Tag Archives: Surgery

“Florida, We Have a Problem”

Tuesday, Judge David Langham, Deputy Chief Judge of Compensation Claims for the Florida Office of Judges of Compensation Claims and Division of Administrative Hearings, wrote a rather lengthy post about the differences between cost-shifting and case-shifting in workers’ comp.

Much of what the Judge wrote were subjects that I already discussed in a number of previous posts about cost-shifting and case-shifting, so I won’t go into it here. I am only focusing on the parts that relate to Florida workers’ comp. You can read the entire article yourselves.

But what caught my attention was what he said about Florida and what the Workers’ Compensation Research Institute (WCRI) reported in some of their studies on these issues.

As Judge Langham wrote this week, he wrote a post two years ago that asked the question “Why Does Surgery Cost Double in Workers’ Compensation?”

Judge Langham noted in that post that Florida employers have been documented paying almost double for shoulder or knee surgery that is paid for under workers’ compensation, compared to group health costs.

The implication of case-shifting in Florida, he says, could arguably be a doubling of cost.

He cited a WCRI report released earlier this year that suggests however that case-shifting is perhaps not as likely in Florida.

According to the report, Judge Langham continues, “as of July 2011, six states had workers’ comp medical fee schedules with rates within 15% of Medicare rates. They were California, Massachusetts, Florida, North Carolina, New York and Hawaii.”

However, Judge Langham pointed out that the WCRI concluded that case-shifting is more likely in states where the workers’ compensation fee schedule is 20% or more above the group health rates, and not in Florida.

Judge Langham stated that this analysis of workers’ compensation fee schedules does not appear to include analysis of the reimbursement rates for hospitals, and that It also seems contradictory to the assertions that Florida workers’ compensation costs for various surgeries have been documented as roughly double the group health rates (100% higher, not 15% higher).

Injured workers who missed work in the Florida workers’ compensation system could be compensated in 2016 at a rate as high as $862.51 per week, the “maximum compensation rate.”

So, if recovery from such a “soft-tissue” injury required ten weeks off-work, he wrote, the case-shifting to workers’ compensation might add another four to nine thousand dollars to the already doubled cost of surgical repair under workers’ compensation.

This could be directly borne by the employer if the employer is self-insured for workers’ compensation; or, if the employer has purchased workers’ compensation insurance, the effect on the employer would be indirect in the form of potentially increased premium costs for workers’ compensation following such events and payments, Judge Langham states.

According to WCRI, the Judge quotes, “policymakers have always focused on the impact (workers’ compensation) fee schedules have on access to care as well as utilization of services.

This has been a two-part analysis, he says:

First, fee schedules have to be sufficient such that physicians are willing to provide care in the workers’ compensation system; and second, the reimbursement cannot be too high, or perhaps overutilization is encouraged.

Lastly, Judge Langham points out that the disparity between costs has also been noted in discussions of “medical tourism.”

The last question he posits is this, “might medical decision makers direct care to more efficient providers, across town, across state lines?”

What about national borders?

I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Will accept invitations to speak or attend conferences.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

Transforming Workers’ Blog is now viewed all over the world in 250 countries and political entities. I have published nearly 300 articles, many of them re-published in newsletters and other blogs.

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Follow-up Visits After Surgery: Telehealth, Medical Travel and Workers’ Comp

One of the questions posed to me when I have discussed the idea of medical travel in workers’ comp is what to do with follow-up care.

In an article this week from Reuters, Andrew Seaman wrote that people may happily, and safely, forgo in-person doctors’ visits after surgery by opting instead for talking with their surgeons by phone or video. Seaman said this was the result of a small study of U.S. veterans.

The study, conducted by researchers in JAMA Surgery, said most patients preferred the virtual visits and that the doctors didn’t miss any infections that popped up after surgery.

Lead author Dr. Michael Vella, of Vanderbilt University Medical Center in Nashville said, “These kinds of methods are really important in the climate we’re in now,”…”So I think anything you can do to save money, see more patients and improve access to care is really important.”

