Workmen's Compensation Insurance Research Articles

The impact of alternative pricing methods for drugs in California Workers' Compensation System: Fee-schedule pricing.

IntroductionCalifornia’s Workers’ Compensation System (CAWCS) Department of Industrial Relations questioned the adequacy of the current Medi-Cal fee-schedule pricing and requested analysis of alternatives that maximize price availability and maintain budget neutrality.ObjectivesTo compare CAWCS pharmacy-dispensed (PD) drug prices under alternative fee schedules, and identify combinations of alternative benchmarks that have prices available for the largest percentage of PD drugs and that best reach budget neutrality.MethodsClaims transaction-level data (2011–2013) from CAWCS were used to estimate total annual PD pharmaceutical payments. Medi-Cal pricing data was from the Workman’s Compensation Insurance System (WCIS). Average Wholesale Prices (AWP), Wholesale Acquisition Costs (WAC), Direct Prices (DP), Federal Upper Limit (FUL) prices, and National Average Drug Acquisition Costs (NADAC) were from Medi-Span. We matched National Drug Codes (NDCs), pricing dates, and drug quantity for comparisons. We report pharmacy-dispensed (PD) claims frequency, reimbursement matching rate, and paid costs by CAWCS as the reference price against all alternative price benchmarks.ResultsOf 12,529,977 CAWCS claims for pharmaceutical products 11.6% (1,462,814) were for PD drugs. Prescription drug cost for CAWCS was over $152M; $63.9M, $47.9M, and $40.6M in 2011–2013. Ninety seven percent of these CAWCS PD claims had a Medi-Cal price. Alternative mechanisms provided a price for fewer claims; NADAC 94.23%, AWP 90.94%, FUL 73.11%, WAC 66.98%, and DP 14.33%. Among CAWCS drugs with no Medi-Cal price in PD claims, AWP, WAC, NADAC, DP, and FUL provided prices for 96.7%, 63.14%, 24.82%, 20.83%, and 15.08% of claims. Overall CAWCS paid 100.52% of Medi-Cal, 60% of AWP, 97% of WAC, 309.53% of FUL, 103.83% of DP, and 136.27% of NADAC.ConclusionsCAWCS current Medi-Cal fee-schedule price list for PD drugs is more complete than all alternative fee-schedules. However, all reimbursement approaches would require combinations of pricing benchmarks. We suggest keeping primary reimbursement at 100% of Medi-Cal and for drugs without a primary Medi-Cal price calculating the maximum fee as 60% of AWP and then 97% of WAC. Alternatively, we suggest using NADAC as a primary fee-schedule followed by either 60% AWP and 97% WAC or AWP-40% for drugs with no NADAC price. Fee-schedules may not offer the best price and a formulary approach may provide more flexibility.

임금근로자의 산업재해에 대한 성인지적 분석

The statistics of occupational injuries and illnesses is one of the most important indicators of worker's safety and health in the field of occupational safety and health. The conventional statistics was produced without consideration of gender difference. This study was planned to investigate the difference of occupational injuries and illnesses by gender because that recently female workers was increased through the change of industrial structure such as from manufacturing dominated to service dominated structure. Statistics of occupational injuries and illnesses collected by workmen's compensation insurance system that have no information about gender composition of population. Economically active population survey was used to calculated the rate of occupational injuries and illnesses by gender. The distribution of estimated rate of occupational injuries and illnesses by industry, occupation and the type of accident were different between male and female employees, but those by the size of enterprise, age of the injured, the duration of the first recuperation, and job tenure were similar between male and female employees. This study has shown that gender sensitive approach may be applied to policy of occupational safety and health because that gender neutral perspective may not discover the fact of gender specific problems.

