Cambridge, MA – Medical payments per claim in California were typical of other states for 2016 claims with experience through 2019 (2016/2019), the effect of comprehensive reform legislation, according to a recent study by the Workers Compensation Research Institute (WCRI). In previous years, medical payments per claim in California were higher than typical.
Average payments in California reflected the effects of multiple policy changes, including Senate Bill (SB) 863, a drug formulary, and two fraud-fighting measures. Overall, medical payments per claim have been stable since 2015, following a period of decrease after SB 863 was enacted in 2013. The average nonhospital payment per claim has been fairly stable since 2015, decreasing 2 percent per year on average for claims at 12 months of experience, while hospital payments per claim grew 5 percent per year.
Payments per claim for nonhospital professional services varied by service, and prices paid were the main driver of the trends in payments per claim for most nonhospital services over the period since 2013.
“Utilization of nonhospital services has been stable overall and for key nonhospital services in California since 2013, despite some year-to-year fluctuations,” said Ramona Tanabe, executive vice president and counsel of WCRI. “Prices paid for professional services in California have changed little since 2017, following a moderate increase from 2013 to 2017, during the four-year transition to the resource-based relative value scale (RBRVS) fee schedule.”
The study, CompScope™ Medical Benchmarks for California, 21st Edition, compared California with workers’ compensation systems in 17 other states. For the study, WCRI analyzed workers’ compensation claims with experience through 2019 for injuries up to and including 2018.
The following are among the study’s other findings:
- Hospital outpatient payments per claim grew 7 percent per year from 2015/2016 to 2018/2019.
- Ambulatory surgery center (ASC) facility payments per service increased rapidly from 2016/2017 to 2018/2019, while services per claim decreased.
- The percentage of claims with ASC facility services and the proportion of claims with hospital outpatient facility services decreased, possibly due to a decrease in surgery rate.
- Average prescription payments per claim, which were higher than typical for 2013/2016 claims, became the lowest of the study states for 2016/2019 claims.
With many wondering what impact COVID-19 will have on state workers’ compensation systems, Tanabe says, “While the full impact is currently unclear, the CompScope™ studies will be a useful baseline to monitor the effects.”
The report was authored by William Monnin-Browder and Rebecca (Rui) Yang.
Learn more or purchase a copy: WCRI: CompScope™ Medical Benchmarks for California, 21st Edition