By Stephanie Goldberg, Crain News Service
CAMBRIDGE, Mass. (Oct. 1, 2015) — As flat-fee, or capitated, health plans become more widespread, healthcare providers could begin classifying more soft tissue conditions as work-related injuries, according to the Workers Compensation Research Institute (WCRI).
Under such plans, healthcare providers are paid a set amount for each patient regardless of how many services or how much care they provide.
Such plans are becoming more common as the Patient Protection and Affordable Care Act (ACA) looks to expand the use of accountable care organizations, Cambridge-based WCRI said in a report released Sept. 29. “This provides strong incentives to classify patients' injuries as workers compensation cases where possible,” to receive fee-for-service payments.
However, workers comp pays for medical care only when a condition arises “out of and in the course of employment,” and there is less certainty about whether soft-tissue conditions are work-related than traumatic injuries, according to the study. Soft tissue injuries include a back sprain or strain.
“Patients covered by capitated group health plans were 11 percent more likely to have their soft-tissue conditions called work-related,” the study says. “This wasn't true for traumatic injuries, such as fractures, lacerations and contusions.”
WCRI found that case-shifting to workers comp was more likely in states where more workers were covered by capitated group health plans.
“In a state where at least 22 percent of workers had capitated group health plans, the odds of a soft-tissue case being called work-related were 31 percent higher if the patient was covered by such a plan compared with similar workers covered by fee-for-service group health plans,” according to the study. “When capitated plans were more common, providers were more aware of the financial incentives that they were presented when treating a capitated patient for a soft tissue condition.”