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California Commission on
Health and Safety
and Workers Compensation
CHSWC Strategic Plan
Commission Members
Tom Rankin, Chair
Allen L. Davenport
Jill A. Dulich
Leonard C. McLeod
Kristen Schwenkmeyer
Robert B. Steinberg
Darrel "Shorty" Thacker
John C. Wilson
Executive Officer
Christine Baker
November 2002
Strategic Planning Process
CHSWC Mission
Goals and Objectives
Priority Areas
Article 14 Labor Relations
A. Current Monitoring
B. Major New Initiative
1. Administrative Efficiency - Organizing Audit Unit data for ongoing monitoring
2. Return-to-Work
3. Prevention - Monitoring California's performance on prevention of occupational injury and illness
4. Dispute reduction and judicial performance
5. Health workers
6. Monitoring the Targeting of Benefits
Evaluation of AB 749
New CHSWC Studies per AB 749
2002 Strategic Plan
Strategic Planning Process
A "Background Issues" document was distributed to the CHSWC members as a starting point to outline the areas that tie to the Commissions mandates in the California Constitution and the Labor Code. See Appendix A for the background issues document.
The workers compensation community -- labor organizations, employer organizations, insurers, and attorneys as well as medical and rehabilitation providers, administrators, educators, government agencies and members of the public -- provided input to the CHSWC staff and, based on these meetings, the background paper was developed.
A 2-day CHSWC meeting in July 2002 was devoted to prioritizing identified areas and developing a preliminary research agenda.
CHSWC staff presented accomplishments to date, which included research that led to policy change in California. Active projects in process were also presented. At the conclusion of the meeting, CHSWC members requested that staff develop a draft strategic plan, action items, and a communications plan based on priorities discussed at this meeting.
CHSWC Mission
CHSWCs mission is specified in Section 77(a) of the California Labor Code:
77. (a) The commission shall conduct a continuing examination of the workers' compensation system, as defined in Section 4 of Article XIV of the California Constitution, and of the state's activities to prevent industrial injuries and occupational diseases. The commission may conduct or contract for studies it deems necessary to carry out its responsibilities. In carrying out its duties, the commission shall examine other states' workers' compensation programs and activities to prevent industrial injuries and occupational diseases. All state departments and agencies, and any rating organization licensed by the Insurance Commissioner pursuant to Article 3 (commencing with Section 11750) of Chapter 3 of Part 3 of Division 2 of the Insurance Code, shall cooperate with the commission and upon reasonable request provide information and data in their possession that the commission deems necessary for the purpose of carrying out its responsibilities. The commission shall issue an annual report on the state of the workers' compensation system, including recommendations for administrative or legislative modifications which would improve the operation of the system. The report shall be made available to the Governor, the Legislature, and the public on request. (Emphases added)
Section 4 of Article XIV of the California Constitution is included as Appendix B.
CHSWC Goals and Objectives
The strategic goal is to improve California workplace health and safety and workers compensation through labor-management consensus. The following objectives support CHSWCs mission and the fulfillment of its mandates.
- Identify recommendations for feasible and practical policies and programs.
- Establish rigorous monitoring and ongoing evaluation of system performance, pursuant to CHSWC mandates (See Appendix C for a monitoring plan)
- Ensure the highest quality research to inform policy makers and system participants.
- Maintain effective communication with decision makers and the public.
- Provide education, training, and effective communication products accessible to workers, employers, and the public. (Per Labor Code Section 6354.7 as established by AB 749)
- Emphasize effective partnerships with stakeholders.
Please note that the following areas developed by the Commission help identify new areas for emphasis. CHSWCs core functions of monitoring the impact of the reforms and the specific mandates required by the reforms remain a top priority. A description and timetable for CHSWCs AB 749 studies are included as Appendix D.
The research topics developed by CHSWC focus in on certain concerns but do not limit the development of additional issues for future study as approved by the Commission.
Priority Areas
1. Efficiency of administration
The efficient administration of workers compensation can lead to prompt resolution of disputes and provision of services. It can also lower costs to employers without reducing benefits to injured workers. Encouraging efficiency in the administration of workers compensation mutually benefits injured workers and employers.
Action items
- Evaluate the current state of the insurance market, including impact on efficiency of different market approaches (competition, monopoly, self-insurance)
- Assess technology and DWC court administration, including court administration reform, and lessons from other states and/or models.
- Establish financial stability and administration of the Uninsured Employers Fund
2. Return to Work
If injury occurs, return to sustained employment avoids much of the costs borne by injured workers and their employers and therefore both benefit. Return to work programs should be carefully designed to avoid return too early, which may lead to subsequent health problems which could lead to the worker quitting, being laid off, or retiring. Thus increasing sustained employment is the key, which is essentially equivalent to reducing wage loss.
Action items
- Develop best practices initiative
- Monitor return to work
- Develop ongoing measurements
3. Prevention and Worker Protection
No area of research should facilitate consensus more than preventing injury. Workers can avoid the potentially devastating consequences of injury, disability and lost work, while employers can avoid the cost of compensation and medical care as well as lost productivity. Policies that encourage prevention must be carefully designed to ensure that they reduce injury and not simply discourage the reporting of injuries.
Action items
- Measure full employer/employee costs of workplace injuries
- Monitor Californias safety performance over time and against other states, including review of the public sector
- Identify and publish best practices in education and training
- Best media and languages
- Focus on unions and outreach to small employers
- Provide oversight to the Cal-OSHA Consultation program, including improving employer acceptance of consultation services.
- Implement the Worker Occupational Safety and Health Training and Education Program (WOSHTEP) and Loss Control Services Coordinator, pursuant to AB 749.
4. Dispute Reduction
Both workers and employers benefit from avoiding disputes before they occur. This must be done to insure that disputes if they arise are properly adjudicated and that the worker has access to representation, if needed. But if the dispute is avoided or resolved prior to litigation, workers and employers mutually benefit.
Action items
- Determine lessons learned from "carve-outs" what aspects of carve-outs are working specifically to reduce litigation?
- Evaluate impact of communication before mandatory settlement conference (MSC)
- Review delays in the system and their outcomes. Claim handing process 30, 60, 90 day acceptance vs. litigation patterns and outcomes.
- Analyze litigation patterns, return-to-work, and role of proactive information.
- Develop schedule for settling future medical (?) [Please note: This was not discussed at the Strategic Planning meeting but was formerly approved depending on the availability of funding]
- Conduct pilots in the public sector for carve-outs(?)
- Continue ongoing evaluation of permanent disability (already being undertaken by CHSWC)
- Examine other states programs that employ ombudspersons.
5. Healthy Workers
With recent increases in the cost of medical care for workers compensation, reducing medical costs is often advocated. But if reducing medical costs lowers the quality of care to workers or denies access to care, the workers recovery could be compromised. This can lead to continued medical costs, or the loss of a valuable employee. For this reason, we recommend a focus on healthy, productive workers, which might imply less expensive medical care, but only if the full employer cost (including future health costs and future lost work time) is lower when medical costs are lowered.
Questions to be answered include:
- Does California deliver quality occupational health care at reasonable cost?
- Are Californias workers healthier than workers in other states and countries?
- What innovative approaches to workforce health policies can deliver quality health care in the most cost-effective manner?
Action items
- Sponsor California Research Colloquium on Medical Benefit Delivery and Return to Work (Already being undertaken by CHSWC. Scheduled for Spring 2003 at UCLA)
6. Targeting of Benefits
While the overall level of benefits can be characterized as a "zero-sum game", the targeting of benefits to workers with greater need improves outcomes for injured workers without increasing costs to employers. This can therefore be a point of mutual consensus.
Questions to be answered include:
- Does Californias workers compensation system deliver benefits equitably?
- Do other states deliver benefits more equitably?
- What alternative approaches are used in other states to deliver benefits to workers with the greatest need?
Action items
- Conduct ongoing monitoring of benefit delivery
- Develop permanent disability tool
- Analyze the utilization of social welfare programs by injured workers(?) [Please note: This was not discussed at the Strategic Planning meeting but was formerly approved depending on the availability of funding]
7. Communications Plan
Specific goals
- Generate support for improving workers compensation for workers and employers in California
- Reach influential decision makers
- Enhance visibility and name recognition
- Facilitate communication in the workers compensation community
- Maintain and increase funding
- From the state?
- From other funders?
Action items
- Publish and distribute short policy pieces
- Hot topics; bimonthly one-pagers on activities
o After each meeting?
- Research highlights: Two-pager summaries of research results
- Disseminate information through print and email
- Hold briefings for specific legislators or for staff
- Issue news releases when studies are completed
- Identify support staff to accomplish action items
Background Issues Document
Workers compensation in California was created in 1913 as a bargain between employers and labor. Workers received the assurance that if they were injured on the job, they would receive prompt medical care and compensation without having to prove in court that the employer is at fault. Employers received protection from potentially high tort damages awarded by juries so that they could have predictable, manageable injury compensation and treatment costs. This bargain between employers and labor was historic, maintaining the incentives for employers to create a safe workplace, and allowing workers to remain productive and healthy.
