Dr. Bogdan Savych is a public policy analyst at the Workers Compensation Research Institute in Cambridge, Massachusetts. He analyzes...
Alan S. Pierce has served as chairperson of the American Bar Association Worker’s Compensation Section and the Massachusetts Bar...
The landscape of health insurance has changed significantly in recent years, and some of these changes have created new challenges in workers’ compensation systems. In this episode, host Alan Pierce is joined by Bogdan Savych, author of the study, “Health Insurance and Outcomes of Injured Workers.” They explore how the study was conducted and how workers’ access to personal health insurance coverage affects the care they receive after an injury on the job.
Dr. Bogdan Savych is a public policy analyst at the Workers Compensation Research Institute.
Special thanks to our sponsor, PInow.
Workers Comp Matters
Health Insurance and Outcomes of Injured Workers
Intro: This is Workers Comp Matters, hosted by attorney Alan S. Pierce, the only Legal Talk Network program that focuses entirely on the people and the law in workers’ compensation cases. Nationally recognized trial attorney, expert, and author Alan S. Pierce is a leader committed to making a difference when workers comp matters.
Alan S. Pierce: Welcome to another edition of Workers Comp Matters here on the Legal Talk Network. This again is Alan Pierce. I am an attorney at the Law Firm of Pierce, Pierce & Napolitano in Salem, Massachusetts, and we are happy to have you join us for another edition of Workers Comp Matters.
Our guest today is Dr. Bogdan Savych from the Workers Compensation Research Institute to discuss a recent study that he authored entitled ‘Health Insurance and Outcomes of Injured Workers’.
Just to acquaint you with Dr. Savych, he is a Public Policy Analyst for the Workers Compensation Research Institute, WCRI, located in Cambridge, Massachusetts. Dr. Savych received his PhD from Pardee RAND Graduate School. He analyzes issues related to labor and health economics, dispute resolution and the design of income benefit systems.
In June of 2019, he concluded and published a study looking at the association between health insurance coverage and outcomes that workers experience after a work-related injury.
Before we begin, I’d like to thank our sponsor PInow. Find a local qualified private investigator anywhere in the United States. Visit pinow.com to learn more.
Dr. Savych, please allow me to welcome you to Workers Comp Matters so that we can have a discussion about your findings.
Dr. Bogdan Savych: Thank you for having me. I’m glad to join you.
Alan S. Pierce: Just, this is not the first show we’ve done with guests from WCRI, I just want to reacquaint our listening audience with the Workers Compensation Research Institute. WCRI is an independent not-for-profit research organization as I mentioned based in Cambridge, Massachusetts.
They began in 1983. The Institute studies all aspects of the area of workers’ compensation, does not take positions on issues at researches rather it provides information obtained through studies and data collection efforts which conform to recognized scientific methods. Objectivity is further ensured through rigorous, unbiased peer review procedures and that WCRI’s diverse membership includes virtually all stakeholders in the workers’ compensation system from employers to insurers, governmental entities, managed care companies, health care providers, labor organizations, administrative agency, not only in the United States but Canada, Australia, and New Zealand.
So having said all of that, Dr. Savych what prompted the study of an association between the availability of health insurance coverage and the outcomes that workers might expect after having a work-related injury.
Dr. Bogdan Savych: That’s a good question. And we are often asked about external factors that may shape outcomes in workers’ compensation system. And one factor that is often mentioned is access to health insurance, while medical care for injured workers is paid by workers’ comp system, access to health insurance for non work-related injuries may also play a role.
And as we all know, health insurance marketplace, what marketplace changed substantially over the last decade. So the question on many people’s mind is what do these changes mean for workers’ compensation system?
So we wanted to answer that question by providing a framework, by thinking well, how did health insurance coverage change over time and what does a relationship between health insurance and worker outcomes may look like.
Alan S. Pierce: And I think leading into this and we’ve done not only have we done a show on this in the past, but this has been — this subject has been the subject of some commentary writings and debate and that is the passage of the Affordable Care Act, ACA otherwise known as Obamacare.
And without getting into all of the controversies political and otherwise surrounding whether something like an Affordable Care Act or Universal Health Insurance or Medicare for all, all of these ideas that are being floated even today, but the availability or the expansion of availability of health insurance to most people in the country including workers.