Disability Evaluation of the Pain : The Present and Prospect in Korea

Pain has long been regarded as a subjective symptom. Recently, however, some regard a type of intractable chronic pain as a disease. Furthermore, chronic persistent pain becomes a cause of permanent impairment (PI). In 6th edition, the American Medical Association (AMA) Guides has rated the pain as a PI. In Korea, pain has been already been rated as a PI. Here, we examined the present status and the prospect of disability evaluation for the pain in Korea. Pain can be rated as a PI by the Workmen's Compensation Insurance Act (WCIA) and Patriots and Veterans Welfare Corporation Act (PVWCA) in Korea. We examined the definition, diagnostic criteria and grades of the pain related disability (PRD) in these two acts. We also examined legal judgments, which were made in 2005 for patients with severe pain. We also compared the acts and the judgments to the criteria of the 6th AMA Guides. The PRD can be rated as one of the 4 grades according to the WCIA. The provisions of the law do not limit the pain only for the complex regional pain syndrome (CRPS). The PRD can be rated as one of the 3 grades by the PVWCA. If there were objective signs such as osteoporosis, joint contracture and muscle atrophy corresponding to the CRPS, the grade is rated as 6. When the pain always interferes with one's job except easy work, the grade is rated as high as 5. In Korea, judicial precedents dealt the pain as a permanent disability in 2005. Although there were no objective criteria for evaluation of the PRD, pain has been already rated as a PI by the laws or judicial precedents, in Korea. Thus, we should regulate the Korean criteria of PRD like the AMA 6th edition. We also should develop the objective tools for evaluation of the PRD near in future.

E-safety: online uses in occupational safety

In today's highly competitive global market, domestic businesses are forced to cut excess costs wherever possible. Among the factors being addressed by industry is the rising costs associated with employee accidents. Accidents lead to higher workman's compensation insurance rates and increased costs from employee lost time, and general societal costs. The challenge is to create an effective safety programme that will produce and encourage a safety culture within the company. E-safety is taking advantage of current technology, effectively using online components to enhance current safety programmes, revitalising them to influence the awareness, knowledge and behaviour of workers and decrease the severity and number of work related accidents. Governmental agencies and corporate partners can streamline the online learning modules and Material Safety Data Sheets (MSDS) for greater efficiencies and compliant requirements.

P1101 労災二次健診における保健指導の効果についての検討(一般演題:ポスター,地方の時代の産業保健,第79回日本産業衛生学会)

P1101 労災二次健診における保健指導の効果についての検討(一般演題:ポスター,地方の時代の産業保健,第79回日本産業衛生学会)

Quality of life and chronic nonmalignant pain

Chronic nonmalignant pain is a prevalent and costly phenomenon. Chronic pain induces stressors that affect personal and work lives of sufferers. Because of this interference, quality of life is impacted. The purpose of this pilot study was to explore the impact of stressors on the quality of life of adult patients with chronic pain. The framework guiding this study was Neuman's Systems Model based on the concepts of stress and reaction to stress. A descriptive correlational research design was used to compare participants' quality of life according to their health and function; family, psychological, spiritual, and socioeconomic status; and the stressors of age, gender, income, marital and work status, occupation, monthly treatment costs, and type of insurance. Each participant was administered the Ferrans and Powers Quality-of-Life Index and a demographic survey. Results revealed that a higher quality of life was associated with participants who were older, female, and employed, whereas a lower quality of life was associated with participants with a low income, higher treatment costs, and a lack of workmen's compensation insurance. Based on Neuman's model, the implications of chronic pain sufferers' resistance to the negative impact of various stressors are discussed. © 2001 by the American Society of Pain Management Nurses

Quality burn rehabilitation: cost-effective approach.

As funding for health care becomes a national concern, and workman's compensation and private health insurance companies attempt to limit their expenditures in the treatment of the client with burns, it may become the responsibility of the burn specialists to create a cost-effective approach to quality burn rehabilitation. Our outpatient rehabilitation program has taken a cost-effective approach that limits the use of inpatient rehabilitation, emphasizes the burn team guiding the client to a quick functional return to home and work, and concentrates costs for therapy rather than room and board. This cost-effective rehabilitation approach emphasizes an intensive 6-hours-per day, 5-days-per-week outpatient program that begins immediately after discharge. In a 2 1/2-year follow-up of this cost-effective program, the following were identified. (1) A 40% reduction in costs for third-party payers and (2) clients returning to work an average of 4 months after their injury. In the cost-effective rehabilitation approach, 82% of the health care costs are concentrated for therapy. In the traditional inpatient rehabilitation program, room and board costs comprise 57% of the charges. Because it is the responsibility of the burn specialists to educate the health care payers, a program description to implement the cost-effective approach to burn rehabilitation is provided.

