Monthly Archives: February 2013

Understanding Medical Tourism’s Role in Early Intervention in Workers’ Compensation

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Early intervention strategies in workers’ compensation cases are key to improving workers’ compensation results, as my LinkedIn connection, Paul Binsfield writes today in his article, Early Intervention Strategies in Workers’ Compensation in PropertyCasualty360.com. Paul is CEO of Company Nurse, a firm specializing in injury management for workers’ compensation.

In his article, he writes that In a tough economy, employers require effective and innovative ways to improve workers’ compensation results. Many program managers are updating their approach and leveraging early intervention such as prompt reporting, nurse triage, proactive claims management, and integrated return-to-work (RTW) coordination to improve performance. These strategies are designed to manage work-related injuries right from the start and bring about best possible outcomes.

He lays out five key areas employers need to focus on to insure better outcomes for their injured workers. These areas do not necessarily relate to how those wishing to implement medical tourism into workers’ compensation would be involved, but it gives one the background of what the employer has already done before the medical tourism option is considered.

The five key areas are:

  • Improving the Reporting Process
  • Quality Medical Care
  • Pre-Injury Foundation for Success
  • Post-Injury Program Improvements
  • Injury Triage as Backbone to Future Success

If medical tourism is to be successful in being implemented into workers’ compensation, a knowledge, understanding and appreciation of the process laid out by Paul and others in the workers’ compensation arena, is essential for those wishing to seek out employers and insurance carriers as partners in this venture. In much the same way that salespersons know, understand and appreciate the manufacturing process of the products they sell, so too should medical tourism facilitators and the personnel at medical tourism destinations.

By doing so, the entire process from first report of injury to initial treatment and final medical tourism care, if that occurs, would be a seamless flow from beginning to end with all interested parties working together to get the patient the best care possible and back to work as soon as medically possible. In this way, medical tourism could be seen as the end stage of the entire workers’ compensation process and the cost savings realized could be used to incentivize the employee to chose the medical tourism option, and in turn, be re-directed back to making improvements in the five key areas above.

The end of the ‘Doctor-Patient’ Relationship?

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While perusing my local South Florida newspaper, I happened to find an opinion piece written by Sally Pipes, the President, CEO, and Taube Fellow in Health Care Studies at the Pacific Research Institute. Ms. Pipes’ article, “Obamacare may put end to doctor-patient relationship” states that the Affordable Care Act, i.e., “Obamacare” is putting an end to the traditional doctor-patient relationship, which she believes will lead to “assembly-line medicine” and impact the quality of patient care.

Some of her criticisms have been addressed in earlier blog posts, especially “Is Medical Tourism “Anti-Union?” where I mentioned that doctors are becoming salaried workers and may one day form a union and gain collective bargaining rights.

But what really caught my eye were the following comments she made:

Fortunately, Americans determined to receive personalized care aren’t without options. In addition to concierge practices, another tactic growing in popularity is medical tourism — traveling abroad for treatments and procedures, often at more affordable prices. This year, three-quarters of a million Americans will travel outside the country for non-urgent care.

The medical tourism group Patients Beyond Borders estimates that Americans can save 25 to 40 percent on their medical bills by traveling to Brazil. For Costa Rica, it’s 45 to 60 percent. And in Thailand, the savings can reach 70 percent.

So if she is right, and the ACA brings an end to the traditional doctor-patient relationship, wouldn’t that also affect the way injured workers receive care? So if Ms. Pipes is advocating patient choice in medical tourism for individuals seeking better medical care, shouldn’t that apply to workers’ compensation? Or are workers “undeserving” of such care?

Summary of “Legal Barriers to Implementing International Providers into Medical Provider Networks for Workers’ Compensation”

Richard’s Note: This is excerpted from my White Paper, “Legal Barriers to Implementing International Medical Providers into Medical Provider Networks for Workers’ Compensation”. The full paper can be accessed here at: http://wp.me/p2QJfz-5c

Throughout the debate leading to the enactment of the 2010 Affordable Care Act (ACA), one area of health care has been relegated to the sidelines; the rising cost of workers’ compensation claims. One major factor for the increase of workers’ compensation claims costs is the rise of medical costs associated with those claims. The average medical cost per loss time claim in workers’ compensation in 2008 was $26,000, and medical losses in that year represented 58% of all total losses. Since 2008, the average medical cost has risen steadily, increasing at a moderate rate.

