Opinion

Health Care Networks:

A New Approach for Workers’ Compensation in Texas

House Bill 7 enacted sweeping workers’ compensation reforms. One of those reforms was the establishment of health care provider networks. After receiving much thoughtful input from system participants, I am proud to announce that we have now adopted the first set of rules to implement workers’ compensation networks in Texas.

Basically, workers’ compensation networks will be similar to the managed care networks we see in health insurance, in terms of the regions to be served. The network will serve a particular geographic area. If an employer chooses to utilize a provider network for its workers’ compensation claims, then an employee who is injured on the job and lives within the service area will choose a treating doctor from the list of network providers. If the employer does not choose to use a network, or if the employee lives outside the service area, the doctor can be selected from the workers’ compensation approved doctor list, just as before.

Workers’ compensation is a health delivery system like other health insurance, except that it has the added goal of not just returning to health but also returning to work in some capacity if at all possible. Experienced health care providers dedicated to understanding treatment guidelines, disability durations, and rehabilitation techniques that facilitate timely return to work will be the cornerstone of success.

The network administrators will negotiate with health care providers to build a pool of highly qualified professionals representing all the specialties required to treat workplace injuries. Providers will be able to negotiate their fees and contract requirements, such as procedures requiring preauthorization, while network management handles the administrative functions unique to workers’ compensation.

Beginning Jan. 1, 2006, TDI will review applications from networks seeking to be certified. Among the criteria we will be looking at are sound financial resources and an adequate number of health care providers for the service area. We want to make absolutely certain that injured workers have an extensive pool of health care professionals from which to choose.

I want to address a concern that has been raised concerning network care, that it is merely a discount program that will cut corners to save money. If workers’ comp health networks are viewed only as a tool to reduce medical costs, without adding any value to the rehabilitation and care of the injured employee, then the networks are headed to failure. Many employers and injured workers with whom I have spoken have emphasized the need for best value, not care on the cheap or, conversely, excessive care. The more effective medical care that a worker receives the sooner he or she will be back to productive work or to a point where their injury is
manageable.

To that end, our network rules incorporate a number of quality assurance tools. Workers’ compensation networks are required to be credentialed and must demonstrate that they have a formal complaint and dispute process in place. The networks are also required to track return-to-work statistics to see how well they are getting injured workers back on the job.

In addition, TDI researchers will compile data to assess each network’s performance on a yearly basis in the form of a “network report card.” The report card will allow comparisons between networks on a variety of measures, including access to care, health-related outcomes, return-to-work outcomes, employee satisfaction with quality of care, and health care costs and utilization of care.

Collectively, we know the problems that occurred during the development of managed care over the past several decades, and this is a new start-a chance in policymaking that does not come very often-to apply what we know works well. As we gain more experience and input from stakeholders, especially the Injured Employee Counsel, we are prepared to revise our network rules as needed, and even implement emergency rules as necessary.

As a guiding principal, no one group can dominate. This is not about one group claiming victory or gaming other stakeholders. It’s about balance and building a health care delivery system to which we would entrust our own family and friends. We must all bring our best ideas and attitudes for success to the table and make these networks work for the benefit of the citizens of Texas who are injured on the job.

Mike Geeslin is Texas Insurance Commissioner.

Editor’s note: The workers’ compensation network rules adopted by the Texas Department of Insurance may be found online at http://www.tdi.state.tx.us/rules/1115a-059.html.