Upload
dangkien
View
214
Download
0
Embed Size (px)
Citation preview
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 1
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Cumulative Trauma Injuries & The Rx Formulary
A California Workers’ CompensationSystem Update
Alex Swedlow, Presidentwww.cwci.org
C CVV I
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Agenda
Exhibit 2
Cumulative Trauma
• Dec 2016 Study
• Collaboration with WCIRB
• Analysis of CT and Non-CT Claim Characteristics and Outcomes
• DOI 2005 - 2013
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 2
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
The peculiar problem of CT in CA
Background:
• A few states prohibit cumulative trauma claims altogether
• Some states impose a high standard of proof
• Other states require that the employee prove that the cumulative injury occurred using a standard of clear and convincing evidence
• California has a relatively low bar for cumulative trauma claims
• Preponderance of evidence standard applies
• Only 1% causation required to obtain TD, PD, and medical treatment for all body parts included in CT claim
Exhibit 3
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Classic Example: Employee spends a 30-year career performing heavy lifting, pushing, and pulling and knees or something else wears out
Other Examples: Physician-Assisted
Attorney-Induced
Created by Co-Defendant
Post-termination
Retirement
Where do CT claims come from?
Exhibit 4
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 3
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Estimated Frequency ChangesAt 1st Report (18 Months)
-6.3
-4.0
-6.2
-3.2
6.4
-1.1
2.9
0.5
-0.2
-6.1-4.4
-6.3
-4.1
5.6
-0.4
2.4
-1.3 -…
-15
-10
-5
0
5
10
15
2006 2007 2008 2009 2010 2011 2012 2013 2014Accident Year
Statewide
Statewide Excluding Cumulative InjuryClaims
%
5
PreliminaryPartial
Source: WCIRB
Exhibit 5
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Cumulative Trauma: Study Questions
1. How do claim characteristics vary for CT vs Non-CT Claims?
2. Are differences in payment flows and the existence of companion claims influencing average claim costs and masking underlying increases?
3. What are the contributing factors that cause the observed differences?
Exhibit 6
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 4
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
• Data Sources for subset of IRIS data contributors:o WCIRB Unit Stat Reportingo Integrate with CWCI IRIS claims data
• CT and Non-CT Claims w Notice Dates from 2005 –13
• Claim milestones and payments valued through 2015
Cumulative Trauma Study:Data Preparation
Exhibit 7
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Percent of Claims that are CT by Region – So. California
6.1%
20.5%
4.1%
13.3%
4.8%
8.9%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
2005 2006 2007 2008 2009 2010 2011 2012 2013
L.A. Inld Emp/Orang SD
Exhibit 8
Carrier Notice Year
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 5
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
2005 2006 2007 2008 2009 2010 2011 2012 2013
Central Coast Bay Area Sierras North Counties Valleys
Exhibit 9
Carrier Notice Year
Percent of Claims that are CT by Region – Rest of California
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Notification – Average Days
Non-CT
Exhibit 10
Preliminary Results: Do Not Cite
Date of Injury
Employer CarrierService
11 Days
24 Days
13 Days
10 Days
Date of Injury
Employer CarrierEmployee
117Days
23 Days
138Days
116Days
Service
Date of Injury
Employer CarrierService
11 Days
24 Days
13 Days
10 Days
CT
Study Sample
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 6
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
0.0%
1.0%
2.0%
3.0%
4.0%
16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68
CT Non-CT
Claim Characteristics:
Age
Exhibit 11
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
24.0% 24.3%
32.7%
8.6%10.5%
43.9%
22.6% 23.0%
4.8% 5.7%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
<= 1yr 1-3 yrs 3-10 yrs 10-15 yrs 16+ Yrs
CT Non-CT
Claim Characteristics:
Tenure
Exhibit 12
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 7
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Claim Characteristics:
Average Weekly Wage
Exhibit 13
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Claim Characteristics:
Region
Exhibit 14
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 8
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
57.0%
32.1%
0%
10%
20%
30%
40%
50%
60%
CT Non-CT
Claim Characteristics:
Percent w Indemnity Payment
Exhibit 15
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Exhibit 16
Low Back Mental DisorderMultiple BodyParts/Systems
Shoulder Wrist or Hand All Other
CT 11.3% 5.7% 25.1% 5.5% 14.4% 38.0%
Non-CT 14.2% 0.8% 7.5% 4.9% 10.7% 61.9%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
CT Non-CT
Claim Characteristics:
Condition
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 9
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Years from Carrier Notice to ClosureIndemnity Claims
26%
5%
97%
83%
Exhibit 17
Carrier Notice Year
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Attorney Involvement
80%
91%
19%
46%
0%
20%
40%
60%
80%
100%
All Claims Indemnity Claims
CT Non-CT
Exhibit 18
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 10
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