In the past twenty years, from 1991 to 2010, the average medical cost per lost-time claim has gone from $8,100 to $26,900. In 2001 it increased to $15,900, and by 2005 it had gone up to $21,300. Given this trajectory, medical costs for workers’ compensation will continue to rise, perhaps even reaching $50,000, if medical costs cannot be controlled. With all the workers’ compensation system calls for reform, one possible solution has yet to catch on; implementing international medical providers into workers’ compensation.

Implementing international medical providers into the U.S. workers’ compensation system sounds far-fetched; however, globalization is rapidly changing many industries around the world, and health care and workers’ compensation should not be an exception to that change.

Just as many legal barriers exist to doing business overseas, the implementation of international medical providers into U.S. workers’ compensation medical provider networks also presents many barriers. This Summary will attempt to examine a few legal and regulatory barriers currently preventing foreign medical providers from treating patients abroad for injuries resulting from work-related accidents.

Considerations of cost are one reason why patients go abroad for medical treatment. Patients also seek medical care abroad for the quality of care received at foreign hospitals. Fears of poor quality result from stereotypes regarding doctors and facilities in developing countries.  The quality of care available at many of the common medical tourism destinations are comparable to that available to the average U.S. patient; also death rates and adverse outcomes for cardiac patients in Indian and Thai medical tourist hospitals are comparable to, and in some instances, lower than those at American hospitals.

Typically, the effectiveness and safety of health care services delivered to patient populations in the U.S. is how “quality of care” is measured. However, quality is generally difficult to measure or define. Also, comparing safety on a state or local level is practically impossible. Federal policy makes reporting adverse events at medical facilities voluntary, and few states require reports to be made public.  Reports, where made, are usually incomplete as well.

Though all patients can benefit, medical tourism’s cost savings are more likely to benefit those with inadequate health insurance coverage.  Lower-middle-class individuals, who typically have sufficient means to pay for reduced-price care out-of pocket, will benefit most from medical tourism.  This is a point to bear in mind with regard to workers’ compensation, as many claimants are generally lower-middle-class.

Medical tourism disproportionately benefits uninsured or underinsured individuals, but they are not the only ones benefitting from cost savings from medical tourism.  Self-insured employers and private insurance companies have begun integrating medical tourism into their policies. It is attractive to small businesses as well. Medical tourism is expanding as self-insured employers and insurance companies have integrated medical tourism into their policies.

One of the most obvious legal barriers to implementing medical tourism into workers’ compensation are the provisions of State workers’ compensation laws that establish who can provide medical care to injured workers. In four of the largest workers’ compensation states, California, Florida, New York and Texas, medical providers must be licensed by the state to practice medicine. Florida’s statutes have a provision to allow certain foreign-trained physicians to practice in the state, but do not mention treatment outside of the state.

On the other hand, two states, Oregon and Washington State, both have statutes or rules that allow workers to choose an attending doctor or physician in another country. Oregon’s labor code states, “…The worker also may choose an attending doctor or physician in another country or in any other state or territory or possession of the United States with the prior approval of the insurer or self-insured employer.”

The WA State Department of Labor and Industries has a page on their website that allows workers to find an attending practitioner in the U.S., Canada, Mexico and Other Countries. The webpage allows the worker to search for a U.S. physician by entering a zip code, miles, doctor or provider type, and specialty.  Workers seeking physicians in Canada, Mexico and Other Countries, such as England, Germany, Honduras, New Zealand, the Philippines, Spain, Thailand and Ukraine are directed to .pdf files that list selected doctors and their specialties and contact information.

Among some of the other barriers to medical tourism is the result of entrenched interest groups wishing to avoid competition with low-cost providers. Also, outdated federal and state laws intended to protect consumers, but only increase costs and reduce convenience. Additionally, state and federal regulations restrict public providers from outsourcing certain expensive medical procedures. Federal laws inhibit collaboration and state licensing laws prevent certain medical tasks being performed by providers in other countries. Foreign physicians lack the authority to order tests, initiate therapies and to prescribe drugs that U.S. pharmacies are able to dispense.

Restrictions on the practice of medicine have been removed, and many still exist. Some laws, for example, make it illegal for a physician to consult with a patient online without an initial face-to-face meeting; it is illegal for a physician who is outside the state and who has examined the patient in person to continue treating via the Internet after the patient goes home; and it is illegal (in most states) for a physician outside that state to consult by phone with the patient residing in that state if the physician is not licensed to practice there.