Today, the workers compensation system continues to function well, delivering over $15 billion in benefits and caring for almost a million new claimants every year. For employers, it is a significant part of the package of compensation provided to employees considerably larger than other programs that are arguably higher profile, such as unemployment insurance (which in 1999 cost $2.6 billion in California).
Workers compensation is critically important to injured workers. As research funded by CHSWC has shown, workers with permanent disabilities from injuries at work on average have earnings losses of approximately $50,000 over the ten years after injury far higher losses than the benefits they receive from workers compensation. RAND research estimates that 33% of working age adults with disabilities (a population at high risk for poverty) became disabled as a result of an occupational injury or illness. Thus, workers compensation benefits are a critically important part of the social safety net.
While some aspects of the workers compensation system are undeniably controversial, few would advocate for its elimination. Indeed, it is noteworthy that no state has ever repealed workers compensation. After almost 90 years, the workers compensation bargain remains as a testament to the value of cooperation and bargaining between employers and labor.
At the same time, the world in which the workers compensation system exists today is very different than the one in which it was created. Social expectations for an adequate standard of living for workers have changed. Medical technology and expectations with regard to health have changed. The American economy and the work performed by its workers have changed. Firms and workers are mobile across state and international borders. To remain useful, the workers compensation system needs to change as well, and the example of the original bargain can serve as a model for how enduring policies can be devised that will continue to serve both workers and employers during the 21st century. In particular, the success of workers compensation in the long run depends upon the maintenance of the bargain: value to both workers and employers.
CHSWC is a policy innovation that was created 80 years after workers compensation in California, but the employer-labor composition was intended to keep the parties to the original bargain at the table. This document argues that by sponsoring research on policies that encourage consensus between employers and labor, CHSWC can facilitate the success of the workers compensation program for the next 80 years.
Can There Be Workers Compensation Reforms that Benefit Both Workers and Employers?
The recent workers compensation legislation, AB749, contained a number of actions that improved the adequacy and distribution of benefits.
- For the first time, temporary disability benefits were indexed for cost of living changes. When fully implemented, 95% of workers will receive at least 2/3rds of their pre-tax weekly wage while on TD.
- Second, for the first time in nearly 20 years, benefits were increased for the workers with PD ratings under 15%, the majority of PD claimants.
- Finally, maximum PD benefit levels were raised and made more similar across disability levels reducing some of the disparities in replacement rates experienced across different levels of income and degrees of severity.
Similar benefit increases were vetoed in two previous years. The legislation has been criticized by many employers. And yet the size of the increase by 2006, after inflation is factored in, essentially restores the benefit level approximately to where it was in 1993.
Part of the problem is that benefit increases are sometimes viewed as a "zero-sum game," to use the language of economics, whereby the workers gain is the employers loss, dollar for dollar. This leaves little room for consensus, and usually requires identifying some employer savings to offset the benefit increase.
The research described in this document focuses on a different set of policies, those for which employer-labor mutual benefit is recognized. With the passage of AB 749 and the benefit level returned to its past value after inflation, fundamental improvements in the workers compensation system can be facilitated by CHSWC by identifying policies that will lead to mutual benefit for employers and labor.
Those mutually beneficial policies are illustrated in Figure 1. This figure, drawn from the forthcoming RAND report which compares the adequacy of compensation for permanent disability across five states, shows ten-year earnings losses for California, New Mexico, Washington, Wisconsin and Oregon on the left, and the total workers compensation benefits paid to compensate these losses on the right. In California, the earnings losses are the highest of the five states. This is driven by the fact that the post-injury employment (return-to-work) in California is the worst of the five states. At the same time, the benefits paid are also the highest in California of the five states.
The combination of high earnings losses and high benefits leads to an outcome where both workers and employers lose: workers end up with benefits that do not completely cover their losses, and employers end up with the highest workers compensation costs. In a context such as this, it is critical to identify policies that improve outcomes for injured workers while also lowering employer costs.
Employers, Labor and the Workers Compensation Service Providers
The difficulty in identifying and passing reforms that benefit both workers and employers is in part driven by the political power of other stakeholders in the workers compensation system, such as medical professionals, attorneys, insurance companies, and government employees involved in the administration of workers compensation. The services provided by the other stakeholders are critical to the functioning of the system, and in order to attract high quality services, the system must be an attractive place for these professionals to conduct their business. At the same time, the purpose of the system is to compensate workers, and the compensation is paid for by employers. The parties represented on CHSWC are the primary stakeholders of the system.
Many groups have an interest in the way the workers compensation system is structured. While the interests of employers and labor form the cornerstone of the system, the political agenda of both groups is large and somewhat diffuse. The costs and benefits of the system are diffused across many employers and workers. However, many of the other interest groups are highly focused on this system because they depend upon it for all or a significant portion of their livelihood, with benefits and costs concentrated among a small number of important constituents. Consequently, interest groups outside the two key parties, management and labor, often dominate the political debate and the flow of information surrounding reforms.
Objective, empirically-driven research on the value of policies that mutually benefit employers and labor can create the foundation for consensus among the primary system stakeholders and the parties to the original workers compensation bargain. In general, outside of CHSWC, the research is funded by the government or by the service providers, the data are largely provided by the services providers, the most intense lobbying is by the service providers, and therefore much of the information to legislators is arguably shaped by parties outside the original bargain. With a properly conceived research and legislative agenda, CHSWC is in a position to fundamentally reform the system to benefit workers and employers.
Strategic planning issues: Summary
While of course, CHSWCs research will need to be flexible and designed to react to the relevant issues of the moment, we propose the following litmus test for the long-range and larger agenda items: Can the research lead to policies that mutually benefit workers and employers?
In this document, we will describe research in six areas that can mutually benefit employers and labor. Comprehensive reforms in these six areas could fundamentally reshape workers compensation in California, improving outcomes for injured workers and lowering workers compensation costs to employers:
1. Efficiency of Administration.Efficient administration of workers compensation can lead to prompt resolution of disputes and provision of services. It can also lower costs to employers without reducing benefits to injured workers. Encouraging efficiency in the administration of workers compensation mutually benefits injured workers and employers.
2. Return to Work.If injury occurs, return to sustained employment avoids much of the costs borne by injured workers and their employers and therefore both benefit. Return to work programs should be carefully designed to avoid return too early, which may lead to subsequent health problems which could lead to the worker quitting, being laid off, or retiring. Thus increasing sustained employment is the key, which is essentially equivalent to reducing wage loss.
3. Prevention. No area of research should facilitate consensus more than preventing injury. Workers can avoid the potentially devastating consequences of injury, disability and lost work, while employers can avoid the cost of compensation and medical care as well as lost productivity. Policies that encourage prevention must be carefully designed to ensure that they reduce injury and not simply discourage the reporting of injuries.
4. Dispute Reduction.Both workers and employers benefit from avoiding disputes before they occur. This must be done to insure that disputes if they arise are properly adjudicated and that the worker has access to representation, if needed. But if the dispute is avoided or resolved prior to litigation, workers and employers mutually benefit.
5. Healthy Workers. With recent increases in the cost of medical care for workers compensation, reducing medical costs is often advocated. But if reducing medical costs lowers the quality of care to workers or denies access to care, the workers recovery could be compromised. This can lead to continued medical costs, or the loss of a valuable employee. For this reason, we recommend a focus on healthy, productive workers, which might imply less expensive medical care, but only if the full employer cost (including future health costs and future lost work time) is lower when medical costs are lowered.
6. The Targeting of Benefits. While the overall level of benefits can be characterized as a "zero-sum game" as discussed above, the targeting of benefits to workers with greater need improves outcomes for injured workers without increasing costs to employers. This can therefore be a point of mutual consensus.
In the following sections, we expand upon these themes, suggesting particular research projects as illustrations of the themes that CHSWC can consider.
1. Efficiency of System Administration
The efficient administration of workers compensation can lead to prompt resolution of disputes and provision of services. It can also lower costs to employers without reducing benefits to injured workers. Encouraging efficiency in the administration of workers compensation mutually benefits injured workers and employers.
Administration of the workers compensation system is an important component of the cost of compensation faced by employers and also an important determinant of the speed, fairness, and cost with which benefits are delivered to workers. System administration involves several key components. 1) Well functioning insurance markets are key to employers being able to acquire fairly priced insurance with quality service. Well functioning markets can involve a range from strongly competitive markets with limited regulation to a state run and regulated monopoly insurer. 2) Markets where employer compliance with the coverage requirement is effectively enforced. 3) Dispute resolution needs to be efficient and just. 4) Even the best judicial systems are typically costly for participants, consequently, a well administered system would also try to reduce the frequency of disputes without compromising equity. Each of these areas has been or will be an important component of the CHSWC research agenda.
