Q1 – 2024 – July 16, 2024
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Research IMR Update Through Q4 2023. CWCI’s review of IMR activity and outcomes through the end of 2023 shows that after hitting a 9-year low in 2022, IMR volume rose in 2023 as the number of decision letters rose 2.9% — the first increase since the adoption of the Chronic Pain and Opioid Guidelines into the MTUS and the 2018 implementation of the Formulary led to a sharp decline in IMRs involving Rx drug disputes. IMR volume continued to fall in 2020, 2021, and 2022, in the midst of the pandemic, but with employment rebounding in 2023, IMR activity edged upward for the first time in 5 years. Overall, IMR physicians upheld UR modifications and denials 89.0% of the time in 2023, consistent with results from the past decade when overall IMR uphold rates ranged between 88.2% and 92.0%. IMR uphold rates by medical service category ranged from 75.8% for E/M services to 93.1% for acupuncture. The review of the 130,883 IMR letters from 2023 showed Rx drug requests still accounted for the largest share of IMR decisions, though that proportion has declined from almost half of all IMRs in 2015 to one-third of the IMRs in 2023. Disputes over opioids accounted for 23.6% of the Rx drug IMRs last year, but that was down from 30.4% a decade earlier, while disputes over musculoskeletal drugs (17.8%); dermatologicals (19.8%), and anticonvulsants (9.9%) all represented a growing share of the Rx drug IMRs. Medical service categories that represented a growing share of the IMRs over the past decade include PT, which increased from 8.7% of the IMR disputes in 2015 to 13.5% in 2023; injections, which increased from 6.8% of the 2015 IMRs to 12.2% last year; and acupuncture, which more than doubled from 2.2% of the IMRs a decade ago to 4.5% in 2023. Most disputed requests continue to come from a small group of physicians: the top 10% named in decision letters accounted for 82.9% of the disputed requests, the top 1% accounted for 39.7%, and the top 10 individual physicians accounted for 11.1%. Executive Briefing (3/28/24) (members only) IMR App Update (3/26/24) (members only) CWCI’s Summary of the NASI Data on CY 2021 WC Benefits, Coverage and Costs. The Institute’s review of CY 2021 data on WC benefits, coverage and costs compiled by the National Academy of Social Insurance, examined nationwide results and those for California. The summary noted that state and federal WC programs, including insured and self-insured employers, covered 140.2 million jobs and an estimated $9.5 trillion in covered payroll in 2021. Aggregate benefits paid under these programs totaled $60 billion ($28.5 billion for medical care and $31.5 billion in cash benefits), up 1.1 percent from the $59.4 billion in 2020, the first year of the pandemic. Calif’s share of all U.S. jobs covered by WC held steady at 11.9 percent between 2020 and 2021, but its share of covered wages rose from 14.7 to 15.1 percent and its share of cash and medical benefits paid to injured workers rose from 20.0 to 20.7 percent. CWCI prepared a table showing the estimated total paid benefits for 2020 and 2021 for the top 10 states based on 2021 aggregate benefit payments; payments under non-federal and federal WC programs; and total payments for each of the top 10 states and nationwide for both years. Bulletin (3/6/24) (members only) Cumulative Trauma and Litigated Claims In California Workers’ Compensation. CWCI’s analysis of cumulative trauma claims in the California workers’ compensation system uses data from 1.4 million claims with claims administrator notification dates of 2010 through 2022 to track the growth in all CT claims and litigated CT claims. The report explores key variables associated with CT claims, analyzes litigation rates and the mix of stand-alone vs. group claims, and uses regression analyses to estimate the impact of variables such as region, tenure, industry, claimant age, and average weekly wage on CT rates for litigated claims. Research Note (3/1/24) (member only) Bulletin (3/1/24) (members only) News Release (3/1/24) (public) Utilization of Mental Health Services