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Anesthesiologists Identify Unnecessary Medical Procudures

Not prescribing opioids first or as a long-term therapy for chronic, non-cancer pain and avoiding MRIs, CTs and X-rays for low-back pain are among the tests and treatments identified by American Society of Anesthesiologists (ASA) that are commonly ordered but not always necessary. As part of the ABIM Foundation’s Choosing Wisely campaign, ASA today released its second list of five targeted, evidence-based recommendations that can support conversations between patients and physician anesthesiologists about what care is really necessary.

ASA’s list identified the following recommendations:

1. Don’t prescribe opioid analgesics as first-line therapy to treat chronic non-cancer pain. Physicians should consider multimodal therapy, including non-drug treatments such as behavioral and physical therapies prior to pharmacological intervention. If drug therapy appears indicated, non-opioid medication (e.g., NSAIDs, anticonvulsants, etc.) should be trialed prior to commencing opioids.

2. Don’t prescribe opioid analgesics as long-term therapy to treat chronic non-cancer pain until the risks are considered and discussed with the patient. Patients should be informed of the risks of such treatment, including the potential for addiction. Physicians and patients should review and sign a written agreement that identifies the responsibilities of each party (e.g., urine drug testing) and the consequences of non-compliance with the agreement. Physicians should be cautious in co-prescribing opioids and benzodiazepines. Physicians should proactively evaluate and treat, if indicated, the nearly universal side effects of constipation and low testosterone or estrogen.

3. Avoid imaging studies (MRI, CT or X-rays) for acute low-back pain without specific indications. Imaging for low-back pain in the first six weeks after pain begins should be avoided in the absence of specific clinical indications (e.g., history of cancer with potential metastases, known aortic aneurysm, progressive neurologic deficit, etc.). Most low back pain does not need imaging and doing so may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery.

4. Don’t use intravenous sedation for diagnostic and therapeutic nerve blocks, or joint injections as a default practice. * Intravenous sedation, such as with propofol, midazolam, or ultrashort-acting opioid infusions for diagnostic and therapeutic nerve blocks, or joint injections, should not be used as the default practice. Ideally, diagnostic procedures should be performed with local anesthetic alone. Intravenous sedation can be used after evaluation and discussion of risks, including interference with assessing the acute pain-relieving effects of the procedure and the potential for false positive responses ASA Standards for Basic Anesthetic Monitoring should be followed in cases where moderate or deep sedation is provided or anticipated.

5. Avoid irreversible interventions for non-cancer pain that carry significant costs and/or risks. Irreversible interventions for non-cancer pain, such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation, should be avoided because they may carry significant long-term risks of weakness, numbness or increased pain.

The ASA Committee on Pain Medicine was charged with developing the Choosing Wisely list on pain medicine. Committee members submitted recommendations for the campaign, and from this list voted on which should be included in the Choosing Wisely list. The literature was then searched to provide supporting evidence. Once approved by the committee, the Choosing Wisely list was reviewed by ASA’s Chair of the Section on Subspecialties, Vice President for Scientific Affairs, Executive Committee, and Administrative Council. The American Pain Society (APS) has endorsed ASA’s Choosing Wisely list on pain medicine.

To learn more about Choosing Wisely and to view the complete lists and additional detail about the recommendations and evidence supporting them, visit

Comp Payment for Medical Marijuana – 2014 CLM Annual Conference Hot Topic

In California, the Medical Treatment Utilization Schedule adopted by the DWC is presumed to be correct. It is the starting point for the UR and IMR decision making process. An applicant would have to overcome that presumption with high quality scientific evidence. The Chronic Pain chapter of the MTUS does not approve medical marijuana. Under the heading “Cannabinoids” the MTUS states “Not recommended. In total, 11 states have approved the use of medical marijuana for the treatment of chronic pain, but there are no quality controlled clinical data with cannabinoids.” Nonetheless, it is just a matter of time before the issue of “medical marijuana” becomes a problem for the comp industry.

According to an article in Business Insurance America, the issue of medical marijuana in the workers’ comp arena is approaching a crucial “tipping point,” and producers who haven’t taken action on behalf of their clients could be in for some nasty surprises. That’s the message from PRIUM Senior Vice President Mark Pew, a 30-year workers’ comp vet and opinion leader on the medical marijuana front. It’s also the message of an upcoming roundtable discussion at the 2014 CLM Annual Conference in Florida. Hosted by PRIUM’s Scott Yasko, the discussion will center on the clinical risks and benefits of medical marijuana, as well as potential legal liabilities and state-mandated payment. It’s all part of rampant industry-wide concern on medical marijuana and its future in workers’ compensation, Pew told Insurance Business. “It’s definitely a concern – especially given these stories that tug at the heartstrings about seizures that can only be controlled by marijuana,” Pew said. “The question is, should there be constraints around it, or should it just be locally legalized?”

Pew said that while no carrier has admitted to making payouts for medical marijuana treatment, “water cooler talk” suggests many workers are already using insurance dollars to pay for the substance. And that could be a problem if agents don’t discuss the issues with employers up front – especially given the dissonance between state and federal law. “Brokers may need to proactively bring up medical marijuana – whether the employer will accept it as a treatment option, how it will be controlled, and how the PBM will enforce formularies,” Pew said. “At the moment it’s not a strategic discussion, but it needs to be.” If producers don’t take this first step of establishing consistent standards when it comes to medical marijuana, the employer could be left open to both federal lawsuits and workplace liabilities in which an employee using marijuana paid for by the employer injures themselves or another worker. Pew believes the industry as a whole is on a “tipping point,” with at least 51% of workers’ comp professionals in favor of allowing medical marijuana as a treatment option. As such, employers and their insurance agents need to make strategic decisions ahead of time to protect both their workers and themselves. “Medical marijuana is a societal inevitability, and workers’ comp professionals need to figure out how they’ll deal with it,” he said. “In many cases, the train has left the station and you’ll either be riding the train or driving the train, or you’re going to get run over by the train.”

The roundtable discussion will be held April 10 at the Boca Raton Resort and Club in Boa, Raton, Fla.

Azusa Massage Parlors Cited for No Comp Insurance

Acting on complaints from residents, police carried out compliance checks at six Azusa massage parlors issuing several citations but making no arrests, officials said. The San Gabriel Valley Tribune reports that police joined with officials from Azusa code enforcement, the California Employment Development Department, the California Department of Industrial Relations, and the Los Angeles County Sheriff’s Department’s Major Crimes Bureau’s licensing unit during the operation, Azusa police Lt. Mike Bertelsen said in a written statement.

“Azusa PD has received complaints that some massage parlors within the city may be offering sexual services to customers in addition to massages,” Bertelsen said. “After learning of the complaints, Azusa PD detectives solicited the help of outside agencies with specific expertise in massage parlor operations to develop and execute this administrative compliance detail.” In addition to verifying that all local, county and state laws and regulations were being followed, police said officials were also seeking to determine whether any victims of human trafficking were associated with any of the massage parlors.

“No victims of human trafficking were located, however numerous citations were issued for violations of various Azusa municipal codes, along with workers compensation insurance or minimum wage violations,” Bertelsen said. “Some of the businesses involved face fines of several thousand dollars each. These investigations are ongoing, so none of the businesses are being identified.” Bertelsen said similar “administrative inspections” are likely to be held again in the future.

Only Two Comments Posted to DWC ICD-10 Forum

We are anticipating the DWC announced transition to ICD-10 at the end of this year. The DWC had public comment on the 16 pages of proposed new regulations from March 18, through March 28, 2014 and the comment period is now closed. Only one half page of comments were received.  Most of the half page consisted of questions by one poster rather than comments, and the only substantive comment was made by Bennett Katz of Zenith Insurance Company and involved a technical error in the proposed regulations concerning the number of digits specified in the codes.

ICD-10 is not simply an upgrade of the current ICD-9 code, it is a total rewrite, intended to provide better detail and data collection for physicians, hospitals and payers.

This detail comes at a price. The sheer volume of these codes, increasing fourfold over the current ICD-9 standard, brings a real set of challenges for workers’ comp adjusters who are expected to quickly review these codes for appropriateness and relatedness on incoming bills. For these adjusters, any additional time spent deciphering these 68,000 codes means less time spent getting injured workers back to work, more jurisdictional penalties as delays impact payment, or higher medical spend as inappropriate bills sneak through.

ICD-10 will offer a much greater level of detail for companies ready to accept the additional data detail. One thing that ICD-10 will do is specify between right and left on bilateral body parts and make a distinction between acute and chronic treatments. This will increase the accuracy of the diagnosis and treatment which will reduce costs by cutting down on unnecessary testing. More detailed data may lead to better preventive safety protocols as a result of identifying the specific source of injury. This data is also helpful in forecasting or predicting trends in medicine. Medical technology and treatments are constantly evolving and improving, and ICD-10 accommodates new breakthroughs in treatments. ICD-10 can allow for comprehensive reporting which will be useful for determining risk and effectiveness of other programs. The impact of ICD-10 on adjusters will be significant if not managed properly.

Once the system is in full swing and everyone becomes more familiar with the codes it may help cut down fraud and abuse. Injured body parts will be more definitive and treatments will be more concise. It will make it harder for a doctor to add a CPT code that is completely unrelated because the ICD-10 will be so very specific. Technology can be a help to payers and adjusters, who need to embrace change and realize that evolving technology will decrease their workflow and enable them to close claims faster. Automating certain aspects of the system will allow adjusters to be two or three steps ahead of a claim to keep it from spiraling out of control rather than always being on the defensive end of a claim.

Whether you are a fan ICD-10 or not, it’s coming; there is no stopping it come October. Time will tell how this affects the workers’ compensation industry.

3D Printed Human Implants Revolutionizing Surgeries

3D printing is a process of making a three-dimensional solid object of virtually any shape from a digital model. 3D printable models may be created with a 3D scanner. To perform a print, the machine reads the design from 3D printable file and lays down successive layers of liquid, powder, paper or sheet material to build the model from a series of cross sections. These layers, which correspond to the virtual cross sections from the model, are joined or automatically fused to create the final shape. The primary advantage of this technique is its ability to create almost any shape or geometric feature.The 3D printing technology is used for both prototyping and distributed manufacturing with applications in architecture, construction, industrial design, automotive, aerospace, military, engineering, dental and medical industries, biotech (human tissue replacement), fashion, footwear, jewelry, eyewear, education, geographic information systems, food, and many other fields. Several projects and companies are develop affordable 3D printers for home desktop use.

NBC News reports that doctors in the Netherlands have for the first time successfully replaced most of a human’s skull with a 3-D printed plastic one – and likely saved a woman’s life in the process.The 23-hour surgery took place three months ago at University Medical Center Utrecht. The hospital announced details of the groundbreaking operation this week and said the patient, a 22-year-old woman, is doing just fine.

The woman, whose name wasn’t released, suffered from severe headaches due to a thickening of her skull. She slowly lost her vision, her motor coordination was suffering and it was only a matter of time before other essential brain functions would have atrophied, Dr. Verweij said in a press release issued by UMC Utrecht. Verweij noted that in some brain operations it’s common for part of the skull to be temporarily removed to reduce pressure on the brain, then put back later or replaced by an artificial implant. In this case, doctors inserted nearly an entire plastic skull that was manufactured with the help of Anatomics, an Australian medical device company that specializes in 3-D printing,

“We used to create an implant by hand in the operating theater using a kind of cement, but those implants did not have a very good fit,” Dr. Verweij said. “Now we can use 3-D printing to ensure that these components are an exact fit. This has major advantages, not only cosmetically but also because patients often have better brain function compared with the old method.”

Three months after surgery, the woman’s pain is gone and she can see again. “The patient has fully regained her vision, she has no more complaints, she’s gone back to work and there are almost no traces that she had any surgery at all,” said Dr. Verweij.

In another success story, Business Insider reports that a British surgeon successfully implanted a 3-D printed pelvis for a man who lost half his pelvis to bone cancer. It was the first transplant of its kind. The patient, who is in his sixties and has remained unnamed, suffered from a rare type of bone cancer called chondrosarcoma. It affected the entire right side of his pelvis. According to orthopedic surgeon Craig Gerrand, who performed the surgery, it would have been impossible to attach a standard implant because so much bone had to be removed. In order to create the 3-D printed pelvis, the surgeons took scans of the man’s pelvis to take exact measurements of how much 3-D printed bone needed to be produced and passed it along to Stanmore Implants. The company used the scans to create a titanium 3-D replacement, by fusing layers of titanium together and then coating it with a mineral that would allow the remaining bone cells to attach. After the titanium pelvis was attached, the team added a standard hip replacement to complete the surgery. The procedure, which happened three years ago, was an unrivaled success. The man has been walking with a cane and remains happy with the results.

3D printing is revolutionizing the health care sector: The technology has been successfully used to make prosthetic limbs, custom hearing aids, now a pelvis and a human skull, and potentially human tissue by what is called “bioprinting.”

Federal Jury Convicts Orthomed Owner in Fraud Case

A Southern California man who ran a durable medical equipment (DME) supply company has been found guilty by a federal jury in Los Angeles for his role in a $1.5 million Medicare fraud scheme. Vahe Tahmasian, 36, of Glendale, California., was found guilty this month in U.S. District Court in the Central District of California of one count of conspiracy to commit health care fraud, six counts of health care fraud and six counts of aggravated identity theft. Sentencing is set for June 9, 2014.

The evidence introduced at trial showed that between April 2009 and February 2011, Tahmasian operated a Medicare fraud scheme at Orthomed Appliance Inc. (Orthomed), a DME supply company in West Hollywood, Calif. Tahmasian and his co-conspirator, Eric Mkhitarian, purchased Orthomed from the previous owners and put the company in the name of a straw owner.The defendant and his co-conspirator then stole the personal identifying information of Medicare beneficiaries and doctors in the company’s patient files and used that information to submit a large volume of fraudulent claims to Medicare. The evidence showed that during a three-month period in late 2010, Tahmasian submitted more than $1.2 million in fraudulent claims to Medicare for services that were never prescribed by a physician and never provided to the Medicare beneficiaries. Tahmasian and his co-conspirator then took out more than $622,000 in cash from the company over a six-week period in early 2011. The evidence at trial showed that Tahmasian used a fake California driver’s license during the course of the fraudulent scheme.Tahmasian submitted a total of $1,584,640 in claims to Medicare and received approximately $994,036 on those claims.

Mkhitarian, Tahmasian’s alleged co-conspirator, remains a fugitive.

The case was investigated by the FBI and the Los Angeles Region of HHS-OIG and brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Central District of California. The case is being prosecuted by Assistant Chief Benton Curtis and Trial Attorney Alexander Porter of the Fraud Section.

Tahmasian’s prosecution is one of a steady stream of cases moving through the justice system that underscore the need to make DME fraud and abuse a high enforcement priority.

Besides the frequent combination of medical identity theft and fraudulent billing, other DME-related schemes to watch for include billing for high-end products but delivering inferior ones, forging product prescriptions and paying kickbacks to professionals authorized to prescribe DME, according to a commentary by former U.S. Health and Human Services Inspector General Richard P. Kusserow.

CDC Says 4% Acquire Infections in Hospitals and Medical Facilities

On any given day, one in 25 hospitalized patients – 4 percent – is battling an infection picked up in a hospital or other healthcare facility, according to a new survey by the Centers for Disease Control and Prevention (CDC). That translates to more than 600,000 hospital patients each year. Roughly 74,000 of them have to fight more than one hospital-acquired infection, researchers found. About half of those infections were either linked to a device attached to the patient, like a catheter or ventilator, or occurred after a surgical procedure at the site of the surgery. An infection acquired in this manner in an industrial case would also be covered as a compensable consequence of the initial injury.

Previous estimates had pegged the annual number of infections at 2.1 million in the 1970s and 1.7 million from 1990 through 2002. “The trend, in magnitude, seems to be going in the right direction,” Dr. Mike Bell, deputy director of the Division of Healthcare Quality Promotion at the CDC, told Reuters Health. Despite continuing concern about hospital-acquired infections, especially ones that are resistant to antibiotics, the U.S. does not have a national system for collecting information on the problem.

The new study, led by Dr. Shelley S. Magill of the CDC and published in the New England Journal of Medicine, was based on an analysis of 11,282 patients treated at 183 hospitals in 10 states. The survey in each hospital was done over the course of a day, involving as many as 100 patients per facility. Pneumonia accounted for about 22 percent of the hospital-acquired infections. Another 22 percent were infections at the surgical site, and 17 percent were stomach or intestinal illnesses. Urinary tract and bloodstream infections ranked fourth and fifth, respectively. The most common bacterium responsible was Clostridium difficile, which kills an estimated 14,000 people in the U.S. each year. It was detected in 12 percent of the hospital-acquired illnesses and was responsible for 71 percent of gastrointestinal infections in particular. Nursing homes, emergency departments, rehabilitation hospitals and outpatient treatment centers were not included in the tally.

