State of Washington | 62nd Legislature | 2011 Regular Session |
READ FIRST TIME 02/17/11.
AN ACT Relating to occupational health best practices in industrial insurance through creation of a state-approved medical provider network and expansion of centers for occupational health and education; and amending RCW 51.36.010.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec. 1 RCW 51.36.010 and 2007 c 134 s 1 are each amended to read
as follows:
(1) The legislature finds that high quality medical treatment and
adherence to occupational health best practices can prevent disability
and reduce loss of family income for workers, and lower labor and
insurance costs for employers. Injured workers deserve high quality
medical care in accordance with current health care best practices. To
this end, the department shall establish minimum standards for
providers who treat workers from both state fund and self-insured
employers. The department shall establish a health care provider
network to treat injured workers, and shall accept providers into the
network who meet those minimum standards. The department shall
convene an advisory group made up of representatives from or designees
of the workers' compensation advisory committee and the industrial
insurance medical and chiropractic advisory committees to consider and
advise the department related to implementation of this section,
including development of best practices treatment guidelines for
providers in the network. The department shall also seek the input of
various health care provider groups and associations concerning the
network's implementation. Network providers must be required to follow
the department's evidence-based coverage decisions and treatment
guidelines, policies, and must be expected to follow other national
treatment guidelines appropriate for their patient. The department, in
collaboration with the advisory group, shall also establish additional
best practice standards for providers to qualify for a second tier
within the network, based on demonstrated use of occupational health
best practices. This second tier is separate from and in addition to
the centers for occupational health and education established under
subsection (5) of this section.
(2)(a) Upon the occurrence of any injury to a worker entitled to
compensation under the provisions of this title, he or she shall
receive proper and necessary medical and surgical services at the hands
of a physician or licensed advanced registered nurse practitioner of
his or her own choice, if conveniently located, except as provided in
(b) of this subsection, and proper and necessary hospital care and
services during the period of his or her disability from such injury.
(b) Once the provider network is established in the worker's
geographic area, an injured worker may receive care from a nonnetwork
provider only for an initial office or emergency room visit. However,
the department or self-insurer may limit reimbursement to the
department's standard fee for the services. The provider must comply
with all applicable billing policies and must accept the department's
fee schedule as payment in full.
(c) The department, in collaboration with the advisory group, shall
adopt policies for the development, credentialing, accreditation, and
continued oversight of a network of health care providers approved to
treat injured workers. Health care providers shall apply to the
network by completing the department's provider application which shall
have the force of a contract with the department to treat injured
workers. The advisory group shall recommend minimum network standards
for the department to approve a provider's application, to remove a
provider from the network, or to require peer review such as, but not
limited to:
(i) Current malpractice insurance coverage exceeding a dollar
amount threshold, number, or seriousness of malpractice suits over a
specific time frame;
(ii) Previous malpractice judgments or settlements that do not
exceed a dollar amount threshold recommended by the advisory group, or
a specific number or seriousness of malpractice suits over a specific
time frame;
(iii) No licensing or disciplinary action in any jurisdiction or
loss of treating or admitting privileges by any board, commission,
agency, public or private health care payer, or hospital;
(iv) For some specialties such as surgeons, privileges in at least
one hospital;
(v) Whether the provider has been credentialed by another health
plan that follows national quality assurance guidelines; and
(vi) Alternative criteria for providers that are not credentialed
by another health plan.
The department shall develop alternative criteria for providers
that are not credentialed by another health plan or as needed to
address access to care concerns in certain regions.
(d) Network provider contracts will automatically renew at the end
of the contract period unless the department provides written notice of
changes in contract provisions or the department or provider provides
written notice of contract termination. The industrial insurance
medical advisory committee shall develop criteria for removal of a
provider from the network to be presented to the department and
advisory group for consideration in the development of contract terms.
(e) In order to monitor quality of care and assure efficient
management of the provider network, the department shall establish
additional criteria and terms for network participation including, but
not limited to, requiring compliance with administrative and billing
policies.
(f) The advisory group shall recommend best practices standards to
the department to use in determining second tier network providers.
The department shall develop and implement financial and nonfinancial
incentives for network providers who qualify for the second tier. The
department is authorized to certify and decertify second tier
providers.
(3) The department shall work with self-insurers and the department
utilization review provider to implement utilization review for the
self-insured community to ensure consistent quality, cost-effective
care for all injured workers and employers, and to reduce
administrative burden for providers.
