cwci update on ct claim formulary - …ccwcworkcomp.org/ccwc/assets/file/2017 conference/ppt...

The Travelers ‐ February 2017

CWCI 2017. All Rights Reserved 1

CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.

Cumulative Trauma Injuries & The Rx Formulary

A California Workers’ CompensationSystem Update

Alex Swedlow, Presidentwww.cwci.org

C CVV I

CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.CWCI 2017. All Rights reserved.

Agenda

Exhibit 2

Cumulative Trauma

• Dec 2016 Study

• Collaboration with WCIRB

• Analysis of CT and Non-CT Claim Characteristics and Outcomes

• DOI 2005 - 2013




The peculiar problem of CT in CA

Background:

• A few states prohibit cumulative trauma claims altogether

• Some states impose a high standard of proof

• Other states require that the employee prove that the cumulative injury occurred using a standard of clear and convincing evidence

• California has a relatively low bar for cumulative trauma claims

• Preponderance of evidence standard applies

• Only 1% causation required to obtain TD, PD, and medical treatment for all body parts included in CT claim

Exhibit 3


Classic Example: Employee spends a 30-year career performing heavy lifting, pushing, and pulling and knees or something else wears out

Other Examples: Physician-Assisted

Attorney-Induced

Created by Co-Defendant

Post-termination

Retirement

Where do CT claims come from?

Exhibit 4




Estimated Frequency ChangesAt 1st Report (18 Months)

-6.3

-4.0

-6.2

-3.2

6.4

-1.1

2.9

0.5

-0.2

-6.1-4.4

-6.3

-4.1

5.6

-0.4

2.4

-1.3 -…

-15

-10

-5

0

5

10

15

2006 2007 2008 2009 2010 2011 2012 2013 2014Accident Year

Statewide

Statewide Excluding Cumulative InjuryClaims

%

5

PreliminaryPartial

Source: WCIRB

Exhibit 5


Cumulative Trauma: Study Questions

1. How do claim characteristics vary for CT vs Non-CT Claims?

2. Are differences in payment flows and the existence of companion claims influencing average claim costs and masking underlying increases?

3. What are the contributing factors that cause the observed differences?

Exhibit 6




• Data Sources for subset of IRIS data contributors:o WCIRB Unit Stat Reportingo Integrate with CWCI IRIS claims data

• CT and Non-CT Claims w Notice Dates from 2005 –13

• Claim milestones and payments valued through 2015

Cumulative Trauma Study:Data Preparation

Exhibit 7


Percent of Claims that are CT by Region – So. California

6.1%

20.5%

4.1%

13.3%

4.8%

8.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

2005 2006 2007 2008 2009 2010 2011 2012 2013

L.A. Inld Emp/Orang SD

Exhibit 8

Carrier Notice Year




0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

2005 2006 2007 2008 2009 2010 2011 2012 2013

Central Coast Bay Area Sierras North Counties Valleys

Exhibit 9

Carrier Notice Year

Percent of Claims that are CT by Region – Rest of California


Notification – Average Days

Non-CT

Exhibit 10

Preliminary Results: Do Not Cite

Date of Injury

Employer CarrierService

11 Days

24 Days

13 Days

10 Days

Date of Injury

Employer CarrierEmployee

117Days

23 Days

138Days

116Days

Service

Date of Injury

Employer CarrierService

11 Days

24 Days

13 Days

10 Days

CT

Study Sample




0.0%

1.0%

2.0%

3.0%

4.0%

16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68

CT Non-CT

Claim Characteristics:

Age

Exhibit 11


24.0% 24.3%

32.7%

8.6%10.5%

43.9%

22.6% 23.0%

4.8% 5.7%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

<= 1yr 1-3 yrs 3-10 yrs 10-15 yrs 16+ Yrs

CT Non-CT


Tenure

Exhibit 12





Average Weekly Wage

Exhibit 13



Region

Exhibit 14




57.0%

32.1%

0%

10%

20%

30%

40%

50%

60%

CT Non-CT


Percent w Indemnity Payment

Exhibit 15


Exhibit 16

Low Back Mental DisorderMultiple BodyParts/Systems

Shoulder Wrist or Hand All Other

CT 11.3% 5.7% 25.1% 5.5% 14.4% 38.0%

Non-CT 14.2% 0.8% 7.5% 4.9% 10.7% 61.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

CT Non-CT


Condition




Years from Carrier Notice to ClosureIndemnity Claims

26%

5%

97%

83%

Exhibit 17

Carrier Notice Year


Attorney Involvement

80%

91%

19%

46%

0%

20%

40%

60%

80%

100%

All Claims Indemnity Claims

CT Non-CT

Exhibit 18




CT Claim Attorney Involvement Rate By year & Region

2005 2006 2007 2008 2009 2010 2011 2012 2013LA Basin 82.1% 84.2% 87.9% 89.2% 89.4% 91.1% 91.7% 91.6% 92.3%Rest of State 64.1% 68.4% 73.8% 68.8% 67.6% 68.7% 67.3% 69.2% 70.7%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