Vella and his colleagues also wrote that there is interest in so-called telehealth to increase access to healthcare while also decreasing the costs associated with traveling to office visits.

Past research has found that telehealth visits may be useful in the treatment of chronic conditions and after surgery, but less is known about patients preferences for these types of visits, they added.

The study team evaluated data collected over several months in 2014 from 23 veterans, Seaman reported, and all but one of them were men, who were seen three times after a simple operation that would require only a night or so in the hospital. One visit was via video, the second was via telephone and the third was an in-person office visit.

The researchers found that no post-operation infections were missed during the video or telephone visits.

Dr. Vella said, “The veterans were very good at describing their wounds,” … “There was one patient who thought they were having problems, we brought them into clinic and there was an infection.”

Overall, the study found that 69 percent of the participants said they preferred a telehealth visit over the traditional in-office visit. Those who preferred the telehealth visit tended to live farther away from the hospital than those who would rather come into the office.

“I think (the study) challenges the paradigm that we need to see all patients back for visits,” Vella said.

Dr. Vella cautioned that the study was small, and they could not say that telehealth visits won’t miss problems. The study also cannot assess how telehealth visits would work for patients who have undergone more complex surgeries, according to Dr. Vella.

An alternative opinion was given by Dr. Sherry Wren, who was not involved in the new study, and also cautioned that not all patient preferences will align with the telehealth model.

“There will be patients who want to be seen, be reassured and want a doctor to check something out,” said Wren, a professor of surgery at the Palo Alto Veterans Affairs Health Care System in California.

Still, she said, many patients will like the option.

“There is a subset of patient that it’s not going to be appropriate for, but I think it’s a great alternative for the vast majority of patients.”

Dr. Vella said future research showing the results of the real-world implementation of telehealth will provide more information on its safety.

“I think it’s just really important that people continue to look at it,” he said.

What does this mean?

It means that when medical travel is ever implemented into workers comp, and that day grows ever closer, after a patient goes home to his/her country, they will still be able to get follow up care from the surgeon who performed the surgery, without having to fly back to the medical travel destination several times.

Will it work for everyone? Both Drs. Vella and Wren indicated that there are people who will not want it, and that there are subsets of patients that it will not be appropriate for, but overall they were both very positive about the future of telehealth visits after surgery.

If it worked for American veterans, it can certainly work for injured workers covered under workers’ comp, Veterans, especially those from our two ill-designed, ill-planned, and ill-conceived wars in Iraq and Afghanistan certainly have wounds more serious than most injured workers would suffer as a result of a work-related injury.

The only thing that stands in the way of introducing telehealth into workers’ comp, with or without medical travel, is what is between the ears of the leaders and “so-called” experts in the industry who have thus far gone and done the same things over and over again, and expect different results.

And you know what that is? Crazy, stupid, ridiculous, without any credibility, and without any traction in logic, which, I suspect is where the stuff between their ears are in.

Knee Surgery in Costa Rica — A Less Expensive Alternative


Richard’s Note: This is probably the last blog post I will write in 2013, so let me take this opportunity to wish all of my readers a very Happy Holiday, and a very Happy New Year. Let’s hope that 2014 will be a year in which medical tourism takes its rightful place as an alternative to high cost, low quality health care. One more thing, 2014 will be the centennial year of the beginning of the First World War, a war in which the leading nations of the world at that time, blundered into, and which ultimately led to an even greater disaster, the Second World War. As globalization brings us closer together, let us remember that one hundred years ago, much of the world was backward and underdeveloped, and being exploited by all major powers; yes, even the ‘good ole USA’, so my hope is that one day, travelling to another country for health care will be as commonplace as going to another city here at home.

Last week, I had a meeting with the C.E.O. of Costa Rica Med Connect, Russell Cuciak. Russell connected with me on LinkedIn in response to my last blog posting. As we are both in South Florida and live in Palm Beach County, we had the chance to talk by phone on a few occasions before arranging a meeting in his office in Boca Raton.