in WC. The issue of mental health services in WC has received increased attention since the pandemic was declared four years ago and as concerns have grown over workplace violence and PTSD. To gain an understanding of the types of claims in which these services are most heavily utilized, and the level of utilization, CWCI used data from its Medical Services App which contains detailed medical service data on insured and self-insured claims from 2016 – June 2023 based on the year treatment started. Focusing on indemnity claims with treatment beginning in 2022, the app showed that 4.8% of insured and S-I claims from that year involved mental health services w/in 1 year of the 1st treatment on the claim, w/an average of 5.4 visits for mental health services during the 12-month span. Statewide, the average payment/mental health visit was $295 in the 1st year and total payments averaged $1,577. Reviewing data back to 2016 show that the share of indemnity claims receiving mental health services in the 1st year of treatment grew steadily from 3.5% in 2016 to 4.8% in 2022. At the same time, the avg number of 1st-year mental health visits fluctuated between 5.3 and 6.4 (peaking in 2020); while the avg payment/mental health visit rose from $183 to $295 and avg payments per claim for 1st-year mental health services rose from $1,070 to $1,577, though they peaked at $1,617 in 2020, retreated to $1,385 in 2021, then rebounded to $1,577 in 2022. Head, Cranial and Intracranial injury claims had the highest percentage of claims involving 1st-year mental health services (17.2%) followed by “Other” claims, including PTSD and Mental Stress claims, (10.4%) Diseases & Disorders of the Spine (10.0%); Diseases & Disorders of Joints (6.2%) and Crushed or Amputated Fingers, Thumbs and Toes (5.6%). The “Other” category consistently had the most visits (averaging between 7.6 and 10.0 1st-year mental health visits from 2016 to 2022). Over that same period, Head, Cranial and Intracranial injury claims w/1st-year mental health services averaged between 5.2 and 6.6 1st-year visits; while Crushed or Amputated Finger, Thumb or Toe claims ranged between 3.7 and 8.7 visits. Executive Briefing (2/28/24) (members only) Utilization of Inpatient Care in California Workers’ Compensation. A CWCI Research Update report uses HCAI data to monitor trends in the utilization of inpatient care in California workers comp from 2012 through 2022, comparing the workers comp trends to those in Medicare, Medi-Cal and private coverage. The report also reviews changes in the types of conditions treated and the services delivered to injured workers before and after the pandemic was declared in 2020; takes a focused look at the primary diagnoses underlying inpatient hospitalizations involving spinal fusions and major joint replacement surgeries; and examines how the growth of outpatient surgery is affecting the total number of injured worker hospitalizations. Executive Briefing (1/24/24) (members only) Research Update (1/31/24) (members only) Bulletin (1/31/24) (members only) News Release (1/31/24) (public) Interactive Tool Update (1/30/24) (members only)
Legal Calif Dept. of Corrections and Rehab v. WCAB (Ayala). Applicant prevailed on Serious and Willful action and argued the 50% increase in benefits should be based on the enhanced industrial disability leave (EIDL) rate rather than the TD rate. Defendants argued the calculation should be based on the TD rate, because EIDL is not a form of compensation created under Division 4 of the Labor Code but was rather conferred by the Government Code. The WCJ ruled the TD rate controlled the calculation of the S&W award. The WCAB reversed on reconsideration. CDCR appealed. The DCA granted review, reversed, and remanded on 08/14/23. The Court followed the reasoning in Ellison (State of California v. WCAB (1996) 44 Cal.App.4th 128), which held that the 10% penalty for unreasonable delay of benefits under Section 5814 must be calculated using the TD rate, and not the EIDL rate. Applicant filed a petition for review on 09/27/23. The petition was granted on 12/13/23. The Institute filed an amicus brief in support of the defendant’s position on 3/20/24. Amicus Brief (3/20/24) (members only)
