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Workers' Compensation

CWCI Examines Medical Access In California Workers' Compensation

Oakland, CA – A new California Workers’ Compensation Institute (CWCI) study finds that overall, injured workers’ access to medical care for their initial treatment remained relatively consistent between 2010 and 2020, though average and median wait times for the first doctor visit varied by type of care, and as in group health and other systems, rural residents have the farthest to travel and access to fewer providers, especially specialists.

For its access study, CWCI used data from more than 1.5 million job injury claims from accident year (AY) 2010 -AY 2020 to measure changes in the amount of time that elapsed between an employer’s notice of injury and the first treatment, and the average distance that injured workers traveled to receive their initial care. Wait times to the first visit were calculated for all types of treatment, with results also broken out for Evaluation and Management (E&M) visits, Physical Medicine (PM) visits, and for the 5 most heavily utilized workers’ comp surgical services. The average distance to the first treatment was calculated for all claimants in the study sample, with more detailed results comparing average distances traveled by workers living in urban, suburban, and rural areas of the state.

The average wait time from employer notice to the initial treatment showed some variation across the 11-year span, ranging from a low of 3.3 days for AY 2011 claims to 4.4 days for claims from AY 2020 – the first year of the pandemic, but the median number of days to first treatment showed no change, as the median values across all 11 years indicated initial care rendered on the same day that the employer was notified of the injury. The average time from the employer’s notice to the first E&M visit also rose slightly over the 11-year span, ranging from 4.1 days for AY 2011 claims to 5.2 days for AY 2020 claims, but again the median values for all years indicated that the initial E&M visit occurred on the same day that the employer was notified of the injury.

On the other hand, the average wait time for some specialty services showed greater variation over time. For example, the average wait time to a first PM visit increased from 31.8 days for AY 2010 claims to 37.5 days for AY 2015 claims, but then trended back down to 31.2 days by AY 2020. The median number of days to first PM visit showed a similar pattern, climbing from 15 days to 20 days between AY 2010 and AY 2015, then falling back to 15 days by AY 2020. Notably, most of the increase in the number of days to the first PM visit began in 2013, coinciding with legislative reforms and emergency regulations impacting workers’ comp Medical Provider Networks (MPNs) and the Utilization Review (UR) process – including a mandate that treating physicians use a new Request for Authorization form effective January 1, 2013, and a requirement that disputes over medical necessity of a requested treatment be resolved through a new Independent Medical Review (IMR) process. CWCI notes that the subsequent declines in the average and median days to the first PM visit may have resulted from improved processes by physicians and payers as they became familiar with these new requirements.

CWCI’s analysis of the wait times between employer notification of injury and the date of the first surgery service, which focused on the top 5 surgery services used in workers’ comp, found significantly different timeframes for the initial service, which likely reflects differences in the scope and complexity of the procedures and differences in the pre-surgery condition of patients receiving them. For example, wound repair and splinting are relatively simple surgical services that are often clear-cut treatment choices for injuries requiring immediate care, so across all 11 years both the average and median wait times suggest that these services were provided on the day the employer was notified of the injury. In contrast, aspiration of, or injection into, a major joint or bursa is a somewhat more complex procedure that may be recommended by the treatment guidelines if a condition does not subside over time or with alternate treatment. In claims with these surgical services, the average and median wait times increased by 17 and 28 days respectively over the 11-year study period. Similarly, average wait times for an injection of a therapeutic agent into a tendon or ligament went from 92.2 days for AY 2010 claims to 104.7 days for AY 2020 claims, while the median days increased from 70 to 91.

In addition to measuring changes in the wait times for various treatment services, the Institute also calculated the average distance from each injured worker’s residence to the location of their initial treatment, with results broken out by year. This analysis found that the average distance traveled by California injured workers to their initial treatment was remarkably stable across the 11-year study period, ranging between 5.3 and 5.7 miles. Segmenting the results into geographic subcategories (urban, suburban, and rural) the study found that the average distances that injured workers living in the more densely populated urban and suburban regions traveled to receive their initial care was about one-third to one-half of the average for those living in less densely populated rural parts of the state. But even among rural residents, who in AY 2020 accounted for 8.8 percent of all California injured workers, the average distance traveled showed only minor variations during the study period, ranging from 11.0 miles in 2010 to 13.1 miles in 2017. Notably, in all cases, the average distances injured workers had to travel were well within the medical access standards set by the state for MPNs, which provide nearly 92 percent of all workers’ compensation treatment in the state. Those standards require that injured workers have a choice of 3 primary care providers within 30 minutes or 15 miles of their home or workplace; a choice of 3 medical specialty providers within 60 minutes or 30 miles; and a hospital emergency room or non-hospital provider of all emergency healthcare services within 30 minutes or 15 miles. The latest proximity to care findings also track with results of CWCI’s April 2021 research which found that 99 percent of claims in which treatment was rendered by an MPN provider, and 98 percent of non-MPN claims met the state’s access standards.

CWCI has published more details on its study in a Report to the Industry, “Can Access to Medical Care in California Workers’ Compensation Be Improved?” CWCI members and research subscribers can download a free copy from the Research section of the Institute website by clicking here, others may purchase a downloadable copy from the Institute’s online store here.