I know when ACA Obamacare was first proposed and first instituted, there was a lot of concern as to how that would impact workers’ comp, would this drive cases away from the workers’ comp system, would it bring cases into the workers’ comp system. So is it sort of an economic factor of something like the Affordable Care Act that has changed the landscape of health insurance that has sort of driven the need for this type of study?
Dr. Bogdan Savych: Affordable Care Act did change how health insurance coverage is provided to many people in the United States including workers. When we look at the trends in health insurance coverage, we do see a substantial expansion in the percent of workers who have health insurance and it’s driven primarily by changes in the Affordable Care Act.
For example, in 2008, only about 84% of people had health insurance and 84% of workers had health insurance. In 2017, about 90% of workers had health insurance and this is driven primarily by the expansion of Affordable Care Act.
We see that the difference is driven primarily by Medicaid coverage, which increased from 4% to 9%. While at the same time, the employer provided health insurance coverage increased for some workers but decreased for most other workers. And where it’s increased, it’s for the younger workers who can remain on their parents’ health insurance, workers under 26 year old directly related to Affordable Care Act. Well, for older workers or any, basically anybody, above 26, the employer-sponsored health insurance decreased a little bit.
So these are trends that are related to how ACA was implemented, who it affected, and the question becomes, well what does this mean for workers’ compensation system, what does this mean for outcomes and what does it mean for many other measures that are important.
Alan S. Pierce: Okay, and as a matter of fact when I first saw your study and even saw the title of your paper, the first question that came to mind is why should it make a difference whether a worker has health insurance if the medical costs associated with his or her work injury is going to be paid by workers’ comp.
Why would it matter that there is health insurance that presumably would pay for non-work-related medical conditions? So perhaps you can explain why the availability of a health insurance system which should not be paying anything associated work with workers’ comp might affect the outcome of the cost of a workers’ comp system.
Dr. Bogdan Savych: It’s a really good question. It’s an important aspect of the system that any medical care that’s associated with injuries is paid by workers’ compensation system. However, we can expect that there is a relationship between health insurance or access to health insurance for non work-related injuries to some of the outcomes.
One way where I would expect there is a relationship is that injured workers who already have health insurance, well they may already have a doctor that they can go to. If they have any underlying medical conditions, those medical conditions may be well managed and under control.
So the dynamic of medical care would be very different when you have somebody who have health insurance, maybe no doctors, know what to expect from the medical system which is somebody who doesn’t have health insurance and may not have a doctor to go to even for routine care and for any other care that’s associated with a work-related injury.
So we would expect that there is a relationship. We don’t know exactly how this relationship may be shaped prior to doing the analysis, but that was the reason for us to do this analysis, to try to see statistically do we see any of the relationship.
And I just wanted to mention that we do not establish the effect of health insurance. What we are talking about is just association with the health insurance and the outcomes, and it may reflect many other features of the system that we might not observe. But we can just hypothesize about what this means; although, we cannot say directly that the effect represents specific mechanisms that might dominate or might reflect something specific about the workers or something specific about employers.
Alan S. Pierce: And let me try to extrapolate the data and the methodology to the real world that I inhabit representing injured workers. I often times will meet an injured worker client sometimes within a day or two or certainly within a week or two of an injury.
And one of the first questions that we do on our intake is to explore whether or not the worker has the availability of health insurance, even though we know that workers’ comp is going to be responsible for the medical care.
And one of the reasons or among the reasons for me as an attorney representing these folks is that initially there is oftentimes a delay between when an injury occurs and when the workers’ comp insurance company is notified, it gets to a claims rep, a file is created as a file number and there’s billing information provided to the injured worker.
Sometimes that can take a day or two more often than not, it can take somewhere a week or two or three before even the injured worker is notified as to who is going to be responsible for his or her medical care and it’s usually in that immediate time period after an injury that the injured worker not only needs emergency care but might need to be referred to a specialist and first question they get in the office is who’s paying for this. And oftentimes, my clients don’t know the name of the workers’ comp carrier or even if they do, they don’t have a claim number of claim rep.