CT Claim Attorney Involvement Rate By year & Region
2005 2006 2007 2008 2009 2010 2011 2012 2013LA Basin 82.1% 84.2% 87.9% 89.2% 89.4% 91.1% 91.7% 91.6% 92.3%Rest of State 64.1% 68.4% 73.8% 68.8% 67.6% 68.7% 67.3% 69.2% 70.7%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
LA Basin Rest of State
Exhibit 19
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
CT as Percent of Attorney Involved Claims
2005 2006 2007 2008 2009 2010 2011 2012 2013
LA Basin 19.0% 20.0% 24.7% 27.1% 30.7% 35.1% 36.0% 37.8% 40.4%
Rest of State 12.4% 14.7% 17.6% 16.7% 18.4% 20.0% 19.6% 18.9% 19.3%
0%
15%
30%
45%
LA Basin Rest of State
Exhibit 20
Carrier Notice Year
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 11
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Percent of Injured Workers with One or More Related Claims
Source: CWCI
Exhibit 21
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Indemnity Claims Indemnity Claims Developed to 7 Years
Adjusted for Mix – Demographics & Condition
Average Cost Per Claim
Exhibit 22
Without Region &Attorney Involvement
With Region & AttorneyInvolvement
CT $73,830Non-CT $48,312
$0
$20,000
$40,000
$60,000
$80,000
Source: CWCI 2017
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 12
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Average Total Cost Per Claim
Exhibit 23
Without Region &Attorney Involvement
With Region & AttorneyInvolvement
CT $73,830 $72,416Non-CT $48,312 $73,046
$0
$20,000
$40,000
$60,000
$80,000
Indemnity Claims Indemnity Claims Developed to 7 Years
Adjusted for Mix – Demographics & Condition
Source: CWCI 2017
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
• Growing frequency – Driven primary by LA Basin
• Late claim notification
• Higher attorney involvement and disputes over compensability
• Significantly slower development, higher average cost per claim
Cumulative Trauma: Summary of Findings
Exhibit 24
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 13
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
The 1Missing Piece In Rx Control: Formularies
November 2014 CWCI Study: Potential impact of a state formulary
Modeled CA data using Texas and Washington State Formularies
Estimated system-wide savings of 10 – 50%
AB 1124 - October 2015
Calls for creation of a State Formulary
Target Implementation - July 2017
Jan 2018
Exhibit 25
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Exhibit 26
Key Draft Components Released August 26th
DWC Draft Regulations
MTUS Drug List
RAND Report
Implementing AB 1124 Drug Formulary and update of MTUS
Proposed Regs Released March 20th
Public Hearing May 1st
Intent of the formulary
Improve quality of care
Reduce UR and IMR friction costs
Lower cost
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 14
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Exhibit 27
Proposed Formulary Components Released March 20th :
MTUS Drug List (N=242)
Implementing AB 1124 Drug Formulary and update of MTUS
Drugs are designated into categories: Preferred
Non-Preferred
Not Listed
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Implementing AB 1124: Drug Formulary
Preferred, Non-Preferred, or Not Listed
Prescriptions and Payments
Source: CWCI 2017
% of Prescriptions % of PaymentsPreferred 25.8% 19.7%Non-Preferred 53.4% 0.0%Not Listed 20.7% 32.2%
0%
25%
50%
75%
100%
74% of currently dispensed drugs eligible for prospective UR26% of currently dispensed drugs are “fast tracked” around prospective UR
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 15
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Therapeutic Group PreferredNon
Preferred
Not Listed
in MTUSAnalgesics - Opioid 0.0% 96.6% 3.4%Analgesics - Anti-Inflammatory 82.4% 2.2% 15.4%Musculoskeletal Therapy Agents 0.0% 98.0% 2.0%Anticonvulsants 0.0% 98.5% 1.5%Antidepressants 0.0% 96.1% 3.9%Ulcer Drugs 98.7% 0.0% 1.3%Dermatologicals 28.7% 34.3% 37.0%Hypnotics/Sedatives/Sleep Disorder Agents 0.0% 1.0% 99.0%Antianxiety Agents 0.0% 44.4% 55.6%Antihypertensives 0.0% 5.6% 94.4%Antihyperlipidemics 0.0% 0.0% 100.0%Laxatives 0.0% 0.0% 100.0%Corticosteroids 0.0% 57.7% 42.3%Beta Blockers 0.0% 0.0% 100.0%Chemicals 1.8% 78.7% 19.4%Cephalosporins 0.4% 68.7% 30.9%Analgesics - Nonnarcotic 68.3% 31.4% 0.3%Antipsychotics/Antimanic Agents 0.0% 0.0% 100.0%Ophthalmic Agents 39.9% 15.2% 44.9%Calcium Channel Blockers 0.0% 75.6% 24.4%All Other 9.5% 15.1% 75.3%Total 25.6% 53.4% 21.0%
Exhibit 29
Implementing AB 1124 Drug Formulary and update of MTUSObjectives
Identifies drug groups that the formulary will most impact;
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 16
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Implementing a formulary
Who does what when how
Balancing access with safety
Guidelines vs patient-specific treatment
Avoiding unintended consequences
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 17
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Payer
PrescriberPharmacy
PBM
Patient
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
Patient Safety
Access to
Care
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 18
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
The Travelers ‐ February 2017
CWCI 2017. All Rights Reserved 19
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.
WE ARE ALL PEOPLE.
EACH OF US IS AN INDIVIDUAL.
CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.