Medical Care Provided to California's Injured Workers: Monitoring System Performance Using Administrative Data

Abstract

Following reforms in 2003-2004 to the California workers' compensation (WC) program, expenditures for medical care provided to injured workers declined for several years, only to begin rising again in 2007. By 2012, total medical spending had increased 32 percent relative to 2007 levels despite a reduction in the number of WC claims. Senate Bill (SB) 863 made additional reforms intended to improve the efficient delivery of high-quality care to injured workers. The Commission on Health and Safety and Workers' Compensation (CHSWC) asked RAND to identify the factors that explain the spending increases and to explore the feasibility of using medical data from the Workers' Compensation Information System (WCIS) for ongoing monitoring of system performance and in-depth analyses of selected issues affecting system performance. This report provides a framework for understanding changes in medical spending levels and provides the results from our analysis of WCIS data for 2007-2012. It establishes a baseline that can be used in a future study to evaluate the impact of the SB 863 provisions. The report should be of general interest to stakeholders in California's WC system and in other WC programs. This research was undertaken for CHSWC under contract 41036037. It was conducted under the umbrella of RAND's Justice Policy Program.

Access to Medical Treatment for Injured Workers in California: Year 1 Annual Report

“…One significant change is that the rate of matching first reports of injuries to medical records has improved over time. In an earlier RAND study, we found that the fraction of injured workers for whom we observed a first report of injury and were able to match it to medical claims ranged from 62 percent to 86 percent increasing as more time had elapsed since the first year of injury (Wynn et al, 2018). In our sample, we have match rates of 55 percent, 54 percent, 61 percent, and 61 percent for years 2012, 2013, 2014, and 2015, respectively.…”

Evaluation of California Senate Bill 863 Medical Care Reforms

“…If the distribution of services in the available WCIS data diverges from the "true" distribution (for all claims), this has implications for our policy analyses. Earlier RAND reports (see, e.g., Wynn et al, 2018) discuss these issues in more detail and conclude that the WCIS data can be assumed to be broadly representative of all WC claims in California.…”

“…Adoption of Medicare's revised payment localities and GAF effective January 1, 2019, should improve payment accuracy and better align OMFS allowances with Medicare rates and private-payer payments. In this regard, an earlier RAND report (Wynn et al, 2018) examined the ratio of commercial health insurance payments to RBRVS payments for physician services. Overall, the commercial rates were 89.5 percent of the OMFS statewide rates; however, the pattern in payment ratios across Medicare payment localities was similar to that for Medicare GAFs.…”

“…In another RAND report, we analyzed WCIS data from 2007 to 2014 to explore trends in billing and payment structure for medical-legal services in California (Wynn et al, 2018). Despite the lack of fee-schedule changes and a reduction in the number of WC claims, WCIS aggregate spending for medical-legal expenses increased 46 percent.…”

Earnings Losses and Benefit Adequacy in California's Workers' Compensation System: Estimates for 2005–2017 Injury Dates

“…SB 899 also led to major changes in medical care delivery, such as the creation of Medical Provider Networks (MPNs), the establishment of treatment guidelines (referred to as the Medical Treatment Utilization Schedule, [MTUS]), and the establishment of a medical fee schedule limiting the amount that insurers and employers were allowed to pay for various medical services. The impacts of these reforms and subsequent trends in spending, utilization, and other outcomes were evaluated byWynn et al, 2018. …”