Workers' Compensation Issues in Construction

Workmen's compensation insurance laws were enacted in the United States to protect injured employees, who were often unable to attain restitution from employers because they could not afford the co...

Cost Benefits of Interdisciplinary Chronic Pain Treatment

Abstract This is a retrospective study of 53 chronic pain patients who were treated at the Boulder Pain Control Center. Only one measure of treatment success was examined: the cost benefit of that treatment to two workman's compensation insurance carriers. This was accomplished by using a model that projected, in our study population, an average cost benefit of $238,515 per patient. The social value of determining such measures in chronic pain patients is discussed.

Insurance Practices of Utility Contractors

The experiences and practices concerning construction-related insurance were the focus of a nationwide survey conducted with utility contractors. The survey obtained information related to: contract requirements for insurance, general liability coverage, workmen's compensation insurance, particular services provided by insurance companies, and specific practices of contracting firms relating to insurance matters. The results show specific differences of the practices of contractors depending on whether the owner is public or private. Additional differences were noted in the practices of firms in differing sizes. In general, the different practices of contractors appear to reflect differences in business philosophy or in the in-house capability of company personnel.

First year hospitalisation costs for the spinal cord injured patient.

This retrospective, descriptive study presents the actual first year hospitalisation costs for a series of 85 spinal cord injured patients, covered by Workmen's Compensation Insurance and cared for in a variety of United States institutions. Mean first year hospital costs for all patients was $35,767. For quadriplegics, $42,240; and paraplegics, $32.619. During initial hospitalisation only, the average length of stay was 184 days and mean cost was $28.637. Room and board comprised 52 per cent of cots; special services, 36 per cent and professional services, 11 per cent. Major special service costs were private duty nursing, medications, medical supplies, respiratory and physical therapy. Major professional charges were centred in the surgical and physical medicine specialties. Home care costs averaged $4000 per patient or $37.00 per day. When compared with the other studies, the costs presented here are higher though the differential is reduced markedly when median rather than mean costs are presented. When compared with the one other known study based on actual and not estimated costs, the results are markedly similar. Differences in costs between this and other studies and the reasons for same are discussed.

Reducing Construction Accidents—Top Management’s Role

A study of the policies and practices used by top managers in construction firms has demonstrated that top managers, by their own actions, can significantly reduce accident costs in their companies. Data were collected from a questionnaire survey, an in-depth study of one company, and face-to-face interviews with top managers and safety directors in 23 construction firms. Data from the interviews were analyzed using each company's workmen's compensation insurance experience modification rate as a measure of safety. From the analysis, guidelines were developed which can be used by top managers who want to reduce accidents in their own companies. The data indicate that top managers should know about accident rates on individual projects, and use this knowledge in decisions about salary and promotion of field managers. They should use their cost reporting system to encourage safety, and should insist on orientation of newly hired workers, and detailed work-planning at the job level.

Classification of Hearing Losses Induced by Noises in Workmen's Accidents, and Counter Measures againt Noise Induced Hearing Loss

While working under noise ranging from the safety noise level up to the harmful, workers are liable to suffer from chronic occupational deafness or sudden hearing loss due to industrial noise. The latter case has been made a subject of the Workmen's Compensation Insurance in Japan since April, 1959. Mention was also made of Aptitude Test in the field (by Kawamura) as a counter measure against hearing losses and Temporary Threshold Shift as criteria of treatment of occupational deafness. On the other hand, a wide range revision of grades of the hearing losses was effected in September, 1975, and the lowest compensation criteria was raised from 60dB to 30dB. Since this kind of revision is related not only to compensation for, but also prevention of hearing losses and arresting their further progress, it is considered that it will pose a serious problem.

Operations Research in the Insurance Industry: II. An Application in Claims Operations of Workmen's Compensation Insurance

This paper presents an application of operations-research techniques to managing claims in workmen's compensation insurance. It describes the investigative studies and their conclusions, outlines the systems design and implementation, and gives a sample of the validation studies. Implementation of the proprietary claims-management system described has provided dramatic reductions in case durations and paid dollar losses, while returning the injured worker to his ultimate level of rehabilitation in a shorter time.

