Discretionary Surgery: A Comparison of Workers’ Compensation and Commercial Insurance

Background: Workers’ compensation is intended for injuries that occur at work and is expected to be mostly for trauma and mostly nondiscretionary conditions. We tested the null hypothesis that there is no difference in the ratio of likely discretionary to likely nondiscretionary surgery between patients treated under workers’ compensation compared with commercial insurance controlling for age, sex, and anatomical site for either traumatic or nontraumatic diagnoses. Methods: Using claims data from the Texas workers’ compensation database and Truven Health commercial claims we classified International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses and procedure codes as likely discretionary or likely nondiscretionary, and as traumatic or nontraumatic. Ratios of likely discretionary to likely nondiscretionary surgery were calculated and compared. Results: Among patients treated under workers’ compensation, the ratio of likely discretionary to likely nondiscretionary surgery was significantly higher for traumatic diagnoses (0.57 [95% confidence interval, CI, = 0.56-0.61] vs 0.38 [95% CI = 0.37-0.40], P < .05) and significantly lower for nontraumatic diagnoses (9.4 [95% CI = 9.20-9.42] vs 13.2 [95% CI = 12.9-13.3], P < .05) compared with commercial insurance. Conclusions: Workers’ compensation often covers likely discretionary musculoskeletal surgery, and insurance type may influence treatment