So oftentimes, the production of a Blue Cross Card or a health insurance card will ensure at least some immediate treatment modalities to be employed, and if a claim is denied or if a claim is governed by treatment guidelines or Utilization Review approval process that sometimes has a delay built into it.
The absence of available health insurance oftentimes I find leads to a delay in treatment, which ultimately leads to a delay in recovery and an increase in cost.
So are these some of the factors that you have found in your research as to the availability of health insurance and how it might impact on early care going into the days and weeks following an injury?
Dr. Bogdan Savych: Yeah, these are exactly the factors that we examined in our analysis.
Alan S. Pierce: Tell us so how you then took this question and analyzed it and came to your conclusions?
Dr. Bogdan Savych: So what we decided to do is to look at the flow, the dozen measures capturing the various dimensions of outcomes, such as access to medical care, how fast they go back to the medical doctors, whether they had problems going to doctors.
Major medical care, like how much care they received, recovery of physical health and functioning, return to work, satisfaction of this care and we even added measures of attorney involvement.
So these measures provide a broad overview of potential outcomes that workers may experience and what we do is compare workers without insurance and with health insurance and look at the outcomes.
Of course, we do lots of statistical adjustments, we might want to make sure that we’re comparing same workers so we — all of the results that we’re going to discuss are based on empirical models that’s controlled for injury characteristics, worker characteristics, employer characteristics, those are important things to take into account.
So even adjust — after adjusting for those characteristics we see that there is a relationship between health insurance and some of the outcomes that we find. Just one of the example that you mentioned, we do find that workers who have health insurance tend to receive their care on average a little bit faster.
For example, they get to their first non-emergency medical office visit by about one day faster on average. This doesn’t translate into all of the workers because we do see that for a typical worker the difference is much smaller, it’s about — for a typical worker both people with and without health insurance on average they go to work, on average they go back to see the doctor outside of the emergency situations three days after an injury, but for an average worker the difference is about one day, 10 days to 11 days for those without health insurance.
So we do see a relationship between how long the workers take to get to the first non-emergency office visit and the health insurance. But for some of the other measures we don’t see a strong effect.
For example, we don’t see that they have any difference in nature of care that medical workers received. So health insurance wasn’t related to the number of office visits that workers received at the end or whether they had a surgery or whether they had physical medicine services.
And it’s not related to most of the measures of access to care whether the workers had big problems getting the care that they wanted to, big problems getting the providers that they wanted.
So for some measures we see a difference, for some others we don’t, but it’s like consistent with some of the stories that you mentioned, with some of the mechanisms that you mentioned in your discussion.
Alan S. Pierce: Okay, and we’ll get into some of the other important findings that came out of your study in a minute, but right now I think we’ll take a break for a message from our sponsors and we’ll be back with Dr. Bogdan Savych in just a few moments.
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Alan S. Pierce: Welcome back. This is Alan Pierce with Dr. Bogdan Savych discussing the availability of health insurance and how this might affect outcomes of workers’ compensation claims.
Dr. Savych you mentioned in your report and I’d like you to expand upon it a bit, about the type of employer that is able to provide employer provided health insurance as opposed to an employer that’s not, typically probably a smaller employer, perhaps somebody an employer that can’t afford to provide health insurance for its employees, how does that distinction play into your study?
Dr. Bogdan Savych: So in our report, we show that health insurance is related to many of the characteristics. Some are characteristics of injured workers, but some of the characteristics of employers. If you look at the employer size, smaller employers they are less likely to provide health insurance.
If you look at some other characteristics of employers, maybe characteristics of workplace environment, we see that employers where a worker is more concerned about been fired, so potentially places was poor workplace environments. In those places workers are less likely to have health insurance for non work-related injuries.
So it’s possible that the effect of health insurance that we find, the relationship between health insurance reflect some of these characteristics of employers, maybe if workers who are working for employers who have relatively poor workplace environments, they will have much difficult time to go back to work because of the nature of employer, and that’s important to realize, because it means that health insurance may reflect some of the underlying characteristics of those employers and that measure may translate into the outcomes that we observe.
