MONTANA SELF INSURERS' ASSOCIATION
April 2022 Update Part I
- MSF Annual Medical Conference 5/19-20
- OSHA Reporting Rules Proposal
- AMA Guides Editorial Panel Meeting 4/14
- MSIA Webinar Series Survey Coming
- WCRI Annual Meeting Review in Part II
Montana State Fund 20th Annual Medical Conference May 19 & 20
Montana State Fund will be holding their 20th Annual Medical Conference this year titled, Harnessing the Future of Workers’ Compensation, on May 19 & 20 at the Delta Hotel in Helena Montana State Fund 20th Annual Medical Conference (regfox.com). This year’s conference topics include:
- Occupational Injury Causation: Fact or Fiction – Mark Melhorn, MD, Clinical Assistant Profession of Orthorpaedics, University of Kansas
- Reducing Costs & Improving Outcomes – Marcus Nynas, DC, FICC, Insurance Chair, American Chiropractic Association
- Top Ten Medical Predictions in Workers’ Compensation – Stuart Colburn, Attorney at Law, Downs Stanford, PC
- Medical Marijuana: Delving Into the Weeds – Kathy Collins, PharmD, BCPS, Craig Hospital
- Issues with Independent Medical Evaluations from the Workers’ Compensation Court Perspective - Judge David Sandler, Montana Workers’ Compensation Court Judge
- Empowering Evidence-Based Claims Decisions Through Advocacy – Denise Zoe Algire, MBA, RN, Albertson’s Copmpanies
- Physical Medicine & Rehab – Dr. Tutukamen Pappoe, MD, Clarus IME
- When Change Chooses You: My Remarkable Journey with Paralysis – Dale Hyll, MD, MPA, Executive Director Neuroworx
Registration is $225 and continuing education credits for medical professionals, attorneys and claims examiners is pending but expected to be available. You can register here: Montana State Fund 20th Annual Medical Conference (regfox.com). Having been intimately involved with a number of MSF Annual Medical Conferences, I have found significant value in these meetings and have benefitted from the opportunity to get together with the Montana workers’ compensation community while learning from medical leaders from both Montana and nationally. The meetings have been well worth the effort. Medical education credits are being provided through MSIA member SCL Health.
New OSHA Reporting Rules Proposed
On March 28, OSHA proposed changes to their electronic reporting requirements for some employers. Comments on the new proposed rules can be made electronically until May 31.
Doug Kalinowski, OSHA Directorate of Cooperative and State Programs recently sent the following announcement about newly proposed rules on the reporting of injury and illness requirements. The big change in this proposal is the decrease in requirement of employers between 100 to 250 to electronically report injuries and illnesses. Comments on the new proposals can be made until May 31.
The Occupational Safety and Health Administration (OSHA) is proposing to amend its occupational injury and illness recordkeeping regulation [gcc02.safelinks.protection.outlook.com] to require certain employers to electronically submit injury and illness information to OSHA that employers are already required to keep under the recordkeeping regulation. OSHA proposes to amend its regulation to require:
- Establishments with 20 or more employees, in certain high-hazard industries, continue to electronically submit Form 300A Annual Summary information once a year to OSHA.
- Establishments with 100 or more employees in the highest-hazard industries to submit Form 300 Log and Form 301 Incident Report information once a year to OSHA. These establishments would continue to be required to electronically submit information from their Form 300A Annual Summary.
In addition, establishments with 250 or more employees, not in designated high-hazard industries, would no longer be required to electronically submit recordkeeping information to OSHA.
Comments, along with any submissions and attachments, should be submitted electronically at https://www.regulations.gov/ [gcc02.safelinks.protection.outlook.com], identified by Docket No. OSHA-2021-0006, which is the Federal e-Rulemaking Portal. All comments must be submitted by the deadline of May 31, 2022. For more information, please see the Federal Register Notice [gcc02.safelinks.protection.outlook.com].
I am far from being an OSHA reporting expert. My understanding is that the 300 log is a report of work-related injuries and illnesses with the extent and severity of each incident. Form 301 provides additional information about each incident recorded in the 300 log. Neither of these reports are required to be reported to OSHA but must be available at the work site. The 300A is an annual summary of the incidents on the 300 log. Currently, the 300A report is required to be posted in the workplace from Feb 1 to April 30 each year and has been held as confidential information by OSHA. OSHA has lost some recent Freedom Of Information Act court challenges. As a result, it is possible that the information required under these proposed rules may become public record.
