One of the changes that were implemented in the 1990 legislation was the creation of managed care organizations for workers comp claims.
Most people did not think this was going to be that significant of a change, and it did take quite a while to get off the ground because putting the infrastructure and building the companies took some time and a lot of money.
The managed care organizations are now well-established, multi-state companies. Some of them have familiar names, such as Kaiser Permanente and Providence. Others have a more obscure name, such as Majoris.
The purpose of managed care organizations is to manage the doctors who provide the care and to create rules about what kind of care is appropriate.
Unfortunately, what happens is that the managed care organizations intimidate doctors so that they won’t prescribe treatment that the doctor really believes will support the patient. When treatment is proposed that is against the rules of the managed care organization, they can not only intimidate the doctor, but they can create a factual case against the treatment.
Recently, two of my clients had a doctor prescribe a spinal cord stimulator for someone with very significant chronic pain. In the middle of the opioid crisis, managed care organizations are blocking attempts to manage pain without opioids. The primary reason is that spinal cord stimulators, while effective, are very expensive.
Back in 1990, there was talk about how having managed care organizations would create so-called company doctors. Some of that has come to pass, but more importantly, we now have two organizations to adjust claims. The insurance company, of course, gets to make all the decisions it wants to about whether the condition being treated is work-related or not, but so too does the managed care organization.
Unfortunately, this leads to long delays in treatment and a large amount of frustration for the injured worker.
Not all insurance companies or self-insured employers use managed care organizations. The insurance company has to pay the managed care organization to do its work, and there are some insurance companies and some self-insured employers that believe that their claims examiners can make the same decisions as the managed care organization, and can limit medical care without having to pay to have it done.
Unfortunately, SAIF Corporation very frequently uses managed care organizations. Once an injured worker is enrolled in a managed care organization, they must treat with the panel of doctors that are managed care providers. Sometimes the panel is large enough that that doesn’t really matter, but other times, the panel is quite small, and if the doctors are not good patient advocates, injured workers lose on whether their claim is work related, and frequently can’t get lawyers to help out because the doctors are so anti-worker.
The take away from all of this, however, is that because managed care organizations spent a lot of money on their infrastructure, they are probably not going away anytime soon, and workers have to, as much as possible, find the doctors on panel that are willing to help and will actually go to bat for them.