Workers’ Compensation and the Affordable Care Act

Workers’ Compensation and the Affordable Care Act

Can the Affordable Care Act (ACA) impact the number of workers’ compensation claims in Illinois or the premiums for workers’ compensation insurance? According to a recent article from, both workers and employers in the Chicago area should be thinking about how health care may influence workers’ compensation in our state.

Learning More About Capitated Health Care Plans and Workers’ Compensation

What is the relationship between health care plans and workers’ compensation claims? The link between the two might not be immediately clear, but as we take a closer look at the way in which “capitated” health plans function, we can see how it might be in a healthcare provider’s interest to classify certain injuries as work-related harms.

According to the article, one of the effects of the ACA has been “case-shifting from group health to workers’ compensation.” To understand why this is so, it is important to grasp the growing shift toward Accountable Care Organizations (ACOs). In short, through ACOs, healthcare providers get rewarded when they meet certain goals pertaining to cost and quality. With such goals becoming more prominent under the ACA, we will also see a rise in “capitated” health plans. This is not a term that has an obvious definition based on the name, but its premise is actually a relatively simple one to grasp: under capitated health plans (also called capitated contracts or flat-fee plans), “providers are paid a fixed insurance premium per insured regardless of the amount of care provided to a given patient during the year.”

In other words, traditional health plans typically involve a provider being paid for each service that is rendered, or for each individual visit. So, if you strain your back and need to visit a healthcare provider on four separate occasions, the healthcare provider would be paid for each of those visits and for the individual care and treatments provided at each visit. However, under a capitated health plan, the provider is simply paid a fixed amount for the insured person, regardless of the number of times she seeks care during the year. So, if we go back to the example of a back strain that requires four visits to the same healthcare provider, that provider would still be paid only the fixed rate for the patient—the same amount if she needed one visit or four.

A recent study conducted by the Workers’ Compensation Research Institute (WCRI) emphasized that capitated health plans could drastically impact the number of workers’ compensation claims across the country.

Repetitive Injuries and Work-Related Injury Classifications

Given the way in which capitated health plans function, you can see how it might be in a healthcare provider’s interest to classify a repetitive injury—such as a back injury or carpal tunnel syndrome—as a work-related injury. If an injury is related to a patient’s work, then she may be able to file a workers’ compensation claim. And if she can file a workers’ compensation claim, then a healthcare provider may not need to perform multiple services for a single fixed rate.

The WCRI study underscored that such a pattern already is emerging. For instance, in states with capitated health plans, the following statistics transpired:

  • Back injuries were “30 percent more likely to be called work-related,” and thus paid for through workers’ compensation.
  • Workers’ compensation costs in Illinois could rise by about $100 million if the number of patients with capitated health plans increases from 12 to 42 percent.
  • Soft-tissue injuries were 31 percent more likely to be considered work-related if the patient had a capitated health plan.

The Law Offices of Robert T. Edens, P.C.

If you suffered a job-related injury and need assistance with your workers’ compensation claim, it is important to seek out an experienced workers’ compensation lawyer. Filing a claim can be complicated, but having to appeal a denial can be even more frustrating. You should contact a dedicated advocate at The Law Offices of Robert T. Edens, P.C. to assist with your case.


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