Medical Funds in California Employees’ Compensation System Present Results of Coverage Adjustments

Medical Payments in California Workers? Compensation system View the effects of policy changes

  • 12/03/20

Cambridge, MA ( – According to a recent study by Workers Compensation Research, medical payments per claim in California were typical of other states for claims experience through 2019 (2016/2019), the impact of a Comprehensive Reform Legislature Institute (WCRI). In previous years, medical payments per claim in California were higher than usual.

Average payments in California reflected the impact of several policy changes, including Senate Bill (SB) 863, a drug formula, and two anti-fraud measures. Overall, medical payments per claim have been stable since 2015, after a decline after SB 863 came into force in 2013. The average payment outside the hospital per claim has been relatively stable since 2015 and decreased by an average of 2 percent per year for claims after 12 months. Experience shows that hospital payments per claim rose by 5 percent per year.

Per claim payments for non-hospital professional services varied by service, and the prices paid have been the main driver of the per-claim payments trend for most non-hospital services over the period since 2013.

“Consumption of non-hospital services has been stable overall and for major non-hospital services in California since 2013, despite some fluctuations from year to year,” said Ramona Tanabe, WCRI executive vice president and counsel. “The prices of professional services in California have changed little since 2017, having increased moderately from 2013 to 2017 during the four-year transition to the Resource-Based Relative Scales (RBRVS) fee structure.”

CompScope ™ Medical Benchmarks for California, Edition 21, compared California with employee compensation systems in 17 other states. For the study, WCRI analyzed the compensation claims of employees with experience up to 2019 for injuries up to and including 2018.

Other results of the study include:

  • Outpatient hospital payments per claim rose by 7 percent per year from 2015/2016 to 2018/2019.
  • The payments for facilities of the Ambulatory Surgery Center (ASC) per service increased rapidly from 2016/2017 to 2018/2019, while the services per incident decreased.
  • The percentage of claims in ASC facilities and the percentage of claims in outpatient hospital services decreased, possibly due to a decrease in the operation rate.
  • Average prescription payments per claim, which were higher than typical for 2013/2016 claims, became the lowest of the study states for claims 2016/2019.

Many are wondering what impact COVID-19 will have on government employee remuneration systems. Tanabe says, “While the full impact is currently unclear, the CompScope ™ studies will be a useful basis for monitoring the impact.”

To learn more about this study or to purchase a copy, visit The report was written by William Monnin-Browder and Rebecca (Rui) Yang.

Cambridge-based WCRI is recognized as a leader in providing high quality, objective information on public policy issues related to employee compensation schemes.


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