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Proposal to reimburse occupational medicine disease and injury claims through third party health insurance.
Am J Ind Med 1994 Aug; 26(2):147-154
The reimbursement of occupational medicine disease and injury claims through a third party health insurance scheme which could operate flexibly within the managed competition plan proposed by the Clinton Administration was proposed and examined. In defining the problem, the barriers to access were discussed. They included criteria for establishing work relatedness of the disease, a reluctance to face an adversarial relationship with employers by the employee, the paperwork burden on the part of the physician, and determination of the level of compensation. Escalating costs posed a further problem. In the proposed scheme, physicians diagnosing a work related injury would need to complete only two forms: a simplified notification form to the workers' compensation agency indicating the nature of the condition, and expected length and severity of disability; and a claim to the insurer for medical services used for diagnosis and treatment. The same fee schedule would apply for both occupational and nonoccupational conditions. Health insurers would bill the workers' compensation agency, and would be prohibited from denying coverage during adjudication. Scheme advantages included simplification, reduction of overheads, and elimination of price discrimination. Its disadvantages included shifts of paperwork costs and monetary losses from payment delays from providers and patients to insurers who could create administrative barriers similar to those faced by physicians today. Also, workers in low risk jobs would end up subsidizing those in high risk jobs, and those in the latter group (loggers and fishers) would face exorbitant premiums. It was argued that cost shifts from the future to the present by insurers could lead to total claims falling over time. Models and empirical evidence suggested that insurers would not file excessive compensation claims if they became the payer of first resort. Options for incremental reform were addressed. The authors conclude that streamlining all illness and injury claims to third party insurers regardless of etiology would reduce reporting bias, moral hazard, and administrative costs, and improve occupational health care.
NIOSH-Author; Administration; Health-care; Risk-analysis; Occupational-health-services; Occupational-medicine; Occupational-sociology; Medical-treatment
Issue of Publication
American Journal of Industrial Medicine
Page last reviewed: April 12, 2019
Content source: National Institute for Occupational Safety and Health Education and Information Division