- How can California reduce administrative costs without increasing the time to resolve claims?
- How can California streamline the administration of claims without affecting the quality of benefit delivery?
Insurance Markets/Insurer Performance
State-of-the-State 1992-2002:
One of the most striking changes in the workers compensation system over the past decade has been the composition and financial health of the insurance market. In the early 1990s, premiums were high and increasing while claims and claim costs were declining. Rates were regulated and competition among insurers was generally on the quality and breadth of service provided rather than price. There were a large number of insurers, many of whom were specifically focused on the California Market. Profits were high and the largest insurer (SCIF) had less than 20% of the market.
In 1995, insurance rates were deregulated and competition among insurers became based on price rather than quality of service. At the same time, the tools available to regulators to monitor this change in markets were not sufficiently strengthened, or at least the application of regulatory oversight was not sufficiently adjusted. The insurance market rapidly consolidated, leaving few domestic California companies, and a few relatively large carriers dominated the market. When cost per claim began to increase rapidly, but premiums remained low, a series of large insolvencies resulted. During this period there was ample evidence that the quality of claims administration, a key to the satisfaction of employers and insures, declined substantially. The DWC Audit Unit annual reports chronicled what appeared to be poor and declining compliance with benefit delivery regulations and increasing violations for unpaid compensation to workers.
Current State-of-the-State:
A number of insurers handling a substantial fraction of Californias market are insolvent or under regulatory monitoring. The second largest claim handling function in the state is supplied by the California Insurance Guarantee Association (CIGA) handling the claims of insolvent insurers. The State Compensation Insurance Fund (SCIF) has come to dominate the market with between 40% and 45% of written premium. Instead of a highly competitive market, the observation has been made that we have evolved into a near de facto monopoly state fund, but with pricing and regulatory controls that were designed for a very different environment. Some conclude that this has led the Insurance Commissioner to pressure SCIF to maintain higher rates for employers to avoid further consolidation through insolvencies or price competition.
Key Issues:
1. The quality of claims handlings affects both employers costs and the adequacy and timeliness of benefit delivery to workers. Quality may be low and deteriorating in the face of insolvencies and rapid fluctuations in market share.
2. Further insolvencies or consolidation may affect the ability of employers to obtain fairly priced insurance and quality service.
3. The current regulatory tools were created for an environment of competitive markets with no dominant player and, to some extent, for a market with highly regulated pricing. Todays market is dominated by a single large insurer and highly competitive pricing.
4. There is reason to be concerned that the claims handling performance, for insurers and third party administrators acting for self-insured employers, has been deteriorating.
5. Compliance with insurance coverage is likely to deteriorate in the face of steep increases in premium rates, leaving workers without benefits and compliant employers at a competitive disadvantage.
2. Return-to-Work
If injury occurs, return to sustained employment avoids much of the costs borne by injured workers and their employers and therefore both benefit. Return to work programs should be carefully designed to avoid return too early, which may lead to subsequent health problems which could lead to the worker quitting, being laid off, or retiring. Thus increasing sustained employment is the key, which is essentially equivalent to reducing wage loss.
There are several specific areas that are related to the return-to-work issue that deserve special attention.
1) Measuring and tracking return-to-work success,
2) Vocational rehabilitation,
3) Planning for the implementation and evaluation of the return-to-work provisions of AB-749.
We will take each of these issues in turn.
- What innovative policies can California adopt to improve return-to-work?
- What innovations have been successfully adopted by other states?
- How can management and labor cooperation improve return-to-work?
- What is the full impact of problems with sustained return-to-work on workers earnings?
Return-to-work indicators and wage loss
State-of-the-State: 1992-2002
The multi-state comparisons conducted by RAND, Boston University, and Michigan State University found that the while compensation levels in California were competitive relative to other states, California did poorly when measured on the basis of replacement rates.
The important factor in this dichotomy is that Californias workers experience much greater difficulty in maintaining post-injury employment.
Over the past decade, employment and wage loss outcomes have improved for the less impaired workers, however, despite a dramatic economic recovery that drove wages up and unemployment rates to 20-year lows, outcomes for the most seriously disabled experienced little or no improvement.
Because permanent disability benefits in California, unlike a number of states, are not indexed, the economic condition of the states injured workers can be expected to deteriorate after AB-749 is fully implemented in 2006.
Key issues:
1) By many measures, replacement rates have been deemed inadequate. However, compensation levels have proved difficult to increase and a divisive issue in political debates. Improvements in workers outcomes over the next decade will most likely come from efforts to reduce wage loss through improved return-to-work.
2) Our current state of knowledge on why California is less successful than other states in keeping injured workers employed is not adequate to confidently identify initiatives in this area.
3) To understand what is effective in return-to-work, on-going assessment is needed to gauge the success of return-to-work efforts.
4) Methods have been developed to accurately measure, and compare over time the State-of-the-State with regards to return-to-work.
Vocational Rehabilitation
For over two decades, Californias workers compensation system has relied on the vocational rehabilitation benefit to help return-to-work the most seriously disabled workers, those with impairments that preclude them from returning to their usual occupation. This benefit has been often criticized as expensive, difficult to administer, costly to implement and monitor, and unsuccessful at improving workers outcomes. AB 749 made major changes to the benefit, allowing represented workers to compromise the benefit for up to $10,000.
State-of-the-State: 1992-2002
In 1992, vocational rehabilitation expenditures exceeded $1.4 billion system-wide, over 20% of indemnity benefits paid to injured workers. Average rehabilitation costs per VR claim were over $13,000, with a quarter of claims exceeding $25,000. The 1993 reforms introduced a $16,000 cap on the VR benefit and a separate cap for the services of rehabilitation professionals. The legislation also introduced incentives to encourage employers to offer work modification and alternative job opportunities to enhance the return-to-work of VR eligible workers.
According to CHSWC research,
the effect was a dramatic decline in the average cost per claim for VR benefits of 45%.
There was a significant increase in workers returning to the at injury employer
Despite the dramatic decrease in VR costs, workers outcomes improved. Approximately 70% were working when interviewed, both before and after reform, but a high percentage were able to return to the at-injury employer in modified jobs.
System-wide, total VR cost have declined to $700 million, approximately 13% of indemnity payments to workers. This still represents an important component of benefit costs and is accompanied by high administrative costs. Only 45% of the benefit cost is actually paid directly to workers.
AB-749 introduced a sweeping change. The legislation allows compromises of the benefit for the first time.
Key issues:
1) Compromising the VR benefit represents a new challenge for both workers and employers. Each party deserves fair valuation. However there is no current knowledge about how to evaluate individual settlements.
2) Data from the DWC Rehabilitation Unit has been somewhat incomplete over the past decade. In response to additional oversight requirements and to develop useful data for monitoring the changes introduced by AB-749 a comprehensive evaluation and revision of the data process will be necessary.
3) Workers eligible for VR are on average substantially more impaired (average rating 28% v. 15%. In addition, these workers suffer the additional disability of being excluded from their occupation. These workers will be faced with new choices about reemployment services. It is imperative that the outcomes of these workers be monitored to ensure that the changes introduced by AB-749 are positive for worker and employer alike.
4) AB-749 shifted the focus of return-to-work from the end of recovery to the beginning of recovery.
AB-749 Return-to-Work Program
AB-749 adds Section 139.48 to the Labor Code requiring the administrative director to establish the Return-to-Work Program in order to promote the early and sustained return-to-work of the employee following a work-related injury or illness. This will be funded out of the General Fund if money is appropriated by the Legislature.
Key Issues:
AB-749 requires several actions in order to implement the Return-to-work program.
1. The Administrative Director must adopt regulations concerning
a. Conditions for payment to employers for workers wages when returned to modified work
b. Reimbursement to employers for work place modifications necessary to return an injured employee to work
c. Refunding of workers compensation premiums for workers returned to modified duty.
2. The administrative director must contract with an independent research organization to evaluate the Return-to-work program.
3. Prevention
No area of research should facilitate consensus more than preventing injury. Workers can avoid the potentially devastating consequences of injury, disability and lost work, while employers can avoid the cost of compensation and medical care as well as lost productivity. Policies that encourage prevention must be carefully designed to ensure that they reduce injury and not simply discourage the reporting of injuries.
- What innovative policies can California adopt to improve prevention?
- What innovations have been successfully adopted by other states?
- How can management and labor cooperation improve safety in the workplace?
- What is the full cost associated with injuries in the workplace, both to employers and workers?
State-of-the-state 1992-2002:
The last decade has seen an unprecedented decline in the number of reported occupational injuries and illnesses. In fact, the number of claims per 100 workers has declined every year since 1991.
