BP BHEAD INT S

AN ACT Relating to conducting systematic pilot projects by the department of labor and industries to reduce the rate of long-term disability within the workers' compensation system; adding a new chapter to Title 51 RCW; creating a new section; and providing an expiration date.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION. Sec. 1. FINDINGS. The legislature finds that the financial costs of long-term disability represent a significant amount of lost productivity for the state's economy and tax base, and result in a lower standard of living for many citizens. Further, the uncompensated human costs of long-term disability affect tens of thousands of injured workers and their families and include loss of self-esteem, lower standards of living, dreams denied, divorce, and, in some severe cases, death.

The legislature also finds that long-term disability is a rapidly growing problem and that the most successful strategies for preventing long-term disability and returning injured workers to work emphasize active employer and employee organization involvement, improved medical treatment and decision making, and better coordination and management of cases that are at high risk of long-term disability.

Therefore, it is the intent of the legislature that the department conduct two pilot projects to reduce the rate of long-term disability and initiate a cultural shift from disability management to disability prevention. These pilot projects are intended to test the viability of new ideas and approaches for system-wide implementation and are also intended to be developed in consultation with the workers' compensation advisory committee to allow for some flexibility in design and intent. Both pilot projects are intended to shift resources to the early portions of the most difficult claims in an attempt to prevent the system failures that contribute to long-term disability.

NEW SECTION. Sec. 2. FIRST PILOT PROJECT. The first pilot project must include the following elements:

(1) Preinjury outreach and planning must be used to prevent disabling injuries, to provide appropriate transitional work and reemployment opportunities for those workers who are injured, and to enhance the abilities of employers and providers to prevent long-term disability. Provider education and outreach must encourage and enable attending providers to more adequately and completely fulfill their responsibilities as currently defined.

(2) Lower claims loads must be combined with return-to-work and on-the-job training projects for more intensive claims management, as provided in this subsection:

(a) A team approach must be used to begin working with claimants at risk of long-term disability as soon as possible after the injury occurs. This project must include the following elements: Lower claims loads for claims managers; intensive screening of claims; and intensive claims management for injured workers at high risk of long-term disability.

(b) In cases in which injured workers would otherwise qualify for vocational rehabilitation services, assistance in on-the-job training for alternative work may be provided earlier in the life of the claim. To subsidize the cost of on-the-job training with the employer, the department may use for a specified contract funds that would otherwise have been used to develop and implement a traditional vocational rehabilitation plan. These on-the-job training contracts must be evaluated for possible expanded eligibility at the earliest time feasible. An injured worker who participates in an on-the-job training program under this subsection and utilizes funds that would otherwise be used to develop and implement a traditional vocational rehabilitation plan is not eligible at a later time in the life of the claim for traditional vocational rehabilitation services.

(c) Every effort must be made to move beyond the finding of medically fixed and stable and employable as the basis for closing claims, and instead work to achieve a circumstance of employment that is mutually beneficial to all parties. If this is not possible, and:

(i) If the worker is found to be medically fixed and stable with no work restrictions, then the claim must be closed with either return to work or a seamless transition, coordinated by the claims manager, to other forms of assistance that might be available, including the basic health plan, unemployment insurance benefits, and job services; or

(ii) If the worker is found to be medically fixed and stable with restrictions, then the claims manager shall work with the employer to use job modification and on-the-job training to enable the worker to be reemployed, either with the original employer or a new employer.

NEW SECTION. Sec. 3. SECOND PILOT PROJECT. The second pilot project must incorporate all of the elements of the first pilot under section 2 of this act and also must provide case managers for injured workers at high risk of long-term disability and reconfigure portions of the current independent medical examination system. In addition to the elements of the first pilot, the second pilot must include the following elements:

(1) Case managers must be used to coordinate a team approach in working with claimants at risk of long-term disability as soon as possible after the injury occurs. It is preferred that case managers be employees of the department.

(2) An intermediate screening of all compensable claims must be used to evaluate their need for intensive services, including the provision of case management.

(3)(a) A medical progress examination, separate from an impairment rating examination, must be used to determine whether a change in diagnosis or treatment is in order. For a claim at six months of time-loss payments or earlier, if there is no clear progress toward return to work or medical progress the claims manager shall request that a medical progress examination be conducted by a physician other than the attending physician. The purpose of the medical progress examination is to determine whether the injured worker's medical condition is making appropriate progress, is fixed and stable, or, if neither, to recommend appropriate changes in either diagnosis or treatment, or both.

