This blithe ignorance is particularly evident among regulators, executives, and service providers; the entities that set policy, develop strategy, and attempt to implement those policies, regulations, and strategies. I’m constantly amazed that these worthies have no concept of reality, no willingness or ability to think thru what happens when their always-well-intentioned policies, procedures, guidelines and directives become law. They don’t contemplate how a doctor’s clerk could possibly remember that Drug A requires a prior authorization if it is used as the first line of treatment for injuries to the ankle but doesn’t need a PA if Drug B drug is tried first. Oh, and Drug A doesn’t need a PA for knee injuries. And don’t get me started on shin injuries.

Then there are the forms docs have to fill out – this one for an initial injury, this other one for subsequent treatment, a different one for return to work, and yet another one for disability assessment. Except on Tuesdays, when all have to be filled out in purple ink by a left-handed person certified as a coder.

Then, policymakers are surprised that patients, providers, employers and family members are confused, frustrated, angry and bewildered. After which they get an attorney. 

Folks, we would do everyone a huge favor if we tried to figure out how to work within the world in which we live, and not try to create an alternative universe. At least not until we’ve perfected time travel.

Until then, first figure out what is working in group health, Medicaid, and Medicare, and copy it as much as humanly possible.  Find out how stakeholders communicate, how they work together, the processes and workflows and standards, and adopt them whenever possible. Yes, those standards and formularies might not be absolutely perfect for workers’ comp, but compliance will be a lot higher, there will be far fewer angry patients, and the only ones upset will be the applicant attorneys.

By Joe Paduda

Joseph Paduda, the principal of Health Strategy Associates, is a nationally recognized expert in medical management in group health and workers’ compensation, with deep experience in pharmacy services. In addition to consulting with managed care organizations, employers, health care providers, insurers and private equity firms, Health Strategy Associates conducts regular surveys on managing work comp pharmacy costs, utilization review, bill review systems and claims systems.

Paduda is also the prolific author of the controversial Managed Care Matters blog and a founder of Health Wonk Review, a collaborative blog on health care policy.

Share This Article: