Will the Affordable Care Act Shift Claims to Workers’ Compensation Payors?

By Richard A. Victor, Olesya Fomenko, Jonathan Gruber

September 1, 2015 Related Topics: Comparing Group Health and Workers’ Compensation, System Overview

According to this study, hundreds of millions of dollars could shift from group health to workers’ compensation as Accountable Care Organizations (ACO) expand under the Affordable Care Act (ACA). 

Although pundits have written about “cost shifting” to workers’ compensation, a significant underappreciated effect of the ACA is “case-shifting” from group health to workers’ compensation. The ACA seeks to greatly expand the use of ACOs―where providers are rewarded for meeting cost and quality goals. This will expand the use of “capitated” health insurance plans. Under these plans, providers are paid a fixed insurance premium per insured regardless of the amount of care provided to a given patient during the year. Under traditional fee-for-service insurance plans, providers are paid for each individual service rendered.  

The question we are addressing in this study is to what extent do the financial incentives facing providers and their health care organizations that arise out of capitation (given that workers’ compensation pays fee for service) influence whether or not a case is deemed to be work-related.  

Will the Affordable Care Act Shift Claims to Workers' Compensation Payors?. Richard A Victor, Olesya Fomenko, and Jonathan Gruber. September 2015. WC-15-26.

Copyright: WCRI

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