Safety Incentives in Workmen's Compensation Insurance

The workmen's compensation insurance premiums of most employers are adjusted, by the use of an experience-rating formula, to reflect the firm's accident record. This paper presents, by firm size, the elasticities of the most commonly used formula with respect to accident frequency and severity. The analysis shows that financial incentives for safety are negligible for small firms, and thus it fails to support the recent National Commission's recommendation that experience rating be extended to still smaller firms. It is also shown that quite large increases in benefit levels would do virtually nothing to increase those incentives.

Workmen's Compensation Insurer as Suable Third Party

Until 1960, lawyers appeared to assume that the workmen's compensation insurance carrier partook of the employer's immunity to common law suit by an injured employee. Since then there has been a rapid. succession of judicial decisions, some holding the carrier liable as a third party for negligent safety inspections or medical services, some holding the opposite. This article analyzes the state and direction of the la w produced by these decisions and related legislative amendments, and proposes a solution.

A Clinical Observation of Sudden Hearing Loss (Acute Acoustic Trauma) due to Noise Exposure

Besides the well-known occupational deafness, a type with relatively acute onset should be included in the group of hearing impairment due to noise. Since 1954, 2628 cases with aural disturbance have been studied by the precise hearing test and 82 cases (3.12%) are found to be of the accidental type.In Sep. 1958 the author first reported sudden hearing loss due to industrial noise. This type of acute hearing loss have been taken into consideration by the Compensation Administration as the item of the Workmen's Compensation Insurance of Japan, since Apr. 1959.Acute hearing impairment, however, can not be recognized in every person under the same condition. It usually befalls to persons specifically susceptible to noise. Even in the case of the same person, development of hearing impairment depends on the psychosomatic and environmental conditions present at the time. This disease shows the wide range of individual susceptibility, therefore, such specifications as follows must be established: onset of subjective symptoms of aggravation of previously impaired hearing, while working under conditions of harmful noise above the safety criteria (about 85phon) in certain place and time.It is difficult to grasp precisely the clinical characteristics of the disease, as in the case of other perceptive deafness, but its developmental specificity deserves attention as one type of hearing impairment due to industrial noise.

The First Computer in Rhodesia

Punched-card equipment was introduced here early in 1956, as a direct result of the decision to centralize the control of staff records for approximately 12,000 civil servants. The machines installed were able to give valuable help in the production of the monthly payroll and the annual income-tax returns. They were also used to prepare and issue wage declaration statements and renewal notices for Workmen's Compensation Insurance and for the payment of pensions. However, their application was necessarily limited, and the volume of work was increasing, so that a computer was ordered in December 1958. The machine was delivered at the end of December 1960, and was handed over in excellent condition on 1 March 1961, after two months' testing and assembly. It has been fully operative since that date.

Safety at the Management Level

This article discusses the role of the top level of utility management, its place, its function, and its importance in a safety program. It discusses in detail management's function of providing constant direction, supervision, and control of the safety program. Workmen's compensation insurance rates, and a cost benefits analyses of an effective accident prevention program are discussed.

Workmen's Compensation and Private Benefit Programs

As our provisions for economic security expand to cover more risks and more people, the American social security system grows increasingly complex. Much has been written on the relationships--actual and theoretical--between public and private pension programs, but only scanty information is available on the relationships between private health, welfare, and pension plans and our oldest social security program, workmen's compensation insurance. There are good reasons for this lack of information. Workmen's compensation has well-developed traditions of separatism. It functions under the aegis and direction of insurance companies, physicians, and attorneys. Until recently, compensation issues have received limited consideration from economists, political scientists, and industrial relations specialists. This paper, therefore, proposes to do two things: (1) It will describe and analyze some of the private plan provisions which are supplementing, duplicating, or perhaps undercutting state workmen's compensation plans and benefits. (2) It will discuss the implications these private provisions may have for the future of workmen's compensation. (Author's abstract courtesy EBSCO.)