(b)(i) The claims manager shall request the medical progress exam, in consultation with the employer, by selecting an examiner from a pool of qualified examiners, with concurrence by both the injured worker and the employer, or the worker or employer's representative. If agreement among the parties cannot be reached after consideration of three proposed examiners, the claims manager shall select the examiner.

(ii) The pool of qualified examiners must be established using new criteria and standards to be developed by the department and endorsed by the workers' compensation advisory committee, with input from other interested parties, before taking effect.

(c) If the examination finds the claimant's medical condition to be fixed and stable, including if appropriate an evaluation of the claimant's physical conditioning and rehabilitation needs, the case must be referred back to the attending provider for review and comment, and an impairment rating if the attending physician concurs with the findings of the medical progress examination.

(d) The attending provider is encouraged to take a more active role in dispute prevention, so consequently all medical progress reports must be reviewed by the attending provider in consultation with the injured worker. As part of this review, the attending provider shall state in writing why the attending provider agrees or disagrees with the examiner's findings and recommendations. The attending provider must receive reasonable reimbursement for this review.

(4)(a) The attending physician must be encouraged to either conduct or participate, or both, in the permanent impairment rating exam to prevent disputes and achieve more timely and impartial decisions.

(b) If the attending physician performs the examination, special resources must be available to assist the attending physician if necessary.

(c) If the attending physician chooses not to be involved in performing the rating examination, the injured worker must be informed of this choice and may choose one of the following options:

(i) The examination will be performed by a physician agreed to under the current procedures for agreed exams; or

(ii) The injured worker and the employer agree upon an examiner from a pool of qualified rating examiners to recommend a rating to the claims manager. The pool of qualified rating examiners must be established on new criteria and standards to be developed by the department and endorsed by the workers' compensation advisory committee, with input from other interested parties, before taking effect.

(d) If the exam is conducted by a qualified rating examiner, the rating physician shall recommend a rating, sending it to the claim manager and the attending provider, with whom the injured worker is urged to meet to discuss the recommended rating. At this point, the attending provider may either agree to the rating of the qualified rating examiner in writing or disagree with the rating in writing, including any suggestions for changes in the rating. The attending provider must receive a reasonable reimbursement for this review.

(e) If the injured worker disagrees with the attending physician's rating, the injured worker may arrange for an agreed examination under the procedures under this subsection.

(f) If the employer disagrees with the attending physician's rating, the employer may choose either:

(i) An agreed-upon examination under the procedures under this subsection; or

(ii) The employer may select a rating examiner from the pool of qualified rating examiners. If the rating recommendation from this examination conflicts with that from the attending physician rating examination, the claims manager shall select one or the other of the ratings but may not split the difference between the ratings.

(5) The closure of claims must be handled with greater sensitivity to the anxiety this action might present for the injured worker, including improved closure notification and medical transition procedures.

NEW SECTION. Sec. 4. EVALUATION. The department shall evaluate both pilot projects established under sections 2 and 3 of this act on the objective, observable results of the services provided. Outcome measures must include:

(1) A principle measure for the pilots must be the amount of reduction, if any, in the rate of long-term disability among state fund claimants;

(2) The measure of increases, if any, in the rate of appropriate return to work before full medical stability, and any increase in the rate of return to work following claim closure;

(3) The measure of the economic advantages to the employer, if any, of taking a more active role in work safety, return-to-work planning, and disability prevention. The cost of claims and the effects of the pilots on employer premium rates must be measured;

(4) The measure of improvements, if any, in the level of customer satisfaction and any reduction in the rate of disputes and appeals;

(5) The measure of improvements, if any, in the efficient functioning and outcomes of the redesigned claims units;

(6) The duration of follow-up data must be sufficient to provide the desired measurements. Measures of services, characteristics, and outcomes must be gathered for individual injured workers and employers in these pilots and a comparative sample of injured workers and employers not included in the pilots, and collected for comparison and evaluation in a common format; and

(7) Further research must be conducted by the department into the identification of persons who are at high risk of long-term disability in the workers' compensation system.

NEW SECTION. Sec. 5. REPORTS. The department shall make annual reports to the legislature on the progress and outcomes of the pilot projects specified in sections 2 and 3 of this act beginning on December 1, 1994, and semiannual reports to the workers' compensation advisory committee, beginning with the committee's meeting in the second quarter of 1994.

NEW SECTION. Sec. 6. CAPTIONS. Captions as used in this act do not constitute any part of the law.

NEW SECTION. Sec. 7. CODIFICATION. Sections 1 through 5 of this act shall constitute a new chapter in Title 51 RCW.

NEW SECTION. Sec. 8. EXPIRATION. This act shall expire June 30, 1999.