(4) The department for state fund claims shall pay, in accordance
with the department's fee schedule, for any alleged injury for which a
worker files a claim, any initial prescription drugs provided in
relation to that initial visit, without regard to whether the worker's
claim for benefits is allowed. In all accepted claims, treatment shall
be limited in point of duration as follows:
In the case of permanent partial disability, not to extend beyond
the date when compensation shall be awarded him or her, except when the
worker returned to work before permanent partial disability award is
made, in such case not to extend beyond the time when monthly
allowances to him or her shall cease; in case of temporary disability
not to extend beyond the time when monthly allowances to him or her
shall cease: PROVIDED, That after any injured worker has returned to
his or her work his or her medical and surgical treatment may be
continued if, and so long as, such continuation is deemed necessary by
the supervisor of industrial insurance to be necessary to his or her
more complete recovery; in case of a permanent total disability not to
extend beyond the date on which a lump sum settlement is made with him
or her or he or she is placed upon the permanent pension roll:
PROVIDED, HOWEVER, That the supervisor of industrial insurance, solely
in his or her discretion, may authorize continued medical and surgical
treatment for conditions previously accepted by the department when
such medical and surgical treatment is deemed necessary by the
supervisor of industrial insurance to protect such worker's life or
provide for the administration of medical and therapeutic measures
including payment of prescription medications, but not including those
controlled substances currently scheduled by the state board of
pharmacy as Schedule I, II, III, or IV substances under chapter 69.50
RCW, which are necessary to alleviate continuing pain which results
from the industrial injury. In order to authorize such continued
treatment the written order of the supervisor of industrial insurance
issued in advance of the continuation shall be necessary.
The supervisor of industrial insurance, the supervisor's designee,
or a self-insurer, in his or her sole discretion, may authorize
inoculation or other immunological treatment in cases in which a work-related activity has resulted in probable exposure of the worker to a
potential infectious occupational disease. Authorization of such
treatment does not bind the department or self-insurer in any
adjudication of a claim by the same worker or the worker's beneficiary
for an occupational disease.
(5)(a) The legislature finds that the department and its business
and labor partners have collaborated in establishing centers for
occupational health and education to promote best practices and prevent
preventable disability by focusing additional provider-based resources
during the first twelve weeks following an injury. The centers for
occupational health and education represent innovative accountable care
systems in an early stage of development consistent with national
health care reform efforts. Many Washington workers do not yet have
access to these innovative health care delivery models.
(b) To expand evidence-based occupational health best practices,
the department shall establish additional centers for occupational
health and education, with the goal of extending access to at least
fifty percent of injured and ill workers by December 2013 and to all
injured workers by December 2015. The department shall also develop
additional best practices and incentives that span the entire period of
recovery, not only the first twelve weeks.
(c) The department shall certify and decertify centers for
occupational health and education based on criteria including
institutional leadership and geographic areas covered by the center for
occupational health and education, occupational health leadership and
education, mix of participating health care providers necessary to
address the anticipated needs of injured workers, health services
coordination to deliver occupational health best practices, indicators
to measure the success of the center for occupational health and
education, and agreement that the center's providers shall, if
feasible, treat certain injured workers if referred by the department
or a self-insurer.
(d) Health care delivery organizations may apply to the department
for certification as a center for occupational health and education.
These may include, but are not limited to, hospitals and affiliated
clinics and providers, multispecialty clinics, health maintenance
organizations, and organized systems of network physicians.
(e) The centers for occupational health and education shall
implement benchmark quality indicators of occupational health best
practices for individual providers, developed in collaboration with the
department. A center for occupational health and education shall
remove individual providers who do not consistently meet these quality
benchmarks.
(f) The department shall develop and implement financial and
nonfinancial incentives for center for occupational health and
education providers that are based on progressive and measurable gains
in occupational health best practices, and that are applicable
throughout the duration of an injured or ill worker's episode of care.
(g) The department shall develop electronic methods of tracking
evidence-based quality measures to identify and improve outcomes for
injured workers at risk of developing prolonged disability. In
addition, these methods must be used to provide systematic feedback to
physicians regarding quality of care, to conduct appropriate objective
evaluation of progress in the centers for occupational health and
education, and to allow efficient coordination of services.
(6) If a provider fails to meet the minimum network standards
established in subsection (2) of this section, the department is
authorized to remove the provider from the network or take other
appropriate action regarding a provider's participation. The
department may also require remedial steps as a condition for a
provider to participate in the network. The department, with input
from the advisory group, shall establish waiting periods that may be
imposed before a provider who has been denied or removed from the
network may reapply.
(7) The department may permanently remove a provider from the
network or take other appropriate action when the provider exhibits a
pattern of conduct of low quality care that exposes patients to risk of
physical or psychiatric harm or death. Patterns that qualify as risk
of harm include, but are not limited to, poor health care outcomes
evidenced by increased, chronic, or prolonged pain or decreased
function due to treatments that have not been shown to be curative,
safe, or effective or for which it has been shown that the risks of
harm exceed the benefits that can be reasonably expected based on peer-reviewed opinion.
(8) The department may not remove a health care provider from the
network for an isolated instance of poor health and recovery outcomes
due to treatment by the provider.
(9) When the department terminates a provider from the network, the
department or self-insurer shall assist an injured worker currently
under the provider's care in identifying a new network provider or
providers from whom the worker can select an attending or treating
provider. In such a case, the department or self-insurer shall notify
the injured worker that he or she must choose a new attending or
treating provider.
(10) The department may adopt rules related to this section.
(11) The department shall report to the workers' compensation
advisory committee and to the appropriate committees of the legislature
on each December 1st, beginning in 2012 and ending in 2016, on the
implementation of the provider network and expansion of the centers for
occupational health and education. The reports must include a summary
of actions taken, progress toward long-term goals, outcomes of key
initiatives, access to care issues, results of disputes or
controversies related to new provisions, and whether any changes are
needed to further improve the occupational health best practices care
of injured workers.