Other barriers or potential barriers, which are extremely important ones, also exist that must be addressed before medical tourism is accepted for workers’ compensation. Issues regarding medical malpractice and liability laws overseas, patient privacy and medical record laws (including HIPAA), ERISA(not a factor in Work Comp) and the impact of PPACA have to be dealt with before medical tourism is a viable option not only for non-compensation patients, but for compensation patients as well.

An exhaustive case law search resulted in identifying three cases that support or refute the implementing of medical tourism into the workers’ compensation arena. However, these three cases do offer some insight into how courts might rule regarding the implementation of medical tourism in workers’ compensation.

In the first case, a Mexican resident, working in California as a laborer, fell from a ladder. The court ruled in his favor, and said employers are responsible for reasonable expense of treatment and medical-legal costs.

The next case, also in California, was a case of domestic medical tourism. An employee of a convalescence hospital slipped and sustained injuries to his back and right elbow. The court that the costs of attending an obesity clinic were reimbursable and that he was entitled to the cost of future medical treatment.

The last case was in Florida, and involved an undocumented Mexican worker. He had twelve surgeries to repair the fracture to his leg. He needed additional surgery, but never got the surgery in the US, as he returned to Mexico and did not have legal documents to return to the US. The court ruled that state law did not preclude the foreign physician’s treatment of the claimant in Mexico. They stated that Florida workers’ compensation law contemplates coverage for non-citizens. They cited cases that held that undocumented workers were entitled to workers’ compensation coverage in Florida. They also stated that Florida law indicates that an injured worker is not prohibited from moving from his pre-injury residence in the state, and receiving treatment outside of the state.

Research into the legal barriers to implementing medical tourism into workers’ compensation found nothing of any real substance that would prevent workers’ compensation cases from benefiting from medical tourism. We have seen that there still remain several legal barriers to the implementation of medical tourism into workers’ compensation. Various federal and state laws need to be changed, and the issues of medical malpractice and liability laws, patient privacy and medical record laws and HIPAA, as well as ERISA and the impact of PPACA must all be addressed. But it is my opinion that these barriers can and will be overcome, especially in light of case law that has broken down some of those barriers already for foreign workers. The cost savings that can be achieved and the quality of care that matches, and even surpasses that found in the U.S., is sufficient reason why medical tourism should be implemented.

Health Care Integration

This article ties in very nicely with one of my earlier posts, A ‘Case Study’ in Implementing Medical Tourism into Workers’ Compensation, available here: http://wp.me/p2QJfz-X

Link to White Paper on the legal barriers to implementing medical tourism into workers’ compensation

Here is the link to my White Paper on the legal barriers to implementing medical tourism into workers’ compensation.

https://www.box.com/s/77inqpo9pa91y6rxt133

Opioid Abuse in Workers’ Compensation: What the Medical Tourism Industry Needs to Know

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One workers’ compensation topic that I have avoided discussing so far, given that the tagline of my blog is about implementing medical tourism into workers’ compensation, is the issue of opioid abuse in workers’ compensation.

Many articles and blog postings have been written describing the problem and the ways in which insurance companies, third party administrators, claims management firms, pharmacy benefit management firms, brokers, claims and risk managers, state and federal government agencies, and other interested parties are trying to get a handle on this problem.

It is a very complex and complicated issue, and one that has many in the workers’ compensation industry concerned because it drives up medical costs for claims, adds to the number of claims filed not only due to an injury, but to the abuse and addiction it engenders. It also impairs workers who then get injured again due to the effects of the medication, and it lowers productivity and prolongs the time employees take to return to work.

Business Insurance issued a White Paper on the subject last year entitled, Opioid Abuse & Workers’ Comp. In the paper, the authors describe the growing use of opioids that create abuse issues, the multiple factors causing the persistent problem, the rise of employer costs as abuse widens, the mix of strategies being used to combat this problem, and how to track selected metrics that are being used to support the goals workers comp managers establish to reduce abuse.

It so happens that some of the individuals who are quoted in the paper are people I know from other blogs, such as Joe Paduda, or are one of my LinkedIn connections, or I knew when I did my summer internship at the Third Party Administrator, Broadspire’s Sunrise, Florida office as part of my MHA degree program requirements in 2011.