There are potentially many causes for this trend.
1. More attention paid to the cost of injuries due to very high comp rates in the early 90s
2. Other safety efforts including increased OSHA enforcement
3. Restrictions on compensability of claims (e.g., psychiatric and post-termination)
4. Anti-fraud efforts (as well as the related stigma attached to comp claims)
5. Changing industrial mix and workplace demographics
6. Declines in the real value of indemnity benefits after the last increase in 1996
The WCIRB anticipates that the indemnity claim rate will continue to decline at least through 2004.
Current state-state-of-the-state:
Occupational injury and illness rates in California are at the lowest levels ever recorded. This can be seen as one of the workers compensation success stories of the 1990s. At the same time there are concerns on the horizon. AB-749 eliminated regulation of loss control services through Cal-OSHA. At the same time, insolvencies and potential insolvencies may cause insurers to reduce short-term expenditures, such as safety efforts, where the benefits are derived in the long-term. However, with premium increases in the range of 50-60% over the past couple policy years, employers can be expected to focus even more efforts on safety.
Key issues:
1. How should the system deal fairly with the rise of "new injury/illnesses"? (e.g., fibromyalgia, Hepatitis-C, illness from environmental factors, or changes in the understanding of causation for psychiatric/stress disorders)
2. Ergonomic related injuries and illnesses remain an area of a significant number of claims, but without standards for workplace safety intervention.
3. Is part of the decline in incidence the result of under-reporting either purposeful or because of stigma attached to claiming? Is the under-reporting concentrated in special populations (e.g., immigrant, ESL, temporary/contract workers).
4. If labor-management cooperation is a key to reduction in injury rates, how does California strengthen its current efforts to support labor-management safety committees?
4. Dispute Reduction
Both workers and employers benefit from avoiding disputes before they occur. This must be done to insure that disputes if they arise are properly adjudicated and that the worker has access to representation. But if the dispute is avoided or resolved prior to litigation, workers and employers mutually benefit.
- Is California an overly litigious workers compensation system?
- What can California do to reduce disputes without reducing access to representation?
California appears to be a very litigious system compared to other states in a forthcoming RAND report for CHSWC, as shown in the figure. Over 30% of lost-time claims in California involve attorneys, which is two to three times the rate of representation experienced by other states.
Consequently, litigation costs are high in California. Defense litigation cost in 2000 was $294 million applicant cost was $199 million, for a total of $493 million. Since indemnity benefits were $3.5 billion, this suggests that litigation costs were equal to 14% of indemnity benefits.
Key Issues:
1. Access to representation is an important protection for workers. The challenge of any reform is to reduce litigation and disputes without limiting workers access to representation.
2. Reducing litigation and related costs depends upon reducing disputes. Some lessons may be learned from the California experience with carve-outs that have achieved very low dispute rates without reducing benefits paid.
3. Carve-outs may offer an opportunity for union workplaces to reduce dispute related costs in workers compensation. They may also offer a model from which the wider system can adopt new approaches to early intervention in disputes that mirrors the actions of the ombudsperson in carve-outs.
5. Healthy Workers
With recent increases in the cost of medical care for workers compensation, reducing medical costs is often advocated. But if reducing medical costs lowers the quality of care to workers or denies access to care, the workers recovery could be compromised. This can lead to continued medical costs, or the loss of a valuable employee. For this reason, we recommend a focus on healthy, productive workers, which might imply less expensive medical care, but only if the full employer cost (including future health costs and future lost work time) is lower when medical costs are lowered.
- Does comprehensive medical coverage improve medical delivery, increase quality and lower employer cost?
- Does inadequate medical treatment or incomplete coverage lead to shifting of costs to other components of the social safety net?
- How can California encourage the health of workers through workplace safety and health policies?
- How does California workers compensation medical care affect the total cost of workplace injuries, to both workers and employers?
Medical Treatment:
Medical treatment is arguably the most important component of the workers compensation system. It is the key benefit for returning workers to the workforce and healthy lives. Hundreds of thousands of workers that never receive a dollar of compensation for disability time receive medical treatment through their employers participation in the compensation system. From the employers perspective, medical treatment represents the majority of the benefits that they finance.
State-of-the-State 1992-2002:
During the early and mid-1990s, the average medical cost per indemnity claim showed low rates of growth. The rapid decline in medical-legal cost was an important contributor to dampening cost increases. At the same time, the growth rate of medical costs on the health benefit side also was moderate. A major revision of the Official Medical Fee Schedule including provisions for a pharmacy fee schedule was introduced in 1994.
During the later half of the 1990s, medical cost became the fastest rising component of workers compensation benefits. The WCIRB reported 15% annual year-to-year growth rates in the average medical benefits paid per indemnity claim. These increases occurred despite the introduction of a new hospital fee schedule in 1999.
Recent CHSWC research has identified presumption as an important component of the higher medical costs after the Minniear decision in 1996. Presumption appears to drive increases in the number and intensity of medical service visits as well as leading workers to change to a physician of their choice more often and earlier in the claim. However, the majority of the growth in medical costs is not explained by presumption and the cost drivers are poorly understood.
Some research has suggested that provisions for future medical benefits within compromise and release agreements may be a likely contributor to the increase in medical costs and overall benefit costs.
Current State-of-the-State
Medical costs are expected to represent 55% of total benefit costs on 2003 calendar year claims, up from 45% in the mid 1990s. These cost are rising at 15% per year. However, there is little consensus about what is driving cost, how to control costs, and the quality of the health care workers receive. While these issues might have been intractable several years ago, there are two new databases of medical treatment data available for research, one from CWCI and another from WCRI. These offer the Commission important opportunities for research about improving medical treatment while controlling costs.
Key issues:
1. AB-749 repealed presumption in all but a minority of cases. This will likely result in stricter application of utilization review, more restrictions on medical treatment, and more disputes about what is medically necessary.
2. Fee schedules cover medical treatment by providers, medical-legal costs, pharmacy reimbursements, and hospital facility fees. The only area outside the fee schedule is outpatient surgery facility fees. These are an area of great concern to insurers and employers.
3. There is limited understanding of what is driving the rapid increase in medical costs. If medical costs continue to rise at current rates, they will impact employers bottom line as well as threatening the level of benefits workers receive and the breadth of compensable injuries that is unique to the California system.
4. Quality of care remains poorly understood within occupational medicine. In addition, there is no research on how quality has changed in relation to the increase in cost.
5. Future medical appears to be a rapidly growing component of the medical benefit. This could reflect underlying medical inflation or it could signify changes in the underlying settlement process. There is insufficient reliable, well researched, independent data to guide judges, workers, and insurers on what constitutes a reasonable settlement of future medical across the range of injuries and illnesses.
6. New technology is constantly introduced in the medical arena. These technological advances are often rapidly adopted by workers compensation providers. However, the cost effectiveness and appropriate pricing are often not well established and consequently are an area of both frequent disputes and potential access problems.
Medical-Legal Issues:
Medical-legal costs are incurred when an opinion, other than the treating physicians permanent and stationary report is required to solve one or more disputed issues. Consequently, the frequency and cost are driven by:
1. The number of disputes, which in turn depends upon the complexity of the system particularly the extent to which we include difficult to determine issues within the compensation system (e.g., psychiatric injuries).
2. The willingness or need for parties to seek medical legal opinions. For example, the impact of presumption on the value of obtaining an opinion other than the treating physicians.
State-of-the-State: 19922002
Source: CHSWC 2001 Annual Report
In 1992, medical-legal costs were in the process of declining from historic highs reached in 1990 and 1991. In 1990-91, medical-legal costs represented approximately 20% of all medical expenditures. 25% of permanent disability claims had at least one psychiatric evaluation. And the average cost of a medical legal evaluation was nearly $1000.
The latest information available indicates that medical-legal costs in 2002 are less than 4% of medical expenditures, fewer than 4% of claims have a psychiatric evaluation, and the average cost of a medical-legal exam is approximately $750.
According to studies by the Commission, the decline in medical legal cost was due to a decline in the frequency of claims, changes in the fee schedule that reduced reimbursements, and declines in the number of exams per claim. Another important savings driver was the restriction placed on the compensability of psychiatric claims that eliminated compensation when less than 51% of the cause arose from work.
Current state-of-the-state:
Medical legal costs over the past 8 years have been steady at less than 2% of total system costs. CHSWC has consistently monitored both the cost and quality of reports over that period, making a number of recommendations to the legislature, IMC, WCIRB and DIR. These recommendations have generally been followed and the medical-legal process appears stable and well monitored as a result. The only area that appears of immediate concern is that the average price of medical-legal reports has risen about 25%, from $600 to $750 over the past several years.
