October 1996 Bulletin

Managed Care in Workers Compensation

Medical care of injured workers should be of high quality, at a reasonable cost, and provided in a timely manner in order to achieve maximum medical recovery and a safe, prompt return to the work force. The integration of managed care programs into workers compensation health care is increasing rapidly.

The American Academy of Orthopaedic Surgeons believes that properly designed and efficiently run workers compensation managed care programs can provide high-quality health care to injured workers and minimize their disabilities.

Effective managed care workers compensation programs can be recognized by the following characteristics:

Providing prompt access to medical care

• Initial evaluation and treatment within 24 hours of the report of the injury or onset of symptoms
• Preliminary verbal report to the injured worker at the time of initial evaluation and/or treatment
• Written report or completed form to the insurer within 48-72 hours of initial evaluation
• Referral of employee without delay to appropriate specialty care for medically necessary services when indicated

Furnishing beneficial services to the employee

• Case manager services for the employee, which includes considering the employee's injury as it relates to such issues as the work and home environment, job and personal skills and education
• Education of the injured employee about how the workers compensation system operates
• Education of the injured employee as to the value of being an integral part of his/her own recovery process

Returning the employee to work

• Alternative or modified useful work made available at the injured employee's regular workplace at the earliest possible opportunity as part of the treatment and/or re-entry process facilitated by case manager services
• Education of the injured employee as to the value of return to regular work at the earliest possible time as an important part of the healing process
• Facilitation of vocational rehabilitation, when necessary, to employees who will not be able to return to their former employment

Using quality assurance measures

• "Best Practice" standards, based on scientific evidence and/or expert consensus, with panel physician/provider input and evaluation in the development, implementation and maintenance of the standards
• Quality of care monitored; remedial programs instituted for deficient patterns of care
• Regular surveys of employees, employers, insurers and providers to assess the satisfaction with and the quality of services provided

Establishing effective communication among all parties

• Proactive case management to ensure effective coordination and communication among employer, employee and provider
• Effective coordination and communication between the third-party administrator (insurer or other) and all integral parties (i. e., case manager, medical providers, utilization review board)
• Prompt response to requests for additional information
• Prompt dispute resolution (e.g., referral, preauthorization, payment issues)

Encouraging safety and prevention measures

• On-going medical contact with employer's safety committee
• Tracking of type and incidence of injury, as well as job stress in the workplace
• Establishing pathways to allow medical input for development of remedial programs

The American Academy of Orthopaedic Surgeons believes that managed care workers compensation programs that meet at least these basic standards deserve public and/or legislative support.

As managed care workers compensation systems evolve, all parties-the physician, the employer, the employee, the insurer and governmental agencies-will share opportunities to introduce and encourage changes in how care is viewed and delivered. By helping to redesign managed care workers compensation systems with safety and prevention as high priorities and by establishing positive incentives for early return to work, employee health and productivity will increase and the number of injuries that occur on the job will decrease.

The American Academy of Orthopaedic Surgeons supports changes in managed care workers compensation programs that establish measures for safety and prevention and improve the timely delivery of high-quality, cost-effective medical care to workers who are injured on the job.

September, 1996