One of the projects that I worked on while at Broadspire dealt with the dispensing of drugs by physicians, which is another important problem in workers’ compensation, and is related to opioid abuse, since most of the drugs prescribed in workers’ comp are the Schedule drugs being abused the most in the US. What I found was that the most serious problem of prescribing drugs was in California, and was not confined to physicians alone, but to pharmacies as well. Florida was the other state that had the most drugs prescribed by pharmacies or physicians. Time did not allow me to look at the other states of the country.

While not wanting to get too deep into the subject, I believe that it is important for those in the medical tourism industry to be cognizant and aware of the problem. Those who would like to pursue implementation of medical tourism into the workers’ compensation system in the US should realize that such a problem exists, so that in the future, if a self-insured employer or commercially insured employer should send one of their injured workers abroad for medical treatment of a work-related injury, the facilitator and the staff of the hospital where treatment is provided, knows that abuse of pain medication is a rampant problem among US workers’ compensation claimants.

This is even more incumbent upon those who, as I mentioned in my last post, What Role Can Medical Tourism Play in Physical Therapy and Rehabilitation for Workers’ Compensation?, might want to get into the area of physical therapy and rehabilitation, since the goal of rehab and therapy is to get the patient back to work faster, and one of the side effects of abuse is prolonged disability.

This is a serious issue for the workers’ compensation industry at the present time, and before medical tourism can be properly implemented, it is advisable that it is taken just as seriously in the medical tourism industry as well.

What Role Can Medical Tourism Play in Physical Therapy and Rehabilitation for Workers’ Compensation?

Physical Therapist Working with PatientPhysical therapy and rehabilitation is an integral part of the workers’ compensation claims process. After an injury occurs, the way the patient/claimant is treated and the sooner they get back to work, depends a lot on the type of physical therapy and rehabilitation they receive.

Today’s post comes courtesy of Joe Paduda, who writes in his blog, Managed Care Matters, about a recent study by two academic institutions and a consulting client of his, in the Journal of Occupational Rehabilitation, published on January 18, 2013.

The study entitled, Differences Among Health Care Settings in Utilization and Type of Physical Rehabilitation Administered to Patients Receiving Workers’ Compensation for Musculoskeletal Disorders, found that there were significant differences in the type and duration of physical therapy provided to workers’ comp claimants.

The authors of the study looked at several variables in the billing data, such as location of service, duration of care, type of care, and other data points. And the data was adjusted for case-mix.

There are three key findings that the authors discovered:

  • Corporate physical therapy centers billed for more visits and more units per episode than other practice settings.
  • There was a “large difference in treatment utilization between geographic regions regardless of practice setting, diagnosis, body-part treated or surgical intervention”
  • These corporate centers billed for “a lower proportion of physical agents indicating a greater use of those interventions supported by evidence-based guidelines (exercise and manual therapy) compared to other practice settings.”

The authors’ findings were consistent across all diagnoses, and controlled for surgical v. non-surgical cases.

As Joe points out, the second key finding comes as no surprise. He states that,

in many instances the care you receive depends more on where your provider was trained, the local standard of care, and the personal opinion of the treater than what has been scientifically proven to work.

He goes on to say that the third finding is “intriguing“.

When I wrote my earlier blog post, No Back Alleys Here, I listed a hospital in Chile, Hospital del Trabajador,(loosely translated – Hospital of Employee or Workman) that specializes in trauma, burns and rehabilitation. There may have been others as well that listed rehabilitation as part of their service offerings, but it seems much of what I have learned about the medical tourism industry has not included rehabilitation or physical therapy for that matter.

Perhaps one of the other ways medical tourism can be implemented into workers’ compensation, is by offering such services to workers’ comp carriers and employers, and perhaps it can be packaged the same way as other medical services are packaged, as all-inclusive services, covering cost of treatment, airfare and accommodations.

Focusing on such things as cosmetic surgery and other unavailable services are good for the industry at the present moment, but if it could branch out into the physical therapy and rehabilitation area, given the wide disparity of care available here in the US, the medical tourism industry could prove its worth to the workers’ compensation insurance carriers and their employer clients.

Being able to provide lower cost, efficient, and effective physical therapy and rehabilitation services to injured American workers’ compensation patient/claimants, in a relaxing and tranquil setting in either familiar cultural surroundings (if the patient is being treated in their country of origin), or in an environment that is free from the stress and strain of everyday life going to and from one’s home and a physical therapy facility, will be a boon to the medical tourism industry for years to come, not to mention the advantage of having working people travel to new places that will further understanding and better relations.

Something to think about.