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 Research University 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 Policy Financing Organization Structural Availability of Care Measured by: Utilization of services Population Needs Measured by Consumer 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 Characteristics Insurance coverage Availability of services Organizational exigencies Measured by: Patient Characteristics Predisposing Health needs Structural indicators Process indicators Outcome indicators ACCESS TO CARE

Bierman et al. (1998): Primary Access Secondary Access Tertiary Access Access to system: trouble getting care delayed care because of cost transportation Structural barriers within system: difficulty getting appointments, advice after hours, referral to specialists Provider ability to address patient needs: aware of conditions and functional limitations, has requisite clinical knowledge 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 Employees UNITE 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 judges 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 reporting occupational causation transportation Structural barriers within system: authorization for care, advice after hours, referral to specialists Provider addressing patient needs: aware of conditions and functional limitations, has requisite clinical knowledge and skills

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 purchasers 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 Research University of Massachusetts Medical School Why comprehensive insurance coverage is not enough to assure timely and appropriate care