The rehabilitation specialist was taking the elevator up to her office at a North Shore health care facility in January when the bottom literally dropped out of her world.
Just as the elevator was about to reach the second floor, it stopped and plunged to the basement, sending shock waves through her body on impact. Her boss took her to the emergency room, where she got a CT scan of her back and instructions to see her primary care provider the next day. Over the next few months, she was diagnosed with compression injuries in her back, displaced ribs, soft tissue damage in her shoulder, and a concussion and vertigo from whiplash.
Because she was injured on the job, the rehab specialist — who asked to be identified by her middle name, Marie, to avoid interfering with legal action involving her accident — filed a workers’ compensation claim.
Employees injured on the job are eligible for the benefits, which must be provided by employers, that cover a portion of lost income and all medical care the workers’ comp insurer deems necessary and work-related. Standard employer-sponsored health insurance doesn’t cover work-related injuries, although it may pay for treatment denied by workers’ comp.
Marie struggled to get workers’ comp insurance to approve her care, but she also ran into another, more unexpected obstacle that has long plagued injured employees across the state: Doctor after doctor turned her away because they refused to take workers’ comp.
In Massachusetts, lawyers and health care providers who deal with the workers’ compensation system describe it using words like “ridiculous,” “dysfunctional,” and “tragedy.” And much of it revolves around the fact that in Massachusetts, the reimbursement rates established for medical professionals who care for injured employees are among the lowest in the country.
Combined with the administrative hassles of using a separate billing system for workers’ comp payments, and the review process doctors’ diagnoses must undergo before treatment is approved, the low payouts mean many medical providers in the state simply won’t treat injured workers. And the delays in care can lead to worse health outcomes and longer absences from work.
“It’s a broken system for everybody involved,” said Lee Okurowski, an occupational medicine doctor and chief executive of the Occupational & Environmental Health Network consultancy in Marlborough. “The system drives providers away from wanting to care for these people, and that’s the tragedy. . . . In a state like Massachusetts, which is a health care mecca, it’s surprising how poor access to care for injured workers is.”
Medical providers who treat injured employees in Massachusetts are paid by workers’ comp carriers according to rates established by the state. Those rates, which can be negotiated, haven’t been updated since 2009, and in many cases, providers’ payments from workers’ comp insurance are less than those from Medicare, which are notoriously low. Overall, workers’ comp rates in Massachusetts are 5 percent below state Medicare rates, the lowest level of the 44 comparable states studied, according to the Workers Compensation Research Institute in Cambridge; in Nevada, on the other hand, the workers’ comp rates are 163 percent higher than Medicare rates there.
Compared to other states, workers’ comp rates in Massachusetts are 35 percent below the median — the lowest nationwide — and when the high costs of practicing medicine in Massachusetts are factored in, the state’s rate falls to 42 percent below the median.
And all that adds up to many doctors choosing not to treat people who were hurt on the job.
Most of the occupational medicine doctors trained at the Harvard School of Public Health leave the state to practice because of the workers’ comp situation, said Thomas Winters, president of the Occupational & Environmental Health Network, who teaches at the school. The number of occupational medicine clinics dedicated to worker care in Massachusetts has dropped precipitously, he said, from more than 50 about two decades ago to only a handful today.
“They don’t reimburse, so they ain’t coming,” Winters said.
The state declined to respond to questions about the status of workers’ comp or if any changes are in the works.
After her elevator accident, Marie struggled to get her workers’ comp carrier to cover the MRIs, CT scans, and physical and occupational therapy her primary care provider recommended. But it was her search for a neurologist — to assess an apparent concussion related to the whiplash she experienced — that was particularly problematic. Marie called four neurology centers on the North Shore, including one that had been treating her migraines for years, with no luck. Finally, after trying in vain for weeks, she called her state senator for help. It was only after a staffer at Senator Bruce Tarr’s office intervened that she was able to get an appointment at one of the providers that had previously turned her away.
She started getting nerve-block injections in the base of her skull, paying with her employer-sponsored insurance and fending off questions about whether the injury was work-related. She’s also getting physical therapy and occupational therapy using her private insurance; supplements for the ringing in her ears, paid for out of pocket; and acupuncture, which she initially paid for herself but stopped getting because she couldn’t afford the $75 appointments.
After initially declining to pay for spinal injections to reduce the inflammation in Marie’s back, workers’ comp approved the procedure, but her attorney is still fighting to get the workers’ comp insurer to pay for the rest of her treatments.
“Almost every day I have appointments because of all the injuries that I have,” said Marie, who is still out of work. “We’re Massachusetts, that’s what we’re famous for, protecting the people. . . . You shouldn’t have to be somebody who knows you can call your senator’s office in order to get care.”
Health care providers can negotiate higher reimbursement rates from workers’ comp insurance carriers, resulting in a lopsided system in which rates for neurology and neuromuscular testing are 37 percent below Medicare rates in Massachusetts, for instance, while major surgery is 106 percent above Medicare rates.
Along with low reimbursement rates, the hassle of dealing with workers’ comp insurance is another reason medical providers shy away from taking it, said Brendan Carney, a Boston attorney who has represented hundreds of injured workers struggling to get their treatment covered, including many building trades union members. The paperwork and the review process create a mountain of red tape for busy doctors, he said.
“It’s just too much of a headache,” Carney said.
Indeed, at North Shore Neurology in Beverly, the practice that finally agreed to see Marie, the office manager said the center doesn’t take workers’ comp because it would require hiring a full-time employee just to handle the claims.
As with any injury, getting treatment quickly is key to recovery. The longer an injured worker is off the job, research shows, the less likely they are to ever return to the workforce. And if people lose their jobs, Carney said, they’ll likely turn to MassHealth, the state’s publicly funded health insurance program.
“It’s shifting the cost of the workplace injury from the employer and the insurance company to the taxpayers,” Carney said.
Delays in treatment can also end up costing the workers’ comp insurance carrier. Acton attorney Steven Kantrovitz represented a worker who injured his hip on the job in the fall of 2021, and a legal battle over reimbursement rates caused the surgery to be delayed until earlier this year. During that time, his client’s condition worsened, driving up the cost of the surgery by $5,000, in addition to the $65,000 in weekly benefits the insurance company had to shell out to compensate for the worker’s lost income.
“It’s moronic, but this is what happens,” Kantrovitz said.
For underserved populations, the problems are compounded. Hotel housekeepers, for example, have physically demanding jobs and tend to be first-generation immigrants who may not know how to advocate for themselves if they get hurt, said Okurowski, the occupational medicine doctor.
“That’s where this system really breaks down, is for the high-labor, low wage-earning individual,” he said. “Imagine trying to navigate this system with a language barrier. It’s just brutal.”