The researchers estimated that in 2011, 648,000 hospitalized patients had to battle at least one hospital-acquired infection. The total number of infections was estimated at 721,800. To put that number in perspective, about 34 million people are admitted to 5,000 community hospitals in the U.S. each year. The new report “validates the work we’ve been doing, focusing on some of the severe infections related to intensive care, related to devices such as catheters in the bloodstream or the bladder, mechanical ventilation or surgical procedures,” Bell said.

To prevent infections, the National Patient Safety Foundation recommends patients wash their hands regularly and remind their doctors and nurses to do the same. Patients should also make sure both bandages and the skin around any catheters are kept clean and dry, it says.

State Sen. Leland Yee Indicted in FBI Corruption Case

State Senator Leland Yee has been indicted for public corruption as part of another major FBI operation. San Francisco Police Chief Greg Suhr described the raids to KCBS as “massive.” “Hundreds of officers are involved in this,” he said.

Yee was taken into San Francisco’s Federal Building wearing handcuffs FBI agents and local police are serving arrest and search warrants throughout the Bay Area, with agents seen in locations in San Francisco and San Mateo, as well as Yee’s Capitol office in Sacramento. Targets of the raid are expected to appear in federal court in San Francisco this afternoon. Yee’s indictment likely ruins his candidacy for Secretary of State, and threatens Democrats’ ability to restore the state Senate supermajority that already has been broken by two other lawmakers’ paid leaves of absence to deal with criminal charges.

Yee represents San Francisco and a portion of San Mateo County. Before becoming the first Chinese-American ever elected to the state Senate in 2006, Yee was an Assemblyman from 2002 to 2006; a San Francisco supervisor from 1997 to 2002; and had been a member and president of the San Francisco Unified School District board. While in the Assembly, he was the first Asian-American to be named Speaker pro Tempore, essentially making him the chamber’s second-most-powerful Democrat.

Yee is the state’s third Democratic legislator recently tied to corruption allegations. In February, State Sen. Ron Calderon, D-Montebello, surrendered to authorities after being indicted on bribery charges surrounding proposed workers’ compensation law and Pacific Hospital in Long Beach. In January, Assemblyman Roderick Wright, D-Inglewood, was convicted of voter fraud and perjury stemming from a 2010 indictment.

Derek Cressman, who until last June was vice president of the non-partisan government watchdog group Common Cause, issued a statement Wednesday morning saying that Yee’s indictment must be “a wake-up call” given other Senate Democrats’ criminal charges. “We are clearly beyond the point of looking at one bad apple and instead looking at a corrupt institution in the California senate,” Cressman said. “The constant begging for campaign cash clearly has a corrosive effect on a person’s soul and the only solution is to get big money out of our politics once and for all.”

Defense Attorney Convicted of Stealing $2 Million From MTA

A former Rancho Cucamonga attorney who once handled some of the Metropolitan Transportation Authority’s toughest legal cases was convicted of stealing nearly $2 million from the transit agency by submitting phony invoices and pocketing settlement money. James Vincent Reiss, who also was convicted of stealing more than $1 million from other clients, pleaded no contest to two felony counts of grand theft. For 15 years, Reiss defended Metro in multimillion-dollar injury lawsuits involving rail and bus passengers until officials realized he was defrauding the agency, said Jane Robison, an L.A. County district attorney’s spokeswoman. Reiss, 52, made the plea as part of a deal in which prosecutors agreed to drop nine other felony counts of theft, forgery and fraud. He is set to be sentenced March 26, and the court is expected to require that he pay more $3 million in restitution and serve a decade in prison.

Reiss created fraudulent documents that led Metro to write checks that he ultimately kept for himself instead of paying plaintiffs who sued the agency. Karen Gorman, acting inspector general for Metro, said a State Bar of California investigation into problems with Reiss’ other clients in 2012 tipped off the agency to the potential for trouble, and officials immediately began auditing his cases. “We aggressively began to investigate – and working with the district attorney’s office we were able to bring Mr. Reiss to justice for his crimes.”