Key issues:
1) AB 749 has virtually eliminated the presumption of the correctness of the primary treating physician (PTP) reports. There is considerable concern that this will return California to the dueling docs environment of the early 1990s. However, previous CHSWC research did not find that presumption was an important contributor to the decline in medical-legal reporting frequency and cost.
2) CHSWC efforts to redefine the permanent disability rating schedule by establishing an empirical basis for the rating of different impairments might lead to substantial revision of the schedule. These efforts might lead to problems with medical-legal evaluations as doctors and raters learn to apply any new schedule.
3) The average cost of medical-legal reports has been rising and is now about 25% higher than it was in the middle to late 1990s.
6. Benefits: Distribution
While the overall level of benefits can be characterized as a "zero-sum game" as discussed above, the targeting of benefits to workers with greater need improves outcomes for injured workers without increasing costs to employers. This can therefore be a point of mutual consensus.
- How can California target benefits to workers with the greatest need?
There are a number of important characteristics of benefit levels. Most often, in legislative and planning, the debate focuses on aggregated levels of benefits or the portion of wages replaced across all workers or groups of workers, this is basically the adequacy of benefits. However, how accurately we target benefits at those who need them most, for example workers who are not able to return to their at injury job is just as important an issue. Even if we achieve a consensus about an adequate overall replacement rate, the benefits might be inequitably distributed because we overcompensated some less serious disabilities and under compensated others. Improving benefit targeting, especially in the face of limited resources is one way to make cost neutral but very effective improvements to the compensation system.
State-of-the-state 1992-2002:
Through out the last decade, the California compensation structure has exhibited three main characteristics.
1. Because the system had relatively low maximum benefit levels, lower wage workers received higher wage replacement rates than higher wage workers.
2. Because compensation rates increased very rapidly with increasing severity, more seriously injured workers received higher wage replacement rates relative to low wage workers.
3. Because California has a very broad definition of permanent disability, a much larger percentage of workers receive compensation than in most other states.
California is very similar to other states on the first two characteristics. In the several states compared in the CHSWC study, low wage workers are better compensated than high wage workers and more serious injuries are better compensated than less severe injuries. However, California differs from other states on the third measure. While California pays generous benefits in the aggregate, it pays somewhat lower benefits for a given injury, but pays for a wider range of injuries. During the decade, while some minor restrictions were placed on the breadth of injuries compensated (e.g., psychiatric, post-termination), benefit increases tended to maintain the much higher replacement rates for low wage, more severely injured workers.
Two very important policy making opportunities in this area emerged as a result of CHSWC research during the past decade.
1. For the first time, the system has accurate measures of wage replacement across different groups of workers. These data allow policymakers to make explicit decisions about issues of equity and distribution.
2. A unique combination of administrative datasets has for the first time given policymakers, researchers, and other stakeholders an opportunity to establish an empirical basis for permanent disability rating schedules.
However, benefits may still seem to be inadequate for many workers suffering permanent disabilities, since only about 40% of lost wages are replaced over the 10 years after injury.
Key Issues:
1. Monitoring benefit levels and values. Recently legislated increases are not fully phased in until 2006 and current overall compensation levels are similar or higher than many states.
2. Future benefit increases should take advantage, in an explicit way, of the knowledge about the distribution of benefits implicit in the current structure.
3. Replacement rates for permanently disabled workers that return to their at-injury employer are at or above 100% after tax. However, replacement rates for workers who do not sustain return to the at-injury employer are significantly lower. Focusing compensation on workers who are not offered the opportunity for appropriate return to the at-injury employer has the double advantage of offering incentives to employers to improve retention while focusing benefits on the workers suffering the greatest loss.
4. CHSWC research over the past several years has focused attention on the unreliability of the rating process. More recent research suggests that much of the inconsistency is a result of a poorly constructed schedule that targets benefits incorrectly across different impairments.
SEC. 4. The Legislature is hereby expressly vested with plenary power, unlimited by any provision of this Constitution, to create, and enforce a complete system of workers' compensation, by appropriate legislation, and in that behalf to create and enforce a liability on the part of any or all persons to compensate any or all of their workers for injury or disability, and their dependents for death incurred or sustained by the said workers in the course of their employment, irrespective of the fault of any party. A complete system of workers' compensation includes adequate provisions for the comfort, health and safety and general welfare of any and all workers and those dependent upon them for support to the extent of relieving from the consequences of any injury or death incurred or sustained by workers in the course of their employment, irrespective of the fault of any party; also full provision for securing safety in places of employment; full provision for such medical, surgical, hospital and other remedial treatment as is requisite to cure and relieve from the effects of such injury; full provision for adequate insurance coverage against liability to pay or furnish compensation; full provision for regulating such insurance coverage in all its aspects, including the establishment and management of a state compensation insurance fund; full provision for otherwise securing the payment of compensation; and full provision for vesting power, authority and jurisdiction in an administrative body with all the requisite governmental functions to determine any dispute or matter arising under such legislation, to the end that the administration of such legislation shall accomplish substantial justice in all cases expeditiously, inexpensively, and without incumbrance of any character; all of which matters are expressly declared to be the social public policy of this State, binding upon all departments of the state government.
The Legislature is vested with plenary powers, to provide for the settlement of any disputes arising under such legislation by arbitration, or by an industrial accident commission, by the courts, or by either, any, or all of these agencies, either separately or in combination, and may fix and control the method and manner of trial of any such dispute, the rules of evidence and the manner of review of decisions rendered by the tribunal or tribunals designated by it; provided, that all decisions of any such tribunal shall be subject to review by the appellate courts of this State. The Legislature may combine in one statute all the provisions for a complete system of workers' compensation, as herein defined.
The Legislature shall have power to provide for the payment of an award to the State in the case of the death, arising out of and in the course of the employment, of an employee without dependents, and such awards may be used for the payment of extra compensation for subsequent injuries beyond the liability of a single employer for awards to employees of the employer.
Nothing contained herein shall be taken or construed to impair or render ineffectual in any measure the creation and existence of the industrial accident commission of this State or the state compensation insurance fund, the creation and existence of which, with all the functions vested in them, are hereby ratified and confirmed. (Emphases added)
CHSWC Monitoring Plan for Continuous Improvement in System Performance
Future research efforts depend on defining specific areas to focus limited resources. In addition some of these efforts depend on developing or maintaining continuous monitoring processes that can form the basis for research and evaluation. There are several important components of the value of continuous monitoring:
- Continuity of these monitoring processes over time offers insights into the changing condition of the workers compensation system and an early warning system for future problems.
- Comparative monitoring across different systems, such as across the 50 states, offers an approach to evaluating Californias system, relative to the performance of other systems on variables such as system administrative cost, where there is no absolute value that is "correct".
A. Current monitoring of system performance and the impact of reforms:
CHSWC has put in place two successful and ongoing monitoring processes that the Commission should consider continuing. They offer valuable insight into the health of the system and are inexpensive to maintain and analyzing the results is straightforward.
a. Uninsured employerstracking uninsured employers through linked EDD and WCRIB data
The pilot effort was developed and analyzed by the Commission. Current and future tracking will be done by the DWC/DIR. The Commission should consider regular analysis and review of the result of the tracking.
b. Medical-legalmonitoring the cost and frequency of medical legal reports using WCIRB PD Survey
The Commission has used this valuable survey for several years to monitor the health of the medical-legal system. The survey was improved substantially through the suggestions of CHSWC studies. Continuing this effort should be considered.
B. Major new initiative--Linked WCIS/EDD data
A number of proposed research and monitoring efforts would require consistent and accurate estimates of wage loss and return-to-work measures. Past CHSWC research has established state-of-the-art methodologies for this type of research that should be considered as the basis for all future CHSWC efforts in these areas. The methods require linking several administrative datasets across two agencies and one non-profit. Specifically, linking the DWCs Workers Compensation Information System (WCIS) with the Employment Development Departments Base Wage File and Unemployment and Disability files and possibly the WCIRB Unit Statistical Report files would create a necessary dataset for future research in the areas of:
i. Wage loss and benefit adequacy
ii. Vocational Rehabilitation reforms
iii. Return-to-work
1. Impact on benefit adequacy
2. Success of AB-749 Return-to-Work Program
Currently, this process requires a series of one-time negotiated arrangements that are time consuming and cause substantial delays in access and the timeliness of the analysis. Setting up a regular, ongoing monitoring process with automatic updates would greatly simplify CHSWC research, reduce the substantial repeated contracting costs and allow results to be more current.