And just as an example, if you look at one of the findings that we have is that workers who have health insurance, they’re more likely to return to work. So if you look at workers with health insurance, 12% of them did not have a return to work for at least one months, that’s the measure of return to work that we highlighted. While it’s much — it’s a little bit higher for workers without health insurance, about 15% of workers without health insurance did not have a return to work that lasted for at least 12 months.
Alan S. Pierce: And let me let me pick up on that Dr. Savych, I know from my own experience representing dozens or hundreds of injured workers that a main factor for many of them to go back to work often times before they really feel they’re ready to or before their doctor is ready to release them, is because with some employers that provide health insurance, there may be a period of time whether it’s three months, six months post-injury, either under the FMLA or through the employer’s own policy that once an absence extends a certain period of time, health insurance coverage will be canceled.
So we have injured workers who may have family members covered under a family plan that have their own health issues and if they are facing a loss of employer provided health insurance or COBRA, which is usually beyond the financial means of any of my clients, their option is either to return to work to prevent the health insurance from canceling.
Or oftentimes if they lose their health insurance they then have to go into Medicaid or a public system which oftentimes is time-sensitive and perhaps not providing better coverages as their own private health plan and employer health plan.
So I have noted very early on that I’m seeing workers going back to work just to prevent the cancellation of health insurance and I would guess that’s probably accounts for some of the return to work differential between workers with health insurance for them without. Did you find that as a factor?
Dr. Bogdan Savych: So we didn’t examine that as a possible factor. So it’s a really good hypothesis for somebody to pick it up and examine it further. In the past, we’ve noticed that there’s a substantial number of workers do say that they did go back to work too fast or they went to work too early but we haven’t examined how is it related to health insurance.
But we do find that that matter didn’t vary too much across the state.
Alan S. Pierce: Yeah have you — did you also look into and I’m not sure that you did, your study was very, very extensive. But I have some workers that received their health insurance through the Union under their collective bargaining agreement. So while their health insurance coverage is dependent upon their working, it doesn’t come from the employer but it comes from their Union and oftentimes under the Union plans.
Once an injured worker is out of work for a certain period of time the health insurance will stop, and will not be started again until after the return to work, and sometimes, you have to have a minimum number of hours, sometimes it’s 400 hours or 600 or 800 hours before health insurance will kick in again.
Have you found a distinction between not so much government provided health insurance, and private employer provided but health insurance provided by labor unions. Has that been a factor in any of your study?
Dr. Bogdan Savych: So in our analysis, we asked about in a survey when we talk to injured workers, we’d ask them like, what’s the source of health insurance? And the most common responses were of course the employer provided health insurance coverage, the coverage from their family member, government provided coverage. And then there was other category and some of it’s included, some of the responses in that other category included either prior employment as COBRA or a union.
But it’s only about 4% in our sample of workers had mentioned one of those sources as a possible source of coverage. And we didn’t find very strong relationship between this specific measure and the outcomes that we’re looking at. So we do find much stronger effects for employer sponsored health insurance or the health insurance from your spouse.
And that’s where the main effects are coming from, its workers who see this difference in outcomes for workers who have health insurance coverage from their own employer or from their spouse’s employer or their employer from one of their family member.
Alan S. Pierce: All right, so I want to sort of end with some of your other findings. You had previously mentioned a bit earlier on the show on average about a one-day faster time to the first non-emergency office visit for evaluations following an injury when there was health insurance. What were some of the other key findings of having the availability of health insurance on outcomes in workers’ comp?
Dr. Bogdan Savych: Well, some of the other measures that we found that were related to health insurance, recovery of physical health and functioning, we do see that there is a difference. Although, while this difference a statistical significance, it’s actually quite small for clinical perspective but it exists.
We also find that workers with health insurance had about a one week shorter time between an injury and return to work that lasts at least one month. So workers who had health insurance tend to go back to work about one week faster.
Alan S. Pierce: So the importance of this is they may not have access to their health insurance, it’s the fact that it was there statistically that in on average allowed for a quicker return to work. There was no correlation between actually using the health insurance just the mere fact that they had it was a fact?