According to a Metro lawsuit filed against Reiss’ law firm in January for malpractice, forgery and negligence, Reiss cost the agency as much as $2.5 million. In 2011, Reiss allegedly told the MTA that it had negotiated a $2.5-million jury award down to $1.765 million. But when the Metro board authorized the settlement and ordered that two checks totaling $1.765 million be written, Reiss kept the money, according to the suit. Reiss then filed an appeal, delaying the case. Metro eventually resolved the case by paying $2.5 million. The suit alleges Reiss also submitted “numerous falsified invoices totaling at least $754,000,” for costs and kept the money.

Prosecutors said that in addition to the MTA, Reiss also took advantage of other clients. In one case, he settled a suit without the client’s knowledge, forged signatures on paperwork and pocketed the money, prosecutors said. In another case involving a trust, he opened a bank account, deposited a client’s money and wrote checks to himself, prosecutors said.

Reiss, was disbarred on March 16, 2013 after a state Bar Court judge called his case an illustration of the “disciplinary consequences of dishonesty,” The State Bar case went on to conclude “the most serious aggravation is found in Reiss’s 10-year pattern of deception in order to cover up mismanagement of his clients’ cases or for his personal economic gain. …Without a hint of remorse, Reiss has refused to acknowledge his misconduct despite overwhelming evidence of his dishonesty and the harm he caused to his clients. While the law does not require Reiss to be falsely penitent, it does require that [he] accept responsibility for his acts and come to grips with his culpability.”

Comp Rates Continue to Climb

Rates and premiums for workers’ compensation insurance are continuing to climb across the US, driven by factors including the prolonged low interest rate environment and rising medical costs. Meanwhile, implementation of the Affordable Care Act (ACA) and the potential expiration of the Terrorism Risk Insurance Program Reauthorization Act (TRIPRA) are two other factors that could make a significant impact on the workers’ comp market as 2014 unfolds.

As the U.S. unemployment rate shows modest declines and wages are slowly increasing, it’s no surprise that workers’ compensation premiums are continuing to show growth. A quick look back at the past 8 years tells us that the workers’ compensation market suffered through a 27% decline in premium from 2006 to 2010 before rebounding with growth in the past 3 years, including a 10% increase in 2012 to more than $39 billion according to an annual study by the National Council on Compensation Insurance (NCCI).

Wells Fargo took a look at what to expect through 2014 in the workers’ comp market in its 2014 Insurance Market Outlook, released at the end of January. In addition to concurring with the Marsh report regarding TRIPRA, the report forecasts continued rate increases for the first three quarters of this year, along with continued reduction in the combined loss ratio, resulting from higher prices seen over the past three years. The report includes several other predictions, such as continued movement away from guaranteed cost program structures into higher deductible program structures, either because they are a more appealing alternative or a necessity. One final prediction in the report says the continued use of predictive modeling analysis to improve risk selection, proper retention levels and pricing will result in more conservative underwriting by the insurers.

Health care reform hasn’t made a significant impact on the US workers’ comp market to date, but that isn’t expected to be the case for much longer. The effects could be both beneficial and detrimental. Ruth Estrich, chief strategy officer at Philadelphia-based MedRisk, a workers’ comp-focused managed care company, says the impact could come in a variety of forms. One way would be reduced severity in worker’s comp. If millions of people who were previously uninsured become insured, one would hope that these people will get healthier. For people that have chronic issues (such as asthma), having health insurance that allows them to manage their issues should impact how quickly they heal, become functional and get back in the workplace. Someone who is not getting care for their chronic issues will likely take longer to recover in a workers’ comp situation.

Estrich says another issue the industry is watching is access to primary care physicians (PCPs). “If you think about all of those folks who will start accessing health care through their PCP, we are headed toward a problem with access to primary care,” Estrich says. “People were already predicting that access to primary care will be a problem. It could be a perfect storm.” In worker’s comp, a lot of the treatment and first response in many cases comes via a person’s PCP. Estrich says it is conceivable that many PCPs, who are already in short supply, will elect to stop treating workers’ comp cases, which can be more challenging to deal with. This would obviously be a negative development for the workers’ comp market.

The third issue Estrich sees in the potential for a cost shift. People without health insurance have an incentive to ascribe their injury to a workplace event when it may well have happened away from the job, simply because they would be covered by workers’ comp and not covered if the injury occurs away from work. With more people being covered by health insurance, they would be less likely to claim an injury happened at work.