Other 2024 Case Law Seminar. Registration is open for CWCI’s 26th Annual Case Law Seminar, which will be presented May 9 as both an in-person event and as a live, online broadcast. The live program will be held at the OCC Conference Center (adjacent to 12th St. BART), but in-person registrations are limited. CWCI has been certified to offer 5.0 hours of MCLE credits (including 5.0 hours of specialization credits in WC) from the State Bar for this program, and upon completion of the program, attendees will receive certificates of attendance for submission to the Assn of Hearing Reps of Calif and for verification of hours toward Dept of Ins. WC claims adjuster certification requirements. Attendees must be fully registered at least two days prior to the session to receive MCLE / CE credits and participation will be tracked electronically for compliance. To register go to our website or call CWCI. Executive Briefing (2/28/24) (members only) Executive Briefing (1/24/24) (members only) Executive Memo (1/4/24) (members only) News Release (2/23/24) (public) CWCI Elects Board of Directors for 2024. Eric M. Hansen, Senior Vice President – Underwriting at Preferred Employers, was elected as Chair of the CWCI Board of Directors for 2024 at the Institute’s 60th annual meeting. Mr. Hansen was first elected to CWCI’s Board in 2014 and has been a member of the Institute’s Executive Committee since 2021. Joining Mr. Hansen on CWCI’s 2024 Executive Committee will be Eric S. Belk, Travelers; Michael Cunningham, Zenith Insurance Company; Amanda Granger, ICW Group Insurance Companies; Kris Mathis, CopperPoint Insurance Companies; Vernon Steiner, State Compensation Insurance Fund; and Matthew Zender, AmTrust North America. Also elected to serve on CWCI’s 2024 Board of Directors were David A. McGowan, AF Group/CompWest; Adnan Pathan, AIG; Paul E. Ziegler, Allianz Global Corporate & Specialty; Andrew Linkhart, Berkshire Hathaway Homestate Companies; Jeff Rush, California Joint Powers Insurance Authority (an associate member); Mary Beth Pittinger, CHUBB; Christopher M. Thurman, CNA Insurance; Michael Gill, EMPLOYERS; Tim Roberts, Everest Insurance; Carmen Sharp, The Hanover Insurance Group; Kevin Wagenknecht, The Hartford; Dr. Mary Capelli-Schellpfeffer, Liberty Mutual Insurance; Justin Smith, North American Casualty Company; Jim Hurley, Republic Indemnity Company of America; Brooks Rice, Schools Insurance Authority (an associate member); Scott D. Lange, Sentry Insurance; Michele Halstenrud, WCF Insurance; and Neil Deblock, Zürich North America. News Release (2/23/24) (public) CWCI’s 26th Annual Case Law Seminar. The Institute will hold the 2024 Case Law Update Seminar on Thurs., May 9 from 9 am to 3:30 pm at the Oakland City Ctr Conference Ctr, 500 12th St, Suite 105, Oakland. Full details have been sent to members and are posted on our website. Executive Briefing (3/28/24) (members only) Executive Briefing (2/28/24) (members only) Executive Memo (1/4/24)_(members only) News Release (1/4/24) (public) Gideon Baum Named CWCI Chief Operating Officer. Gideon Baum, former Staff Director for the Calif Senate Committee on Labor, Public Employment, and Retirement, who worked as a Committee Consultant with the State Senate for nearly 15 years and was instrumental in the drafting and analysis of multiple WC bills, including the 2012 reforms (SB 863) was named COO of the Institute. In his new role, Mr. Baum will manage CWCI’s day-to-day operations and provide support and expertise to the Research and IT departments on designated projects. He will begin work at CWCI on February 1. News Release (1/2/24) (public) CWCI Q4 2023 Quarterly Summary. Quarterly listings of all CWCI publications, including publication dates, summaries of each topic and the various formats in which the information is available (e.g., research report, Bulletin, Exec Briefing, news release), so users can choose the level of detail they want to view. Listings include live links so users can click into the CWCI website to access specific documents quickly and easily. |