Russell told me that he has been sending patients to Costa Rica for about two years now, and has been very active in taking a hands-on approach towards his clients’ care, which was in evidence during our meeting when he called a former potential client who had weight loss surgery in Florida, instead of in Costa Rica. The client had lost a significant amount of weight from the surgery, but since Russell followed up with him even though the client did not seek his care in Costa Rica, it proved to me that Russell stands by those who come to him for his services, whether they use them or not.

His patients are sent to the CIMA Hospital in Escazú, or its more formal name, San Miguel de Escazú, the capital city of the canton of Escazú in the province of San José in Costa Rica. It is also the name of the district that includes the city, a subnational entity with 14,815 inhabitants. Escazú is 9 kilometers from the national capital of San Jose, which is in the center of the country between the Caribbean Sea and the Pacific Ocean.

Over the past couple of decades Escazú has become an expatriate enclave: several embassies have their residences located here, including the residence of the US Ambassador and the British Ambassador. The past few years have seen a significant influx of newly arrived foreigners from North America, South America and Europe. It is home to many bars and restaurants, especially those of the more chic (and expensive) variety. Rents and prices reflect this and Escazú is the most well-known upscale location in Costa Rica. Here, one can find English movie theaters and even a luxurious country club. There are also many fine restaurants and dining areas in this part of town, with an excellent nightlife. Banks, pharmacies, shops, grocery stores and even an 18-hole championship golf course can be found here, along with one of the biggest and most modern shopping malls in Central America, Multiplaza.

For those of you who have read my blog article, No Back Alleys Here: Medical Tourism Hospitals, Clinics and Networks in Latin America and the Caribbean, you will remember that CIMA — Centro Internacional de Medicina, was one of the hospitals I listed in Mexico, particularly the one in Chihuahua.

I asked Russell to give me a ballpark figure of what the cost of knee replacement surgery would be in Costa Rica, and he quoted me a figure of $13,000, which includes everything except the airfare and hotel. He told me that several of the resorts in the area cater to specific patients having surgery at CIMA, so that there is a resort for patients recovering from plastic surgery, a resort for patients recovering from orthopedic surgeries, etc. It was explained to me that these resorts allow his patients to be around other individuals like them so that they do not feel uncomfortable. One particular hotel, the Holiday Inn, which is next to the CIMA hospital, takes all patients, and has special medical rooms for them.

The cost for a room in some of these resorts are anywhere from $25 a night to $250 a night, so with the cost of surgery for a knee replacement of $13,000, adding the airfare and accommodation would add another $2,000 or $3,000 to the total cost, which when compared to costs in the US of the same procedure, could be double or triple that, depending on the hospital’s bill, the surgeon’s bill, the anesthesiologist’s bill, etc.

Russell told me that in 2012, 40,000 Americans went to Costa Rica for medical tourism. As I said in my No Back Alleys Here piece, Costa Rica is one of the “rising stars” of medical tourism, and Russell’s company is one of at least a half a dozen that I know of, if not more, that are capitalizing on those 40,000 medical tourists.

During our conversation, I discussed what I found in my research paper about the barriers to implementing medical tourism into workers’ compensation, and with medical tourism in general, was the issue of legal liability. Russell told me that he carries $1 million in liability insurance, and I gave him some names of insurance companies that provide medical tourism insurance that I found on my smartphone while talking to him.

I told him of my difficulty in getting the workers’ compensation industry interested in my idea for medical tourism, and he asked me why I thought that the insurance companies had not jumped on this. I told him that there are many people in medical tourism who are asking the same question, and the most logical answer was that it is not on their radar.

We spent more than an hour and a half talking inside and outside his office, and we hope to be able to drum up more interest for medical tourism with individuals, employers, and insurance companies, both in health care and in workers’ compensation.

As uncertainty with the ACA continues, and as the cost of health care keeps rising, despite the drop in health care spending, traveling to a medical tourism destination such as Costa Rica, will become a viable option not only for health care patients, but for workers’ compensation as well. HAPPY NEW YEAR!