Monitoring related to AB-749 and the strategic Plan:
1. Administrative Efficiency--Organizing Audit Unit data for ongoing monitoring
The quality of claims administration has been an important concern of both employers and labor. It is often claimed that the quality of claims administration has declined over time and is particularly threatened by the rapid changes in the make-up of the insurance markets. The DWC Audit Unit has collected and will continue to collect data on claims administration that, if made available in the correct format, would allow inexpensive evaluation of past, present, and future system performance in the areas of:
i. Claims handling performance
ii. Claim frequency
iii. Denial of benefits
iv. Failure to pay compensation
v. Amount of compensation underpaid
vi. Timeliness of benefit delivery
vii. Reporting to WCIS
While these data have been available, the current reporting by the Audit Unit does not allow consistent estimates of trends in system performance or measures of any of the above outcomes. A short, one-time research and planning effort would set up appropriate reporting that could be recreated historically and continued on an annual basis in the future.
2. Return-to-work
A. On-going monitoring of Californias performance in returning workers to sustained employment.
CHSWC research has developed methods and established base-line measures of return-to-work. The Commission should consider monitoring on a regular, on-going basis wage-loss and return-to-work. Linking WCIS and EDD data, for annual analysis would be valuable. This will be simplified if a Labor Agency that includes both EDD and DIR is established. At a minimum, DIR or CHSWC should create a series of longitudinal cohorts of injured workers by linking samples of WCIS and EDD.
Return-to-work efforts undertaken by the State or the Commission should always include an evaluation component to determine what actually works. Evaluation methodologies should, to the extent possible, use the methods developed from previous CHSWC efforts.
B. Vocational Rehabilitation
Monitoring and evaluating the changes introduced by AB-749 require high quality, consistent data, collected in a timely manner. An immediate priority for the DWC is the introduction of effective data collection by the Rehabilitation Unit. CHSWC is already working with the Division to identify effective strategies. Past data collection at the Rehabilitation Unit has been inconsistent, often reduced as a simple solution to budget and staffing problems. CHSWC should consider monitor the data collection process and periodically evaluate the data. This could be done as part of a VR evaluation.
Similar to the return-to-work initiatives discussed above, the Commission should consider conducting an evaluation of outcomes for workers eligible for VR, on an ongoing basis, using methodologies already developed as part of CHSWC research into wage loss and return-to-work.
Monitoring could also be conducted through the WCIRB Annual PD Survey. The survey already includes questions concerning VR. To these the Commission would request that the WCIRB add questions about whether a worker is QIW and whether there was a settlement, and if so, what was the dollar amount of the settlement.
C. Monitoring the AB-749 Return to Work Program
The evaluation of the program is required. It would be appropriate for this evaluation to be done in a manner consistent with the evaluation methods developed for previous CSHWC research. This evaluation will likely require data on return-to-work for industrially injured workers from the period prior to the implementation of the legislation. This may require CHSWC and DWC to implement a data collection process even before implementation of the actual Return-to-work Program.
3. Prevention--Monitoring Californias performance on prevention of occupational injuries and illnesses
A very informative and very high profile monitoring series would involve creating an annual comparison of Californias injury and illness rate as compared to the rates in the other 50 states. The basis of a comparison would be the annual BLS employer survey with weighting to adjust the relative rates for industry mix and other factors. The comparison could include in addition to the injury/illness rates, rates of lost time and restricted work cases and average lost work day rates. These later comparisons would also help monitor Californias return to work performance.
4. Dispute reduction and judicial performance
A. The current CHSWC evaluation of the judicial process could be used to develop recommendations for implementation of measures of judicial performance that could be the basis of ongoing monitoring. This process could include a review of current reporting (including quality of statistics), recommendations for future reporting (including monitoring of quality), and annual analysis of the results. The planning of the monitoring process may require considerable thought and analysis input by CHSWC and associated researchers, but the data collection would be conducted by the DWC and consequently be relatively inexpensive for CHSWC. Annual review and analysis of these data would likely entail only moderate cost.
B. Monitoring Medical-Legal:
CHSWCs current ongoing monitoring of the medical-legal process through use of the WCIRB Permanent Disability Survey seems sufficient. This monitoring is simple and inexpensive. For the near future, this monitoring should focus on examining the cause for the current rate of increase in the average cost of reports when the fee schedule has remained fixed of over a decade.
5. Healthy Workers
WINS survey will be the basis for monitoring a number of quality and access issues.
6. Monitoring the Targeting of Benefits:
The distribution of benefits relative to losses, the replacement rate, differs substantially across different groups of workers, by wage, by severity of injury, and by whether they return to sustained employment with the at injury employer. The differences in replacement rates across these groups represents implicit decisions by policymakers about equity. These relative rates can be easily monitored using the linking of WCIS and EDD data that is also suggested for monitoring over time changes in return to work, vocational rehabilitation and several other areas. An example of reports on performance related to targeting could be developed. These are likely to include
- Measures of replacement rates across wage groups
- Measures of replacement rates across PD severity levels
- Measures of replacement rates by return to work at the at-injury employer
Description and Timetable for CHSWC Studies per AB 749
It is extremely important that CHSWC receive sufficient funding resources to carry out all its mandates, including the consultations. In the past, CHSWC, in a consultation role with the Division of Workers Compensation, has shared data from its studies and surveys and tested informational prototypes in various focus groups including workers and employers. This has ensured that workers compensation program information is clear, concise, non-legalistic, and easily accessible to workers, employers, and Californias diverse population.
Evaluation of AB 749
Pursuant to Labor Code Section 77(a), CHSWC is mandated to "conduct a continuing examination of the workers' compensation system and of the state's activities to prevent industrial injuries and occupational diseases. The commission may conduct or contract for studies is deems necessary to carry out its responsibilities."
With the passage of AB 749, CHSWC plans to conduct studies to carry out its responsibility to evaluate the impact of new reform legislation on the workers compensation system, particularly with respect to
� Costs, benefits, and outcomes of the reforms
� Medical cost controls
o Elimination of the presumption of correctness of primary treating physician reports,
o Pharmaceuticals,
o Qualified Medical Examiners [QME],
o Health Care Organizations [HCOs])
� Vocational rehabilitation and return to work,
� Fraud, and
� Court procedures.
It is important to lay the foundation to analyze the before and after effects of the legislation. These efforts will need to begin immediately to be able to determine the changes from the reforms.
Timetable of Activities
July 2002 December 2002
CHSWC will begin by designing a comprehensive evaluation plan for the recently enacted (AB-749) workers compensation reform legislation, incorporating the following activities:
- Identifying the research and public policy questions connected with the reforms
- Recommending appropriate data collection strategies
- Evaluating proposed research designs, and
- Recommending among competing proposals for evaluation.
January 2003- June 2003
- Creation of a research and data infrastructure to enable evaluation of all components
- Development of data collection and research protocols
Beginning July 2003
- Establishment of baseline measurements
- Updating findings
- Developing outcome measurements, including employer savings and worker outcomes
- Reporting on the performance of the program, including successes and identifying areas for further attention
New CHSWC Studies per AB 749
The provisions of AB 749 specifically mandate that CHSWC carry out new projects and consult with the Division of Workers Compensation and other entities on specified studies. The following descriptions of the CHSWC studies cite the AB 749 authorizing section and the revisions to the Labor Code.
Report on Medical
Treatment Provided to Industrially-Injured Workers
Section 32 of AB 749 amends Labor Code Section 127.6 which requires CHSWC to consult on a study of medical treatment provided to industrially-injured workers:
" (a) The administrative director shall, in consultation with the Commission on Health and Safety and Workers' Compensation, the Industrial Medical Council, other state agencies, and researchers and research institutions with expertise in health care delivery and occupational health care service, conduct a study of medical treatment provided to workers who have sustained industrial injuries and illnesses."
Timetable of Activities
July 2002 December 2002
- Establish parameters and scope of the study
- Develop Request for Proposals
January 2003- June 2003
- Evaluate proposed research designs.
- Select among competing proposals
- Initiate study
Benefit Notice Study
Section 20 of AB 749 amends Labor Code Section 77 which requires CHSWC to issue a report regarding improvements and simplification of the workers compensation benefit notices:
" (b) On or before July 1, 2003, and periodically thereafter as it deems necessary, the commission shall issue a report and recommendations on the improvement and simplification of the notices required to be provided by insurers and self-insured employers."
Timetable of Activities
July 2002 December 2002
- Establish parameters and scope of the study
- Develop Request for Proposals
January 2003- June 2003
- Evaluate and select among competing proposals
- Initiate and carry out study
- Issue report
- Continue monitoring and update findings
- Issue report on or before July 1 of each year
Information Notice in Workplace
Section 44 of AB 749 amends Labor Code Section 3550(d) which requires CHSWC to consult regarding development of a workers compensation information notice to be posted in the workplace:
" (d) The form and content of the notice required by this section shall be prescribed by the administrative director, after consultation with the Commission on Health and Safety and Workers' Compensation, and shall advise employees that all injuries should be reported to their employer. The notice shall be easily understandable. It shall be posted in both English and Spanish where there are Spanish-speaking employees. "
Timetable of Activities
January 2003- June 2003
Work with DWC to
- Establish parameters and scope of the study
- Evaluate and select among competing alternatives
- Initiate project
Workers Compensation Information for New Employees
Section 45 of AB 749 amends Labor Code Section 3551(a) which requires CHSWC to consult on the development of a notice provided to new employees by their employers:
"3551. (a) Every employer subject to the compensation provisions of this code, except employers of employees defined in subdivision (d) of Section 3351, shall give every new employee, either at the time the employee is hired or by the end of the first pay period, written notice of the information contained in Section 3550. The content of the notice required by this section shall be prescribed by the administrative director after consultation with the Commission on Health and Safety and Workers' Compensation."