AMA Guides Editorial Board Meeting – April 14
The AMA seems to be following through on their pledge to be more open to others participating in their Guides update efforts. They have announced their next AMA Guides Editorial Panel meeting for Thursday, April 14, scheduled from 8:30a – 11:30a MDT. A specific agenda does not seem to be available as yet.
There is no charge to sit in and learn more about what the Editorial Panel is considering and the AMA provides a process to suggest topics for the panel to consider through this page, Editorial Panel Meeting. You can register to attend the next AMA Guides Editorial Panel meeting here: Register Now
MSIA Webinar Series Survey Coming Soon
MSIA held our first webinar featuring national MSA experts Ciara Koba of Allan Koba Compliance Solutions and Amber Worman of MSIA member Montana Municipal Interlocal Authority. Both are on the Board of Directors for the National Medicare as Secondary Payer Network. The slide deck is available to webinar attendees and MSIA members. If you would like a copy, please contact us through the MSIA office. Overall feedback on the webinar was very positive – thank you.
Moving forward, MSIA would like to learn from you what would be valuable to you from a webinar series. What topics would you like to learn more about, and possibly get CE credits for? Who would be good presenters for our programs?
If you are an MSIA member, watch your email inbox for an informal survey asking for your thoughts coming soon. As with all MSIA surveys, responses are held in the strictest of confidence and individual responses will not be shared with anyone. Responses may be aggregated (without attribution) for discussion purposes only.
Topics currently under consideration for our series include:
- An overview of Montana Workers’ Compensation system results
- Claim Closure Strategies – How to deal with those difficult claims
- What’s New in the World of Drugs and Formularies
As a rule, there will be no charge for CE webinars for members and their staff.
WCRI 38th Annual Meeting Review
My review of the Workers’ Compensation Research Institute 38th Annual Meeting will be coming as the MSIA March Update – Part II, later this week. There was just too much information to put it all into one Update.
Thanks for your support. If you know of something we should include in our Updates or Extras, don’t hesitate to contact me!
MONTANA SELF INSURERS' ASSOCIATION
April 2022 MSIA Update – Part II
WCRI Annual Meeting Recap
I attended the Workers Compensation Research Institute’s 38th Annual Meeting a couple of weeks ago. WCRI is a national workers’ compensation think tank and seeks perspectives and participation from all walks in the workers’ compensation world. One of the things I particularly like about WCRI is their active pursuit of labor, plaintiff attorneys and different medical perspectives in their work. Their studies and research are routinely held up as objective and complete. Here’s my perspective on the presentations provided at the Annual Meeting.
Impact of COVID-19 Disruptions on the Workers’ Compensation Line: Trends, Challenges and Outcomes
Bob Hartwig, Clinical Associate Professor of Finance, Risk Management & Insurance, Darla Moore School of Business, University of South Carolina provided his take on the US economy, the workers’ compensation world and what we might expect going forward as a result of COVID-19’s impact on the economy.
Inflation is currently running at about 7.5%. In the last two years the Federal government has released $5.7 trillion in six COVID related stimulus packages. Hartwig called it a textbook example of how to create inflation. At the same time, he did not back away from the idea that we would be in far worse shape without those packages. The Fed’s job at this point, is walking a tightrope to tame inflation without creating a recession. Hartwig identified that medical CPI is currently about 2.4% and cautioned that we should expect this to change upward towards the end of this year and early in 2023.
Hartwig pointed out that the comparisons to our current inflation to the early 80’s do not hold water. In the 80’s our mortgage rates, unemployment rates and the basis for wage/price inflation were much different than they are today. Mortgage rates were in the 16 – 18% range – today they are about 3.6%. Unemployment was nearing double digits, while today, again about 3.6%. Wage and price inflation were different issues in that there were plenty of people chasing too few jobs. Today, just the opposite is true, there is about .6 of a person for every job opening. Our economy is still growing – although it feels different because we are going from the 7.5% GDP growth to about 2% GDP growth within a year. While it may feel like a recession, the economy is still growing.
