Access to Medical Care for Work-Related Injuries and Illnesses

Allard E. Dembe, Sc.D.Associate Professor and Senior Research Scientist

Center for Health Policy and ResearchUniversity of Massachusetts Medical School

“Why comprehensive insurance coverage is not enough to assure timely and appropriate care”

What is meant by “Access to Care”?

Aday and Anderson (1981):

“Entry of a given population group to the health care delivery system”

Health PolicyFinancing

Organization

StructuralAvailability of Care

Measured by:Utilization of

services

PopulationNeeds

Measured byConsumer

satisfaction

Weissman and Epstein (1994):

“Access is the attainment of timely, sufficient, and appropriate health care of adequate quality such that health outcomes are maximized”

Health System CharacteristicsInsurance coverage

Availability of servicesOrganizational exigencies

Measured by:

Patient CharacteristicsPredisposingHealth needs

Structuralindicators

Processindicators

Outcomeindicators

ACCESS TO CARE

Bierman et al. (1998):

Primary Access

Secondary Access

Tertiary Access

Access to system:trouble getting caredelayed care because of costtransportation

Structural barriers within system:difficulty getting appointments,advice after hours, referral tospecialists

Provider ability to address patient needs:aware of conditions and functionallimitations, has requisite clinicalknowledge and skills

General Medical Care

Major access-to-care problem is the lack of affordable health insurance

Workers’ Compensation Medical Care:

Primary Access

Secondary Access

Tertiary Access

Access to system:

Structural barriers within the system:

Ability of provider to address patient needs

General Medical Care

Major access-to-care problem is the lack of affordable health insurance

WC Medical Care

Universal coverage - paid by employer First dollar coverage

No co-payments or deductibles

Workers’ Compensation Medical Care:

Primary Access

Secondary Access

Tertiary Access

Access to system:

Structural barriers within the system:

Ability of provider to address patient needs

Workers’ Compensation Medical Care:

Primary Access

Access to WC system:

• Barriers to reporting of condition and filing of claim

• Availability of providers who will see WC cases

• WC Insurance denials (group health exclusions)

• Need to establish occupational causation

• Coverage and eligibility restrictions

WC Reporting Problems (Azafoff et al. 2002):

• Employer disincentives (e.g., safety award programs)

• Employer reprisals (e.g., fear of job loss)

• Stigmatization and labor market consequences

• Lack of employer or employee knowledge about WC

• Language and cultural barriers

• Waiting times and masking of lost work days

• Employer in-house first aid and medical care

• Failure of clinicians to diagnosis work-related conditions

Insurance Denials: An Example

Union of Needletrades and Industrial Textile EmployeesUNITE Health Center in New York City:

Low-wage, female, immigrant textile workers diagnosed with occupational carpal tunnel syndrome:

• 79% of claims denied (96% eventually accepted)

• Average of 429 days from claim filing to judge’s ruling

• 226 days from physician authorization to treatment

• 318 days from physician authorization to surgery

• Likelihood of rejection linked to ethnicity and social class

Workers’ Compensation Medical Care:

Secondary Access

Structural barriers within the WC system:

• Low fee schedules inhibit provider availability

• Need for out-of-pocket payments (prescription drugs)

• Lack of trained occ. medicine providers (e.g. rural)

• Extensive UR requirements and authorization for care

• Limitations regarding choice of provider

Among patients with low-back pain in New York State, the need to obtain insurer authorization delayed access to specialists and physical therapists, increasing costs by 25%.

source: Gallagher and Myers (1996):

Utilization Review: Examples

Authorization for care was required approximately four times more often for WC cases compared to cases paid for by general (non-WC) health insurance, after controlling for diagnosis, age, gender, region, location of care, and other factors

source: Dembe et al (2002):

69% of WC claimants in the New York state civil service obtain prescription medications for their work-related injuries using their group health plan.

source: Stapleton (2003):

Out-of-Pocket Expenses: An Example

Workers’ Compensation Medical Care:

Tertiary Access

Ability of provider to address patient needs:

• Mistrust in WC impairs patient-doctor relationship

• Many providers unable to evaluate functional impairment

• Physician lacks familiarity with worksite or job demands

• Few WC quality or clinical effectiveness standards

• Inadequate coordination with general health care

Injury prevention was discussed at only 11.4% of medical visits for work-related disorders.

source: Dembe (2002)

Tertiary Access Problems in WC: Examples

Patients receiving care for work-related musculoskeletal disorders under WC have their blood pressure taken 42% less often than patients receiving care for musculoskeletal disorders under general health plans, after controlling for age, gender, and other confounders .

Workers’ Compensation Medical Care:

Primary Access

Secondary Access

Tertiary Access

Access to system:claim reportingoccupational causation transportation

Structural barriers within system:authorization for care,advice after hours, referral tospecialists

Provider addressing patient needs:aware of conditions and functionallimitations, has requisite clinicalknowledge and skills

Table 1: Potential Barriers to Accessing Medical Care

General Medical Care Workers' Compensation Medical Care

Primary Access(blocked entry to the system)

Lack of insurance, under-insurance*Coverage and eligibility restrictionsInsufficient number, type of providersInadequate location of providers

Employer doesn't carry WC insurance**Coverage and eligibility restrictionsInsufficient number, type of providersInadequate location of providersNeed to prove occupational causation**Insurer denials & group health exclusions**Employer supression of reporting**Inadequte knowledge about WC filing**

Secondary Access(structural barriers within the system)

Limitations on services covered*Excessive premiums, co-pays, cost-sharing*Limitations on choice of providerAggressive utilization reviewLimitation on choice of providerInability to see specialistsDelays in getting appointments

Limitations on choice of providerLow WC fee schedules in some states**Aggressive utilization reviewInability to see specialistsOut-of-pocket expenses (prescription drugs)Delays in getting appointmentsLack of rehabilitation and therapy services**Medical-legal exigencies (e.g., IMEs)**

Tertiary Access(failure to address patient needs)

Inadequate knowledge and skillsPoor provider-patient communicationCultural/language barriersPoor care continuity

Inadequate knowledge of occupational care**Poor provider-patient communicationCultural/language barriersLack of coordination with general health care**Inability to assess job demands/function**Pressure to return to work prematurely**Few preventive services**Mistrust in WC impairs doc-patient relationship

* problems particularly distinctive to general medical care** problems particularly distinctive to workers' compensation medical care

So, what can be done to ensure appropriate access to WC medical care?

Protective measures include:

From Dembe, 1999

• Worker involvement in design and selection of WC health care plan

• Guarantees on choice of primary provider and specialists

• Provisions in purchaser’s contract to ensure adequate access

• Government oversight & regulation specifying access requirements

• Certification and accreditation standards regarding access

• Methods to ensure access during periods of controversion

• Appeals and complaint procedures for injured workers

• Internal/external audit procedures aimed at access problems

Specific access requirements might include:

• Precise time requirements for responding to requests for care

• Distance requirements for location of care facilities

• Minimum staffing levels to ensure availability of clinicians

• Patient surveys to monitor satisfaction with access to care

• Educational programs about WC care for workers and providers

• Specific information for employees about contacting providers

• Cultural and language accommodations for specific populations

Access to Medical Care for Work-Related Injuries and Illnesses

Allard E. Dembe, Sc.D.Associate Professor and Senior Research Scientist

Center for Health Policy and ResearchUniversity of Massachusetts Medical School

“Why comprehensive insurance coverage is not enough to assure timely and appropriate care”

Allard.Dembe@umassmed.edu