Timetable of Activities
January 2003- June 2003
Work with DWC to
- Establish parameters and scope of the study
- Evaluate and select among competing alternatives
- Initiate project
Notice and Claim Form for Workers Compensation Benefits
Section 77 of AB 749 amends Labor Code Section 5401(b) which requires CHSWC to consult on the development of a notice of potential eligibility and claim form for workers compensation benefits:
"b) Insofar as practicable, the notice of potential eligibility for benefits required by this section and the claim form shall be a single document and shall instruct the injured employee to fully read the notice of potential eligibility. The form and content of the notice and claim form shall be prescribed by the administrative director after consultation with the Commission on Health and Safety and Workers' Compensation. The notice shall be easily understandable and available in both English and Spanish. "
Timetable of Activities
January 2003- June 2003
Work with DWC to
� Establish parameters and scope of the study
� Evaluate and select among competing alternatives
� Initiate project
Report on Access to Funds Paid to Injured Workers
Section 65 of AB 749 amends Labor Code Section 4651(c) which requires CHSWC to provide oversight and consultation to DWC for preparing a report on how to provide better access to funds paid to injured workers:
"(c) On or before July 1, 2004, the administrative director shall present to the Governor recommendations on how to provide better access to funds paid to injured workers in light of the requirements of federal and state laws and regulations governing the negotiability of disability indemnity payments. The administrative director shall make specific recommendations regarding payments to migratory and seasonal farmworkers. The Commission on Health and Safety and Workers' Compensation and the Employment Development Department shall assist the administrative director in the completion of this report."
Timetable of Activities
January 2003- June 2003
Work with DWC to
- Establish parameters and scope of the study
- Develop Request for Proposals
- Evaluate and select among competing alternatives
- Initiate project


text:
Click on the bold blue text below, or on a topic listed on the left side of the page to read more. You can also find information about the treatment of your type of porphyria under your specific type.
The American Porphyria Foundation promotes comprehensive care necessary for treating individuals with Porphyria. Although there is no cure for porphyria, there is treatment available for each type of the disease.
In this section of our website you'll find detailed information on Panhematin® for acute porphyria (AIP, VP, HCP or ADP) and Lumitene for Erythropoietic Protoporphyria (EPP), tips on finding a local doctor and building a good working relationship with your doctor. Treatment for each of these diseases involves more than a single medication. Please see the disease descriptions for additional information.
The medications mentioned in this section of the site are for acute porphyria and EPP only. For treatment options for Porphyria Cutanea Tarda (PCT), Congenital Erythropoietic Protoporphyria (CEP) and Hepatoerythropoietic Porphyria (HEP) please see the disease descriptions.
Panhematin® for Acute Porphyria (AIP, VP, HCP, ADP)
Panhematin® is a treatment for the acute porphyrias manufactured by Recordati Rare Diseases in Lebanon New Jersey. It is a lyophilized form of alkaline heme that has to be reconstituted immediately prior to administration. Panhematin® should be infused into a large peripheral vein. A large central line or port may be used, if available.
Doctors administer Panhematin® to correct heme deficiency in the liver and repress production of porphyrin precursors. Panhematin® almost always normalizes porphyrin and porphyrin precursor values. Three to four mg/kg of Panhematin® given once daily for four days early in an attack produces a highly beneficial effect in most patients. Commonly noted are decreases in pulse rate, blood pressure, abdominal pain, as well as decreased levels of urinary porphobilinogen (PBG). These effects can occur within a day.
Panhematin® is the only commercially available heme therapy in the United States. (Heme arginate is another preparation, but is only available outside of the U.S.) While a high carbohydrate diet is recommended for patients with porphyria, it is not regarded as highly effective by itself. Intravenous glucose therapy is a treatment option for mild attacks. When heme therapy was introduced as a treatment, it was recommended that it be initiated only after several days of glucose therapy was unsuccessful.
Today, physicians experienced in treating patients with attacks of porphyria recommend early use of Panhematin® rather than waiting to see if glucose alone will be of decisive help.

subset: commoncrawl


text:
This story appears in the October 2011 issue of National Geographic magazine.
The biggest fish in the sea is as long as a school bus, weighs as much as 50,000 pounds, and has a mouth that looks, head-on, wide enough to suck down a small car. Despite this distinctive profile, scientists know very little about Rhincodon typus—the whale shark.
The behemoths are indeed sharks: They breathe through gills, like fish. They are cold-blooded, like fish. The "whale" part of the name refers to size and how the animals eat. They are one of only three known shark species that filter feed, as baleen whales do, swimming slowly through plankton-rich water, maws agape. Water goes in carrying edibles of all sizes, and water sans food flows out.
The giant fish is hard to study in part because it is hard to find and track. By tagging individual specimens, scientists have learned that whale sharks can log thousands of miles in years-long trips. But they sometimes disappear for weeks, diving more than a mile down and resting in the chilly deep for a spell. No one has ever found mating or birthing grounds.
Whale sharks are ordinarily loners. But not in one corner of Indonesia. The photographs on these pages, shot some eight miles off the province of Papua, reveal a group of sharks that call on fishermen each day, zipping by one another, looking for handouts near the surface, and nosing the nets—a rare instance when the generally docile fish act, well, like the rest of the sharks.


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Submitted 14 December, 2015; v1 submitted 8 December, 2015; originally announced December 2015.
Comments: 28 pages. v2: added and expanded several sections; some additional references
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Abstract : {\bf R}-matrix calculations combined with the adiabatic nuclei approximation are used to compute electron-impact rotiational excitation rates for three closed-shell diatomic cations, HeH ^+ , CH ^+ , ArH ^+ . Comparisons with previous studies show that an improved treatment of threshold effects leads to significant changes in the low temperature rates, furthermore the new calculations suggest that… ▽ More {\bf R}-matrix calculations combined with the adiabatic nuclei approximation are used to compute electron-impact rotiational excitation rates for three closed-shell diatomic cations, HeH ^+ , CH ^+ , ArH ^+ . Comparisons with previous studies show that an improved treatment of threshold effects leads to significant changes in the low temperature rates, furthermore the new calculations suggest that excitation of CH ^+ is dominated by ΔJ =1 transitions as is expected for cations with a large dipole moment. A model for ArH ^+ excitation in the Crab Nebula is presented which gives results consistent with the observations for electron densities in the range 2-3\times 10^3 ~cm ^{-3} . △ Less
Sebastian Oberthür is Professor for Environment and Sustainable Development at the IES. Trained as a political scientist with a strong background in international law, he focuses on issues of international and European environmental governance, with an emphasis on institutional issues and perspectives. His current research interest extends in particular to the horizontal and vertical integration of international institutions and policies relevant to the environment, including the interplay between environmental agreements/institutions and other policies (e.g. trade, transport), as well as the role and performance of the EU in international (environmental) institutions.
From 2005 to 2015, Sebastian Oberthür served as IES Academic Director. From 2006 to 2013, he was a member of the Compliance Committee of the Kyoto Protocol to the UN Framework Convention on Climate Change. Since 2000, he has furthermore acted as a special policy advisor on international climate policy to the German Federal Ministry for the Environment, Nature Protection and Nuclear Safety. Since 1996, he has also been an appointed member and representative of the International Council of Environmental Law (ICEL). From 2005 to 2007, Sebastian Oberthür served as a member of the Scientific Steering Committee of the Institutional Dimensions of Global Environmental Change (
) project of the International Human Dimensions Programme (IHDP). He is a member of
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– an international research network focusing on climate and energy policy.
Sebastian Oberthür has dealt with issues of international environmental policy as well as climate policy since the early 1990s. He has worked on the development and implementation of various environmental agreements and international environmental institutions, as well as climate policies. He has, inter alia, conducted studies on the interaction between international institutions, the Kyoto Protocol to the UN Framework Convention on Climate Change, the structure and design of the system of international environmental institutions, the role of non-governmental organizations in international environmental governance, the reporting of data under the Montreal Protocol on Substances that Deplete the Ozone Layer, and the foreign environmental policy making of the European Union in international environmental agreements.