Since shutdown, we have 2.1 million fewer workers in the the labor market. For the first time in US history, over half the adults in the over 55 year age bracket are out of the workforce. For that matter, in many states, death rates exceeded birth rates – also a new phenomenon. Overall, our population grew just .1%.
In another odd situation, workers’ compensation suddenly has become one of the more profitable lines of P & C insurance with loss ratios continuing in high 80’s and low 90’s. WC is also taking on average among the lowest average premium increases across the P & C lines. WC premium changes, from the Council if Insurance Agents and Brokers data and the University of South Carolina Center for Risk and Uncertainty Management, were up at 0.3% while Commercial Auto, EPL, D & O, Umberella and Cyber all saw double digit increases. Cyber coverage was reported to be up an average of 34.3%.
Hartwig pointed out, as NCCI has, that COVID claims just have not been the bugaboo they were first thought to be. While nationally, 11% of claims were related to COVID, overall payments represented 2.4% and incurred losses were 3.5% nationally. That being said, the variations between states were broader than with most claims and costs – some due to the Executive Orders and new laws providing for presumptions of coverage, while other states did not change their coverage laws. MT for example had the lowest in COVID related claims at 1%, while KY saw 29% of all claims be related to COVID. The median across states was 7% of claims. Losses too, were all over the place, with AL reporting only 0.2% of incurred losses related to COVID claims, but 12% of incurred losses in DC from those claims. The median was 1.7% of workers compensation losses were related to COVID claims and Montana was below that.
Overall, the P & C industry remains strong, stable, sound and secure, with WC among the best performing lines. The payroll exposure base already exceeds pre-COVID levels. That however is a double edged sword as the number of workers remains down, but payroll is up – meaning rising wages and ultimately, rising indemnity severities. Medical inflation remains in check – for now – but it will increase as the year goes on.
The Future of the Workplace After COVID-19
This panel featured Dr. Craig Ross, regional medical director for Liberty Mutual, Dan Allen, Executive Director of the Construction Industry Service Corporation (CISCO) and Denise Algire, Director of Risk Initiatives and National Medical Director for Alberstons. They identified four major changes in the current post COVID workplace:
1.Vaccines – the law seems to be pretty clear that employers can mandate vaccinations. However, the panel agreed employers are wisely proceeding with caution in issuing mandates. More and more employers are using communication, empowerment and education much more frequently and encouraging, rather than mandating vaccinations. The added communication efforts pays off elsewhere as well.
2.Long COVID – it appears that 10 – 30% of people who contract COVID suffer from what is commonly referred to as Long COVID. However, with over 200 symptoms affecting up to 20 different body systems, it is a bit more complicated than most other respiratory maladies. The ADA considers Long COVID a disability, so employers need to be ready to work and help accommodate workers who might qualify with Long COVID symptoms. Here too communication, listening and remaining flexible are keys for employers.
3.Returning to the Office – well, kind of returning to the office. If we learned nothing else from the past two years it is that employers and work places are flexible. Our ability and willingness to use technology and , creativity provides for a different work environment than our parents – for that matter, than we had until 2020. Employers are advised to survey employees about their comfort level, consider the requirements, versus desires, of working in an office and to remain flexible. Most agree that a hybrid approach will likely be our office experience going forward.
4.Executive Level Hearing – one of the most positive changes the panel found was the C-Suite was more attuned to the need for cleanliness, safety, the emotional needs of their workforce, the importance of telehealth and for those traditionally physical jobs, stretching and calisthenics. There has been a notable shift in meeting the emotional and physical needs of the workforce. As a society and in workplaces, we are discussing suicide and prevention much more frequently, and are accepting – from the top down – that emotional support and emotional health of our community and workforce are important.
Pandemic Impact on Indemnity Benefits
WCRI Senior Public Policy Analyst Dr. Rebecca Yang reported on preliminary findings from a review of the WCRI ConpScope data regarding durations of non-COVID indemnity claims in both 2019/2020 and 2020/2021. These results are preliminary and are subject to change based on further review of the data. However, given the data set there are directions that can be gleaned from the information. Please Note - - Montana is not a CompScope reporting state, therefore our state system information is not included.
- Of the states reviewed, only four saw indemnity benefits increase by less than 3% per year for the period studied (2019/2020 and 2020/2021) – that means that others saw more than a 3% increase in indemnity benefit payments. Only one state, Indiana, saw a decrease (-2.7%); Minnesota had the highest increase at 18%.