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Surgical Shenanigans: How Workers’ Compensation is being ripped off


Now that I’ve cleared the air, and professed the faith of my conviction, I would like to get back to the subject at hand, which is implementing medical tourism into workers’ compensation. In my last post, I asked the following question:

Is there something different about patients who can afford to pay for medical treatment abroad or who have private health plans that do, from those who get injured on the job and have their treatment paid for by an employer or insurance carrier under workers’ comp?

In that same post, I also asked this question as well:

What difference is there if a person injures their hip or knee by engaging in some sort of physical activity outside of their employment, or if the person gets hurt on the job? Are the surgical procedures for these types of surgeries different for a working person than those for a middle-class or upper-middle-class person?

Well, according to a recent study just released by the Workers’ Compensation Research Institute (WCRI), and reported this week by WorkersCompensation.com, there is something different in what hospitals were paid for shoulder surgeries in workers’ compensation and what hospitals were paid by private or group health insurance for the very same surgeries.

The article, Hospitals Were Paid At Least $2,000 More For Common Surgeries For Injured Workers Than The Typical Patient, stated that in half of the study states, hospital outpatient payments for shoulder surgeries in workers’ compensation were at least $2,000 (or 43 %) higher than group health insurance.

The study, entitled Comparing Workers’ Compensation and Group Health Hospital Outpatient Payments, is the first, WorkersCompensation.com says, that compares hospital payments for the same surgical procedure when paid for by group health versus workers’ compensation.

According to Richard Victor, the executive director of the WCRI, “These are large differences in costs in many states. Policymakers looking to contain medical costs in these states may want to ask if the difference is necessary to induce hospital outpatient departments to treat injured workers”.

The WCRI study also found that workers’ compensation payments exceeded group health payments by the most in states where the price regulations were based on a percentage of the hospital’s charges, or had no price regulation.

The study compared outpatient payments made by workers’ compensation and group health insurers for treatment of common surgical cases in 16 large states, which represents 60% of the workers’ compensation benefits paid in the US, and covers outpatient services delivered in 2008.

So apparently, there is a difference between workers’ compensation and group health insurance after all. The only problem is it does not have to do with the treatment received by patients covered under each type of insurance, but rather on how much workers’ compensation carriers paid hospitals for outpatient surgeries. Silly me, all this time I thought it had to do with the type of patient, now I see it has to do with the kind of insurance he is covered under.

So now, my question to the workers’ compensation industry is this:

How long are you going to put up with overpaying for the same surgical procedure for your workers’ compensation claimants, than what group health insurance pays for its patients for the same procedure under their plans?

And my question to the medical tourism industry is this:

If you claim that medical tourism destination hospitals offer lower cost health care than what is available in the US, then why are you not actively pursuing the workers’ compensation market, instead of just pursuing the private or group health care market? Do breast augmentations/reductions, plastic surgery and other common medical tourism procedures make more profit than that of the US workers’ compensation industry, or is it a lack of vision thing?

Do I have to spell it out every time I write an article? The American health care system (and that includes workers’ compensation) is too expensive. Yes, I know there are regulatory differences between health care and workers’ compensation. Yes, I know that in certain cases, there may be different processes involved with the same type of surgery for different patients. And yes, I realize that there are risk and complications; but really, what difference does it make if the patient was injured on the job and needs shoulder surgery, or if the patient was a weekend warrior playing hoops, football, baseball, or a myriad other sports and activities and needs  the same type of surgery? Not much.

The only difference is who pays, and how much, and based on this latest study, it seems the workers’ compensation industry is being hosed, big time. Time to wake up and explore the alternatives to high cost medical care for injured workers. Time to wake up and realize that the rest of the world is catching up to the “good ole’ USA” and providing better quality health care at lower cost.

I am not saying that it will be easy to implement medical tourism, so no one should think reading this that this is what I am advocating. And I am not saying that every destination is up to the task of providing such services. Far from it, but those that can, should be explored. Those that would like to in the future should be encouraged to seek out workers’ compensation carriers, third party administrators and case management firms here in the US for their advice and guidance.

The workers’ compensation industry can take the next step and seriously consider medical tourism, or it can continue to pay at least $2,000 more for the same surgery a group health plan pays. It’s your choice.