Dr. Oberthür has published widely on these subjects and is invited regularly as an expert to participate in and speak at relevant conferences and workshops. He has followed the international negotiating processes on the protection of the ozone layer and on global climate for several years as a scientific observer and a government advisor. He serves on the editorial boards and review panels of various journals and as a reviewer of several national science foundations. He is also co-editor of the book series on "The European Union in International Affairs" with Palgrave Macmillan.
Before joining the IES in 2005, Sebastian Oberthür served as a part-time assistant professor for international relations at the Otto-Friedrich-University Bamberg from 2001-2005. Previously, he was a senior research fellow with Ecologic, the Institute for International and European Environmental Policy in Berlin, with which he remains a Senior Policy Advisor. In 1996 and 1997, Dr. Oberthür also taught International Relations at the Technical University Berlin.
From 1987 to 1992, Sebastian Oberthür studied political science in Marburg and Berlin. In 1995, he received a PhD from the Free University Berlin for his work on "The Contribution of International Regimes to Solving Environmental Problems" (summa cum laude).
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Melissa J. Monroe , Jury Commissioner Clarence M. Mitchell, Jr. Courthouse 100 North Calvert Street, Room 239 Baltimore, Maryland 21202 (410) 333-3775 (410) 333-0057 (f)
Received a "Summons and Juror Qualification Form"?
Read both sides of the SUMMONS AND JUROR QUALIFICATION FORM in its entirety. The form tells you if you are being called as a Grand or Trial Juror. You must complete and return the qualification form within (10) days of receipt to ensure that the Jury Office receives your information in time. Be certain to complete items 1 through 24 of Part B – Juror Qualification Form, and return it to the Court with any relevant documentation (refer to the DOCUMENTATION CODE LEGEND noted in Part B).
If you prefer, you may complete the JUROR QUALIFICATION FORM online . In addition to completing the form online, the website also allows you to update your juror profile or to submit a request (one time only) that your service is postponed to a later date. If any of your answers on the form disqualify or exempt you from serving, or if your request for a postponement of service is granted, you will be notified before the date your service is to begin (as shown on the bottom right portion of the summons) and you will not have to attend. It is important that you return the form within ten (10) days as requested.
Jurors are not to bring/invite visitors or companions with them. Only the person with a jury summons for the day of service will be permitted in jury assembly areas. Therefore, children, spouses, parents, neighbors, friends and other guests may not accompany or visit with a juror in any assembly area. Caregivers will only be permitted with prior authorization from the Jury Commissioner.
This notice is to inform Baltimore City residents of a jury scam that has been reported nationwide and to provide guidance on how to proceed if you believe you are being targeted by this scam.
Citizens are being contacted via phone by a scam artist who identifies himself as a staff member of the Jury Division, Sheriff or Police Departments. The scam artist claims that the office needs to verify your personal information AND/OR informs you that a fine has been assessed for failing to appear for jury service. The scammer may even threaten to issue a warrant for your arrest and instruct you to obtain a form of money card, cash advance, etc., to satisfy the fine.
The scam artists are using disposable cell phones, so they have no problem giving a citizen a phone number to call them back. Once the citizen gets the money card, they are instructed to give the money card information over the phone, which the caller claims will satisfy the fine and result in the warrant being dismissed. This allows the scam artist to get the money without the need for actual face-to-face contact. The scam artists sound very convincing over the phoneand have been known to threaten the citizen with jail and fines in order to get them to comply.
The Jury Commissioner's Office of the Circuit Court for Baltimore City does NOT contact citizens by phone regarding the payment of fines for failing to appear for jury servi c e. Rather, the Court sends a Failure to Appear notice before taking any action. Subsequently, if a Show Cause order is issued as a result of your failure to appear for jury duty or some other infraction, there is no warning phone call.
Please protect yourself. Never give personal information when answering an unsolicited phone call and/or email. Instead, write down the phone number the person is calling from. Do not give any personal information about yourself. Contact your local police department and request to file a complaint.
Proper Dress is required. Dress as if you were going on a job interview. The following list provides examples of the type of attire that should not be worn for jury service:
Jury service may be rescheduled one time within a 12-month period. Jury service should be rescheduled within the next 45-60 days after the initial summons date. This may be done online or by calling the Jury Office. You may talk with Jury staff at 410-333-3775if other arrangements are needed.
The Jury Commissioner's Office operates under legal requirements to safeguard the privacy of juror information. Therefore, communications with the Office regarding service should be made by jurors themselves, and not by family members or other persons.
If you are no longer a resident of Baltimore City, be certain to change your address with the Motor Vehicle Administration and Voter Registration Office in the Board of Elections Supervisors AND provide proof to the Jury Office that these changes were made. Since juror records are taken from these sources, it is important that you promptly notify them of your address change so that your name can effectively be removed from the jury pool for Baltimore City.
If you are not a US Citizen, provide a valid, legal copy of your current permanent resident card, green card, work visa or passport. If you do not have any of these documents, contact the embassy of your country of citizenship for assistance.
Click here to check the embassy of your country of citizenship.
Unable to Speak English? No Puede Hablar Ingles?
English Prospective Jurors that are unable to speak, read, write or comprehend English will need to meet with the jury commissioner or jury supervisor. They are to call 410-333-3775 to schedule an office visit.
Spanish Posibles miembros del jurado que son incapaces de hablar, leer, escribir o comprender Inglés tendrá que reunirse con el comisionado de jurado o el supervisor del jurado. Son de llamar 410-333-3775 para programar una visita al consultorio.
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MEXICO CITY (AP) — About a dozen Honduran migrants who lost legs and arms after falling from trains during northbound journeys across Mexico asked the country's Senate on Tuesday to stop the government's persecution of Central Americans, protect them from criminal gangs and contribute money to shelters for their care.
The migrants say that drug gang members and other criminals frequently beat, stab or push them from moving trains during their journeys through Mexico to the United States.
The migrants wore prosthetic limbs — in some cases, for both legs — and pinned-up shirt sleeves in place of missing arms. They expressed hope that Mexico would agree to allow them transit visas or free passage without documents to cross the country on their way to the U.S. border.
Jose Luis Hernandez, the leader of the Association of Disabled Returning Migrants, said the group hopes to meet with President Enrique Pena Nieto to discuss their demands. Hernandez said there are 452 mutilated migrants from Honduras alone, and more from other Central American countries.
"We have hit bottom," Hernandez said. "It is no longer even news when two people die on 'The Beast,' or that somebody fell under the train and lost his legs," Hernandez said, referring to the train that travels through southern Mexico that migrants call "La Bestia."
Criminal gangs often board the trains to rob migrants, many of whom have relatives in the United States. They are sometimes kidnapped and held until their families send ransom payments.
The migrants are often afraid to report such crimes for fear they will be deported, and some accuse police in Mexico of turning detained migrants over to the gangs, or robbing them themselves.
Hernandez said migrants believe that railway employees work with criminal gangs by slowing down to allow them to board the trains. "There is a plot that involves the engineers and the railway guards, it's all about extorting money from the migrants," he said.
A criminal complaint filed last week by prosecutors in the southern Mexico state of Veracruz alleges that railway companies or their employees have been complicit in crimes committed against migrants riding their trains. Ferrosur, a Mexican rail line, and KCSM, a subsidiary of the U.S. railway Kansas City Southern, noted that migrants board their trains illegally, and said they were doing everything to cooperate with authorities.
"The guidelines of KCSM state that security personnel must respect the physical safety of those who travel illegally on the trains," the company said in a statement.
Ferrosur said it "provided full cooperation" with Mexican immigration agents.
But Hernandez said immigration agents shouldn't be pursuing migrants who don't want to stay in Mexico and only wish to reach the United States.
In 2008, Mexico removed rarely enforced criminal penalties of 1 ½-10 years in prison for migrants in the country illegally. Being an undocumented migrant is now a minor offense punishable by fines. But then, and now, most migrants have simply been deported.
Rather than deportation, Hernandez's group is calling on Mexico to provide transit visas to guarantee safe passage of central American migrants through the country, something that Mexican Congresswoman Amalia Garcia said "is possible," with some legal changes.
Hernandez also said migrants want federal police officers aboard the trains — not to catch migrants, but to protect them from criminals.
He also expressed hope that Mexico's government would help support migrant shelters, most of them run by Roman Catholic relief and charity organizations. Such shelters could have made the difference for Hernandez, who lost an arm, a leg and part of his other hand when he fainted and fell on the tracks in the northern state of Chihuahua in 2005 after 20 days of riding the train, not eating and hiding from police.
Sen. Gabriela Cuevas, who met with the migrants, said that Mexico should give migrants the same kind of protections it demands from the United States when Mexicans are deported.
"We are no model of what we demand from the United States," Cuevas said. "It would be nice of Mexico could become an example of what we are demanding."