- Every state saw an increase in Temporary disability in 2020. The increases ranged from 1% in LA to 11% in WI. Prior to the 2019 – 2020 period, temporary disability durations were decreasing in five states, NC, TX, AZ, PA and CA.
Typically, preliminary findings presented at the WCRI Annual Meeting means a final report is soon to come out. MSIA is a member of WCRI and when the report is released, I will share the results with members.
Patterns and Outcomes of Chiropractic Care
WCRI Economist Dongchun Wang reviewed the preliminary findings of research on the use and costs of Chiropractic Care in workers’ compensation. I found the results surprising and look forward to more information from the final report. The data set included claims which were non-surgical low back pain occurring from 10/1/2015 to 9/30/2017 for the first 18 months up to 3/31/2019. Montana data is not included.
Chiropractic Care was defined as care from a provider who diagnoses and treats people with back pain – it is typically hands-on treatment without surgery. This is in contrast with Physical Therapy where the therapists focus more on excersize, versus diagnosis and treatment. Note too, that the findings do not reflect all low back pain claims, only those where chiropractic care was identified as having been provided.
- 12 of the 28 states reviewed used chiropractic care in less than 5% of claims. In 11 of these 12 states, employers had the statutory right to choose the physicians. Four of the remaining 16 states had the same statutory set-up.
In other words, most of the states with low chiropractic care usage, the employer chooses the physician.
- In the 16 states with over 5 % of claims, that is those states where chiropractic care is prevalent, 29% of these low back pain claims had chiropractic care.
MN, WI, CA and NY were the top five states ranging from almost 15% of cases to almost 35% of cases. In all these states the injured worker chooses the medical provider.
- Half of the claims where physical medicine was the only treatment, had exclusively chiropractic care.
Wang identified the supply and demand of chiropractors, provider choice laws, utilization review, fee schedules and system limitations on services/visits, environmental and cultural factores and patient preference as the basis for the differences in chiropractic utilization. Based on her presentation, there was an obvious and direct correlation of provider choice and the use of chiropractic care in these claims.
However - - for these claims, indemnity costs were 35% lower and temporary disability durations were 26% shorter for those claims that had exclusively chiropractic care as their physical medicine treatment. These numbers are statistically significant. A copy of the Conference presentation package is attached. Again, these results are preliminary – typically from the WCRI Annual Meeting, that means we can expect a full study release sometime during this year. When the full report becomes available, I will share the results with our membership.
Provider Consolidation Impact on Workers’ Compensation
Dr. Bogdan Sayvch, WCRI Public Policy Analyst presented his preliminary findings on the impact the changing nature of the business of medicine is having on workers’ compensation costs. Generally, there is consensus that consolidation in medicine leads to increase prices and some research that it leads to decreased quality of care. Sayvch addressed the cost component and reported he does not have enough data to address the quality questions. His data is from 2018; we know consolidation in the medical field has continued since then.
Sayvch first explored the differences between vertical integration (physician practices being absorbed by health systems) and horizontal integration (similar businesses merging – health systems merging with health systems or practices merging with other practices). There are limitations in the data – identifying specific physicians responsible for care and outcomes of individual patients, case mix adjusting – comparing patients with the same or similar diagnoses over time, as examples. And, Sayvch pointed out that the provider consolidation issues are driven more by locality than most other workers’ compensation systems information provided. Differences in states vary widely in the numbers and types of both vertical and horizontal integrations. There are also questions of how often primary care providers, and even orthopedic providers, saw workers’ compensation patients. The answer at the national level, is not much. Here too, Montana information and our personal knowledge may be somewhat different – at the least based on our shortage of providers.
Even so, Savych identified that vertical integration of physician practices into health systems seem to lead to more expensive treatments being ordered and conducted, resulting in higher prices. Here too, we can expect the release of a formal study later in the year and I will provide the information when it is available.
