Surprising Share of Workers’ Comp Cases Involve ‘Adverse Surprise’ Costs

Workers’ compensation cases with significant unanticipated medical care and costs are most common in California and Texas, and can represent as much as 30 percent to 40 percent of medical costs in most states, according to a new study by the Workers Compensation Research Institute.

These so-called “adverse surprise” cases involve those where medical conditions and costs worsen beyond what insurers originally estimated. They often involve back injuries.

“Cases with adverse surprises are the ultimate ‘lose-lose’ for workers and employers,” said Dr. Richard A. Victor, executive director of the Cambridge, Mass.-based WCRI.

“In these cases, workers’ medical conditions may have become chronic, a result that was not anticipated earlier in the case. The costs to employers may have significantly exceeded expectations, compared to how the medical condition presented at an earlier point in the case,” Victor explained.

After California and Texas, the states where adverse surprise costs are highest include Florida, Louisiana and North Carolina.

The study found that in some of the 12 large states reviewed, the frequency of these adverse surprise cases was increasing more rapidly than in others. The other states in the study were Connecticut, Illinois, Indiana, Massachusetts, Pennsylvania, Tennessee and Wisconsin.

Among the other findings of the study, Adverse Surprises in Workers’ Compensation: Cases with Significant Unanticipated Medical Care and Costs:

• Adverse surprise cases were disproportionately chronic conditions with multiple surgeries. They were also disproportionately back pain cases.

• Cases with significant or moderate surprises represented about 30 percent to 40 percent of medical costs in most states. However, they represented 57 percent in California, but only 15 percent in Indiana.

• Adverse surprise cases became relatively more frequent in almost all of the study states, with the largest increase in California. In Indiana and Wisconsin, there was little growth in the likelihood of an adverse surprise.

Victor said that while specific actions to prevent adverse surprise cases are not identified in this study, it is likely that some improvement in public policies and medical management are part of the answer.

In other recent research, the National Academy of Social Insurance reported that employers’ costs for workers’ compensation grew faster than combined cash benefits for injured workers and medical payments for their treatment. The cost increase in 2003, the most recent data available, continues a trend that began in 2000, when workers’ compensation costs and benefits relative to wages were at their lowest point in the last 15 years.

“The fact that employer costs rose faster than payments for benefits and medical care reflects broader developments in the insurance industry,” according to John F. Burton Jr., of Rutgers University, who chairs the panel that oversees the report. “Employer costs reflect rising premiums insurers charge to cover future benefit costs. The recent rise in costs appears to be part of a longer cycle of ups and downs in the insurance market.”

Total workers’ compensation payments for injured workers rose by 3.2 percent to $54.9 billion, while employer costs rose by 9.6 percent to $80.8 billion. When shown relative to aggregate wages of workers, payments rose by just one cent for every $100 of wages in 2003-or from $1.15 to $1.16. The costs to employers-which include the premiums they pay for workers’ compensation insurance (or their administrative costs if they self insure)-rose by 12 cents per $100 of wages, to $1.71 in 2003.

Since the low point in 2000, employer costs per $100 of wages rose by 39 cents, from $1.32 to $1.71, while total payments on workers’ behalf rose by 12 cents from $1.04 to $1.16 per $100 of payroll. Despite the recent rise in costs, both costs and benefits in 2003 remain far below their peak levels relative to wages. Total payments for cash benefits and medical care combined peaked in 1992 at $1.69 per $100 of wages, which is 52 cents higher than in 2003. Costs to employers peaked in 1993 at $2.16 per $100 of wages, which is 45 cents higher than in 2003.

According to Burton, “The decline in employer costs in the 1990s occurred as favorable investment returns led insurance companies to cut premiums in order to expand their market shares. Since 2000, low interest rates and poor stock market returns led insurers to raise premiums in order to cover future benefit costs.”

Since 2000, the growth in payments on workers’ behalf is due largely to increased spending for medical care. Of the 12-cent increase per $100 of wages between 2000 and 2003, nine cents was due to increased spending for their medical treatment, while three cents were increased payments to replace lost wages.

Topics California Workers' Compensation