The Ohio Bureau of Workers' Compensation: an analysis of the status quo and a proposal for improvement (a medical perspective).

• Author: Seitz, William H., Jr.

1. OVERVIEW AND HISTORY OF THE OHIO BUREAU OF WORKERS' COMPENSATION II. EXAMPLES OF PROBLEMS WITH THE OHIO BUREAU OF WORKERS' COMPENSATION A. Case Example 1 1. Case Example: The Physician who Treats the Patient Without Getting the Initial Diagnosis Changed 2. The Result: The Bureau of Workers' Compensation Does Not Reimburse the Physician B. Case Example 2 1. Case Example: The Physician who Follows the Proper Protocol in Getting the Initial Diagnosis Changed 2. The Result: Patients Must Wait Months Before They Can Receive the Proper Treatment C. Conclusion: Ohio Must Streamline Its Workers' Compensation System III. RECOMMENDATIONS FOR REMEDYING THE WORKERS' COMPENSATION SYSTEM A. Recommendation 1: Physicians Should Only Identify the Body Region of the Injury at the Initial Intake Point B. Recommendation 2: A Certification Process that Allows Amended Diagnoses Without Extensive Mandates C. Recommendation 3: Test Guidelines that Establish Specific Diagnoses D. Recommendation 4: Eliminate Reviews of the Bureau of Workers' Compensation's Certified Physicians' Diagnosis and Treatment Strategies E. Recommendation 5: Notation on a Prescription Should Be Adequate to Obtain that Prescription IV. CONCLUSION: OHIO MUST STREAMLINE ITS WORKERS' COMPENSATION SYSTEM SO THAT PATIENTS RECEIVE TREATMENT AND RETURN TO WORK AS QUICKLY AS POSSIBLE V. APPENDICES A. Appendix A: Claims Flow Chart B. Appendix B: Forms Used in a Bureau of Workers' Compensation Claim C. Appendix C: A Theoretical Flow Chart of Billing and Reimbursement I. OVERVIEW AND HISTORY OF THE OHIO BUREAU OF WORKERS' COMPENSATION

   Ohio, one of the nation's centers of manufacturing and commerce around which the Industrial Revolution was built, provided little protection for workers who sustained injuries in the work place, at the turn of the twentieth century. Due to limited medical resources and access to care, injured workers frequently lost their ability to earn a living and became a burden rather than a source of productivity for the community. By the early 1900s, the groundswell of response to this situation and the social injustice that it represented increased.

   In 1911, the Ohio General Assembly passed the state's first Workers' Compensation law. (1) Participation by employers in the Workers' Compensation program was voluntary. (2) The law created a state fund to compensate workers injured on the job. (3) Through this process, the employer paid ninety percent and the employee paid ten percent of the proposed premium. (4) However, because participation in the program was totally voluntary many employers declined to participate. Consequently, a 1913 amendment made the program compulsory for all employers. (5) Provisions in the law mandated the use of the state insurance fund for claims by an injured worker. (6) Alternatively, employers could be self-insured if they created their own fund that was deemed qualified to provide care for the number of workers they employed. (7)

   As the program grew over time, the Bureau of Workers' Compensation (BWC) developed into two divisions, an administrative arm and an insurance arm. (8) The existing legislation provides that the Chief of the BWC, who is appointed by the Governor, oversees the system's administrative and insurance arm. (9) On the other hand, the Industrial Commission has been the system's arm for claims adjudication. (10) The three members of the Industrial Commission are appointees of the Governor and confirmed by the Ohio Senate, one member each representing labor, employers, and the public. (11)

   This system grew to become one of the largest monopolistic insurance companies in the world. (12) In 1995 due to the size of the fund, an oversight commission was developed to review investments as well as the investment policy of the BWC. (13) A second five-member committee was charged with maintaining a viable fund to serve as the reservoir for providing medical care and appropriate wage reimbursement to workers who sustained work place injuries. Based on the size of the fund ($19 billion by the end of the 2006 fiscal year), it would appear the reserves available for coverage of injured workers' medical care and wages should be more than adequate. (14) However, due to poor financial oversight and expanding costs for administration, cuts in benefits, such as the elimination of non-generic prescription drugs and processes designed to deny coverage, have evolved.

   Just as the work place has increased in complexity since the inception of the BWC, so has the practice of medicine and the delivery of health care. Expanding the understanding of disease and the response of human physiology to disease has improved diagnostic skills. Technology and early intervention have reduced suffering and shortened disability. Streamlined, minimally invasive, and innovative treatment modalities have provided the source for successful treatment of many diseases and injuries with significant reduction of morbidity and rapid return to function. Unfortunately, the BWC "system" has become so mired in red tape through its rules and regulations and dozens of complex forms that it is often difficult for injured workers to take advantage of the improvements in medical care in a timely fashion, and the "system" itself has frequently proven to be an obstacle to providing care. (15)

   Moreover, the system has established an adversarial situation under which workers are pitted against their employers, and physicians frequently find themselves restricted in their ability to provide the needed care for their patients. (16) This adversarial situation is not unique to Ohio. In fact, it is prevalent in most states. (17) In reports published in peer-reviewed medical journals and presented at national scientific meetings considering outcomes of various medical treatment modalities, BWC patients are frequently factored out of the general pool of patients and considered a separate sub-group, because typically their outcomes are less successful than those of the general population. (18)

   Why should this be? The answer lies in the system's inherent adversarial environment under which a worker injured on the job frequently has to fight to prove the injury was in fact job-related. (19) In the current process, the employer, in an attempt to keep premium costs down, contests the worker's claim. (20) The worker develops a sense of anger at the employer while attempting to prove her point. In the lengthy, expensive ensuing debate the worker feels that the employer and the "system" have wronged her, has further caused injury by delay, and as a result feels that she is owed compensation not only for the injury but for the aggravation, anxiety, and frustration involved. Once the worker begins to obtain benefits, the injured worker has lost a significant amount of loyalty to the employer and, therefore, has also lost incentive to return to the work place in a timely fashion.

   The system also fosters incomplete diagnosis and treatment by accepting only the initial diagnosis at the patient's "point of entry," which is usually a corporate clinic or an emergency room. (21) From this point forward, amending the diagnosis requires a special hearing. (22) As a result, the insurance fund created to provide a resource and refuge for injured workers has substantially changed and no longer meets the goals and ideals for which it was created. Rather, the system fosters misdiagnosis, impedes ability to amend to include accurate diagnoses and delays prompt and appropriate care. From a physician's standpoint the system appears to be designed to delay treatment, escalate cost, and defer resources away from the injured worker and the health delivery system whose goal is to restore health. The result is a legal and bureaucratic entanglement in which it seems that a large percentage of the insurance dollar is spent on the system itself rather than on the injured worker.

   A worker's compensation claim is frequently a nightmare for the patient (injured worker), the employer (insurance payor), and the physician (health care provider). Because of the wastefulness inherent in the system, the overall cost of providing workers' compensation care in the State of Ohio has increased dramatically and as a result has seen significant reductions in hospital reimbursement levels and patient benefits, such as prescription drug availability. (23)

2. EXAMPLES OF PROBLEMS WITH THE OHIO BUREAU OF WORKERS' COMPENSATION

   To understand the problems with the workers compensation system, consider the following two clinical examples. (24)

   1. Case Example 1

      The first case example demonstrates what happens when the patient's initial diagnosis upon entering the system is incorrect but later corrected and treated by a physician capable of making a more accurate diagnosis, but the physician...