Early intervention, predictive modeling help curb claims
September 11, 2011 – 6:00am
Chronic pain is an infrequent but growing aspect of workers compensation claims, but employers need concrete programs with measurable outcomes to respond to and reduce those types of injuries.
Dr. Gary Franklin, medical director for the Department of Labor and Industries in Washington state, which administers the state-run workers compensation insurance fund, said experiencing chronic pain is equivalent to becoming disabled.
From his experience, “everyone who remains in the system (after five months) is disabled,” he said. “If you are not putting most of your effort” into preventing an injury from developing into chronic pain and therefore long-term disability, “you’ve lost the ballgame.”
In March, Washington state’s governor signed legislation into law to further establish medical homes to treat injured workers according to the state’s best practices, and support monitoring patients for their entire recovery period.
Chronic pain is not defined precisely.
Dr. David Deitz, vp-national medical director for Liberty Mutual Insurance Co. in Boston, defines the situation as “any injury in which pain is as important as the disease and (the duration) is beyond the normal course of the injury.”
According to the Institute of Medicine, chronic pain affects more than 116 million U.S. residents—more than heart disease, cancer and diabetes combined—and costs up to $635 billion a year in medical treatment and lost productivity.
Some people view pain as something “to work through,” while others find it “difficult to maintain a positive attitude,” Dr. Deitz said. Treatment depends on the individual patient’s needs, but may include orthopedic, neurological, rehabilitative and psychological professionals.
A rise in claims involving chronic pain “coincides with an increase in the aging workforce,” who are more likely to have other conditions or diseases, said Steven Iler, president of domestic primary claims at Chartis Claims Inc. in New York.
To prevent an injury from becoming a chronic pain claim, early intervention is required, said Maureen McCarthy, senior vp of workers compensation claims and managed care at Liberty Mutual.
Ms. McCarthy said the predictive modeling that Liberty Mutual launched in June “helps identify soft-tissue small kinds of claims that have the likelihood of escalating into high-cost claims. There’s a disproportionate percentage of very simple soft-tissue claims that can become very serious,” she said.
The model uses factors such as smoking, early treatment with narcotics and doctor shopping to flag claims that have the potential to escalate.
A predictive model also has been undertaken by grocery retailer Ahold USA Inc. in collaboration with its actuary, said Libby Christman, Ahold’s Carlisle, Pa.-based senior director of risk management. The unnamed actuary is building a model based on 10 years of the company’s workers comp data, Ms. Christman said. The grocery retailer expects the model, using factors about the claims and the incident, to create awareness of a claim’s potential severity within 30 days of the injury.
Red flags, said Chartis’ Mr. Iler, include patients with unrealistic expectations or those who are unwilling to cooperate, the absence of clear treatment goals, extended use of injected drugs or a doctor’s opinion that the patient is prolonging treatment for their symptoms.
The insurer’s peer-to-peer intervention with doctors has had a 40% success rate in getting them to stop prescribing narcotics outside of appropriate treatment guidelines, said Don Hurter, senior vp of medical management for Chartis in Orlando, Fla.
Messrs. Iler and Hurter said the proactive approach, which the company calls Pre Injury Management, encompasses educating employers to identify injured workers’ pain and to understand treatment goals to enable an early return to work. Other steps, including preparing job descriptions to facilitate a stepped approach to modified-duty jobs have resulted in yearly increases in the number of employees who return to work after 21 days and 60 days, Mr. Iler said.
Preinjury management at Ahold starts with physical evaluations for associates offered warehousing jobs to ensure they can handle the physical demands, Ms. Christman said. The risk management department also conducts ergonomic evaluations on new equipment, certain work-area designs and work processes. Other efforts include having safety specialists meet with employees who have minor pain to change how the worker does their job.
Washington state’s Dr. Franklin said there are several early steps to take when an injury occurs: Screen for disability risk, emphasize graduated exercise, get the patient back to work, track the doctor’s activity and coach the employee.
Employers must have a plan and communicate it to supervisors, said Tom Lynch, chief executive of consultant Lynch Ryan in Wellesley, Mass. Supervisors also must be trained to “treat the employee as if he or she is still valued,” he said.
A list of modified-duty jobs can be drafted by asking supervisors to list projects they would like to have done but don’t have time to complete, Mr. Lynch said. Tailor the list to accommodate different injuries. Have health care providers review it. Then monitor how well-suited the job is to the injury and the employee’s performance, he said.
Doctors must specify to employers an injured worker’s capability for light-duty or modified-duty work, said Kim Haugaard, vp medical units at Texas Mutual Insurance Co. in Austin. “Don’t let the employee sit home and focus on what’s causing them pain,” Mr. Haugaard said. “Show an interest in the employee. That really goes a long way.”
“An employer should be very clear about their return-to-work program with their insurer or third-party administrator and also with the health care providers,” said Ms. Christman. Her team often meets with health care providers to explain job modifications and build trust so doctors are not afraid to allow an employee to return to a modified-duty job.
The most alarming problem that employers face is the long-term use of narcotics to treat an employee’s chronic pain.
Insurers are monitoring opiate prescriptions, watching for those that exceed 60 days and using peer-to-peer medical review to combat this problem.
“Sometimes when a doctor sees a patient’s drugs listed line item by line item, it’s a little shocking,” said Texas Mutual’s Mr. Haugaard. “The doctor may not realize that the patient has been on a drug for 11/2 years.” The insurer will encourage a step-down program to gradually reduce and eliminate an injured worker’s opiate prescriptions or pay for a detoxification program, if warranted.
Employers are doing the same. Oklahoma City-based Hobby Lobby Inc. has intensified a front-end monitoring program in conjunction with its TPA to be alert to instances where treatment of a minor soft-tissue injury has escalated to stronger medication at higher doses, said Fay Collier, assistant risk manager. They will discuss treatment approaches with the physician, sometimes bringing a nurse case manager on the team to communicate with the physician and injured worker and oversee treatment.
The craft and hobby retailer also recently began pharmacological reviews of longer-term claims for excessive narcotic use and other signs of ineffective or harmful treatment.
Employers also should, with their insurer’s help, establish a benchmark against which to measure performance of their post-injury plans. Mr. Lynch recommends charting loss costs per $100 of payroll for a specific job classification.