Dr. Bogdan Savych: That’s exactly right, we actually don’t know if they are using health insurance. All we know that they said that yes, I had coverage before I was injured for anything that’s not work-related. And that’s actually fascinating aspect of this analysis is that its presence of health insurance provides you with potentially another managed security blanket for potential care that you’ll need either or maybe it just explains a relationship.
Alan S. Pierce: And it also, yeah, it also may go into the broader context of employer or employee satisfaction. We know that in a troubled personnel setting a work injury is more likely to be lengthy, than in a happy work setting pre-injury. So that if an employee is satisfied with his employment relationship and the fact that his employer provides health insurance, that is one of the intangible reasons why injured workers may tend to want to get back to work faster, because of this culture in the workplace.
So we see this in many different, a variety of situations, even so much as how the employer deals with his injured worker after an injury, the employer that kind of circles the wagons and really doesn’t contact the employee, and encourage them to get better quickly and come back to work as opposed to an employer that sometimes gets hostile. That tone that is set oftentimes may dictate the outcome.
You also mentioned in your study a higher rate of satisfaction with the medical provider. How does that impact outcomes?
Dr. Bogdan Savych: So what would we do find that, yeah, when workers have health insurance they tend to be a little bit more satisfied with their, with the medical doctors that they have. And it’s not clear to us what exactly the reason for that relationship, may be they know what to expect from medical doctors, because if they have health insurance, they seen doctors before, they know what medical care can and cannot do. If they have to wait in the emergency room, they know that that’s — they had to do that before, they know that it happens. So now they are not that surprised. So there maybe that what’s explains it.
But also following up on your prior point, we do find that workers with health insurance tend to be less likely to report that they had an attorney helping them with their claim. Meaning that it’s consistent with your arguments about potentially workers with health insurance, they may work for employers who are less litigious or who have a much better relationship within the workers and employers, and there is less need for workers to seek an attorney. And that’s and that was one of the other factors, it was little bit surprising to us but sort of not fully unexpected. But provide an interesting avenue of how do we think about the role of health insurance in the workers compensation care right.
It potentially reflects many features of the system, it may reflect how workers are interacting with the employers, may reflect workers characteristics and the employer characteristics, and that not necessarily reflect just a causal effect of the health insurance.
Alan S. Pierce: Yeah and there’s so many other areas that we could get into here when we have a system that has multiple potential choices for medical coverage, workers’ comp, health insurance, government assistance. And you have a workers’ comp system where it’s not always clear what is work-related and what isn’t work related. And it sort of begs the question, should there be one type of insurance, the medical insurance that covers everything as opposed to having workers’ comp, health insurance, governmental insurance or no insurance.
And that’s a topic that is political, it raises questions that we can’t answer today, but I can tell you especially in workers’ comp if I have a client who has a knee injury in the setting of arthritis and two months after the knee injury, the doctor wants to do a knee replacement, sorting out whether the knee replacement is the responsibility of workers’ comp or private health insurance is a lengthy time-consuming and frustrating task. And when we have two different sources of medical care available and neither one may want to pay it claiming the other, it leads to frustration, delay, increased costs, and a whole myriad of other problems.
Dr. Savych if somebody wants to access your study or gain more information about WCRI or this particular study on ‘Health Insurance and Outcome of Injured Workers’, how might they be able to do that?
Dr. Bogdan Savych: So all our studies are available on our website, which is www.wcrinet.org, these studies are available for free to policy makers, they are available for free to all members or people can buy them for a nominal fee on the website.
Alan S. Pierce: Okay. Well I want thank you Dr. Savych for being a guest today and trying to help explain to our audience the myriad difficulties in looking at a subject matter like this, and the methodology employed, and the conclusions that you came up with.
And I want to congratulate you and WCRI for all the excellent work you do guiding all of us who deal with the workers comp system to try to make it as good a system as it can possibly be despite its flaws.
So again, this is Alan Pierce, thanking our listeners for joining us today. And we hope you tune in again on our next show here on Workers Comp Matters. Thank you for joining us.
Outro: Thanks for listening to Workers Comp Matters today on the Legal Talk Network, hosted by attorney Alan S. Pierce, where we try to make a difference in workers’ comp legal cases for people injured at work. Be sure to listen to other Workers Comp Matters shows on the Legal Talk Network, your only choice for legal talk.
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