National Commission – 50 Years Later
WCRI provided a panel consisting of a plaintiff attorney, Alan Pierce, an insurance counsel, Bruce Wood and a Florida Workers’ Compensation Judge, David Langham on a retrospective of our workers’ compensation systems 50 years after the release of the National Commission report. The panel started off with a portion of a taped interview with John Burton, Chair of Commission conducted by Pierce and Jennifer Wolf, then director of the IAIABC. In the clip, Burton discussed that the recommendation that full coverage for diseases was not adopted by most systems. The clip concluded with Burton’s thought that systems are better than they were prior to the report, but that work needed to be done yet. That was an over-arching theme of the panel. Even so, there were some fun sparks and highlights.
Pierce, a plaintiff attorney practicing in Massachusetts, bemoaned the fact that the Commission made no recommendations on PPD benefits. He cited the National Academy of Social Insurance study which puts benefits at 20 – 40% of replacement of pre-injury actual wages. He remained true to form in claiming that every change from the reforms of the 90’s and 00’s came at the cost of the injured worker and that compensability has been severely limited, further reducing access to benefits. He claimed of the 19 essential recommendations in the Commission report, states had adopted an average of 13 of them. The conclusion, was the work was at best, 2/3s done, so there was still a ways to go. Pierce concluded that with overall advances in medical care, the systems were in better shape than they were in 1972 but clearly compensability and adequacy of benefits still needed to be addressed.
Wood countered that the changes brought by the Commission increased system costs but did not provide for market pricing to follow. As a result, the systems had an existential crisis by the late 80’s and early 90’s – something we know all to well in Montana. Other state systems were also bankrupt – ME, TX, RI and OR as examples - and absent reforms from the Commission driven changes, there would be no systems to worry about. As much as employees need employers, employers need a WC system with a semblance of balance. One of the first 90’s reforms, in OR, was to require work be the major contributing cause of the injury/illness. This provided a level of common sense and balance to the systems which has allowed them to recover, if not thrive. Wood picked out the MA system, where things were so bad according to him, organized labor proposed cutting the benefit level from 66 2/3% of AWW to the current 60% level. He pointed out to no one’s surprise, when labor proposes to reduce benefits in a WC system, things are really bad. Wood concluded that unlike prior to reforms, physicians were willing to take on WC patients and that while nothing is perfect, overall the systems were far better than they were prior to the report.
Langham pointed out that the Commission was working under a time deadline set by Congress and understood they could not address everything. As a result, they agreed to address those issues they could agree on. The result was a tremendous piece of work, but an incomplete piece of work. That being said, the systems are in much better shape than they were prior to the report.
The panel then started to get to be fun.
- Pierce accused states of “racing to the bottom” in an effort to promote economic developmentby cutting benefits and access to benefits. He posited that the Federal government could do more to assure a balance in the systems. He agreed that no one wants the federal government to take over the systems but proposed they could provide a floor for all so the systems were more fair (to his position).
- Wood pointed out that if states have been racing to the bottom in their reform efforts, after 30 years, we would have already reached the bottom. More to the point, the Commission increased benefits and access to benefits, and in doing so, created an imbalance in the systems. The reforms were necessary and provided a balance the Commission ultimately did not address.
- Langham, in what I think was the line of the conference, said if the federal government is the answer, it’s a really stupid question.
One final note – I noted no one on the panel addressed the proliferation of benefit presumptions we have seen adopted in systems over the past 10 years or so.
The Short and Long Term Consequences of COVID-19
Finally, we heard from Dr. Sandro Galea, MD, MPH, DrPH, Dean of the Boston University of Public Health. Galea quoted Allan Brandt, Harvard University professor, “We tend to think of pandemics and epidemics as episodic, but we are living in the Covid-19 era, not the Covid-19 crisis. There will be a lot of changes that are substantial and persistent. We won’t look back and say, ‘That was a terrible time, but it’s over.’ We will be dealing with many of the ramifications of Covid-19 for decades, for decades.”
- COVID was the third leading cause of death in the US in 2020 following heart disease and cancer
- 216 million Americans have received the COVID vaccine and 95 million are fully vaccinated and boosted. We have never before attempted to inoculate an entire population. The closest analogy may be polio, which targeted children and took over two years to get a majority of the audience vaccinated.
- COVID has hit our populations differently – for example blacks are twice as likely to die from COVID than whites. The poor are also much more likely to die, than the middle or upper classes.
With almost 1 million Americans dead from COVID, our population has been among the hardest hit. It is a reflection of how un-healthy we are, despite our society spending the most on health care.
As the WCRI reports become available, I will provide the information to our membership.