LA Basin Rest of State

Exhibit 19


CT as Percent of Attorney Involved Claims

2005 2006 2007 2008 2009 2010 2011 2012 2013

LA Basin 19.0% 20.0% 24.7% 27.1% 30.7% 35.1% 36.0% 37.8% 40.4%

Rest of State 12.4% 14.7% 17.6% 16.7% 18.4% 20.0% 19.6% 18.9% 19.3%

0%

15%

30%

45%

LA Basin Rest of State

Exhibit 20

Carrier Notice Year




Percent of Injured Workers with One or More Related Claims

Source: CWCI

Exhibit 21


Indemnity Claims Indemnity Claims Developed to 7 Years

Adjusted for Mix – Demographics & Condition

Average Cost Per Claim

Exhibit 22

Without Region &Attorney Involvement

With Region & AttorneyInvolvement

CT $73,830Non-CT $48,312

$0

$20,000

$40,000

$60,000

$80,000

Source: CWCI 2017




Average Total Cost Per Claim

Exhibit 23

Without Region &Attorney Involvement

With Region & AttorneyInvolvement

CT $73,830 $72,416Non-CT $48,312 $73,046

$0

$20,000

$40,000

$60,000

$80,000

Indemnity Claims Indemnity Claims Developed to 7 Years

Adjusted for Mix – Demographics & Condition

Source: CWCI 2017


• Growing frequency – Driven primary by LA Basin

• Late claim notification

• Higher attorney involvement and disputes over compensability

• Significantly slower development, higher average cost per claim

Cumulative Trauma: Summary of Findings

Exhibit 24




The 1Missing Piece In Rx Control: Formularies

November 2014 CWCI Study: Potential impact of a state formulary

Modeled CA data using Texas and Washington State Formularies

Estimated system-wide savings of 10 – 50%

AB 1124 - October 2015

Calls for creation of a State Formulary

Target Implementation - July 2017

Jan 2018

Exhibit 25


Exhibit 26

Key Draft Components Released August 26th

DWC Draft Regulations

MTUS Drug List

RAND Report

Implementing AB 1124 Drug Formulary and update of MTUS

Proposed Regs Released March 20th

Public Hearing May 1st

Intent of the formulary

Improve quality of care

Reduce UR and IMR friction costs

Lower cost




Exhibit 27

Proposed Formulary Components Released March 20th :

MTUS Drug List (N=242)

Implementing AB 1124 Drug Formulary and update of MTUS

Drugs are designated into categories: Preferred

Non-Preferred

Not Listed


Implementing AB 1124: Drug Formulary

Preferred, Non-Preferred, or Not Listed

Prescriptions and Payments

Source: CWCI 2017

% of Prescriptions % of PaymentsPreferred 25.8% 19.7%Non-Preferred 53.4% 0.0%Not Listed 20.7% 32.2%

0%

25%

50%

75%

100%

74% of currently dispensed drugs eligible for prospective UR26% of currently dispensed drugs are “fast tracked” around prospective UR




Therapeutic Group PreferredNon

Preferred

Not Listed

in MTUSAnalgesics - Opioid 0.0% 96.6% 3.4%Analgesics - Anti-Inflammatory 82.4% 2.2% 15.4%Musculoskeletal Therapy Agents 0.0% 98.0% 2.0%Anticonvulsants 0.0% 98.5% 1.5%Antidepressants 0.0% 96.1% 3.9%Ulcer Drugs 98.7% 0.0% 1.3%Dermatologicals 28.7% 34.3% 37.0%Hypnotics/Sedatives/Sleep Disorder Agents 0.0% 1.0% 99.0%Antianxiety Agents 0.0% 44.4% 55.6%Antihypertensives 0.0% 5.6% 94.4%Antihyperlipidemics 0.0% 0.0% 100.0%Laxatives 0.0% 0.0% 100.0%Corticosteroids 0.0% 57.7% 42.3%Beta Blockers 0.0% 0.0% 100.0%Chemicals 1.8% 78.7% 19.4%Cephalosporins 0.4% 68.7% 30.9%Analgesics - Nonnarcotic 68.3% 31.4% 0.3%Antipsychotics/Antimanic Agents 0.0% 0.0% 100.0%Ophthalmic Agents 39.9% 15.2% 44.9%Calcium Channel Blockers 0.0% 75.6% 24.4%All Other 9.5% 15.1% 75.3%Total 25.6% 53.4% 21.0%

Exhibit 29

Implementing AB 1124 Drug Formulary and update of MTUSObjectives

Identifies drug groups that the formulary will most impact;





Implementing a formulary

Who does what when how

Balancing access with safety

Guidelines vs patient-specific treatment

Avoiding unintended consequences





Payer

PrescriberPharmacy

PBM

Patient


Patient Safety

Access to

Care




WE ARE ALL PEOPLE.

EACH OF US IS AN INDIVIDUAL.


cwci update on ct claim formulary - …ccwcworkcomp.org/ccwc/assets/file/2017 conference/ppt...

Documents