Accountable Care Organizations May Shift Claims into Workers’ Comp

As reported Monday on the Insurance Information Institute’s blog, Terms + Conditions, and posted by Claire Wilkinson, the Affordable Care Act (ACA) may actually cause millions of claims dollars to be shifted into the workers’ comp system, according to research by the Workers’ Compensation Research Institute (WCRI).

Under the ACA, a mechanism called an Accountable Care Organization (ACO), which was designed to control costs, was used by the researchers at WCRI to estimate the nature of the cost shift, as well as giving a general idea of the magnitude of the shift. They used the ACO’s similarity to Health Maintenance Organizations (HMOs) in their research.

The ACA calls for the creation of ACO’s, which is a network of doctors and hospitals that share the financial and medical responsibility for a group of patients. The ACO receives a set amount per patient for a year, regardless of the services. This is called a capitated plan.

What the WCRI found by looking at a nationwide sample of more than 700,000 claims from 2008 to 2010, was that about 17 percent came from HMO’s. In those states with a large HMO presence, HMO doctors declared 26 percent of soft tissue injuries into workers’ comp. This was 30 percent higher than doctors in fee for service arrangements.

The Executive Director of WCRI, Dr. Richard Victor, estimated that ACO’s could increase the percentage of workers in capitated plans by 25 percent. Such an increase was determined would allow capitation plans to regain 15 percent of the market it has lost since 2000.

As stated in the blog article, cost-shifting in Illinois would out $90 million of claims into workers’ comp. and in Pennsylvania, it would cost insurers $55 million.

As I’ve said in my post, Workers’ Comp at a Crossroads: Where Does it Go from Here?, and in many other articles, things are not looking up for workers’ comp in the near term and well into the future.

But still, with the handwriting on the wall, and the trumpets blaring that will bring down the walls of the padded cell that is the American workers’ comp system, this industry insists on playing the “see no evil, hear no evil, speak no evil” game.

A conversation I had earlier today with a broker about medical travel and workers’ comp convinced me that at some point there needs to be a safety valve in this system, otherwise it will collapse in on itself.

Shortages of doctors, nurses, rising inpatient and outpatient costs, consolidation of hospitals, and other pressures will mount even greater, and not even the move towards domestic medical travel within the US will be sufficient to alleviate the bottleneck that is coming down the road.

But go ahead and keep running around on that wheel you see in squirrel cages, because in the final analysis, you are all just rats in a maze, with no clue.


I am willing to work with any broker, carrier, or employer who is sick and tired of being bled by the Wall Street vulture capitalists and the entire medico-legal system known as workers’ comp, to save money, and to provide the best care for their injured workers or their client’s employees, while at the same time, helping to break the monopoly of the American health care cartel.

Call me for more information, next steps, or connection strategies. Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp. Connect with and follow me on LinkedIn and my blog. Share this article, or leave a comment below.

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