Sensors Show Promise for Recovery and Prevention
Emerging technologies in biomechanics offer huge promise for the workers’ compensation world.
Take the Motus Pro: a multi-sensor training tool that tracks the throwing and batting movements of baseball players, particularly those who are rehabilitating from injuries.
Developed by the Massapequa, N.Y.-based biomechanics software and analytics firm Motus, the sensor provides feedback to baseball teams’ medical staff to aid in their return-to-play programs.
But the firm has always set its sights beyond baseball, developing its physics engine, hardware and training tools in a manner that would allow the firm to eventually address the larger population beyond athletes, said co-founder and chief executive Joe Nolan.
“We are starting to work on early projects with partners outside the world of sports to refine applications that can be applied to worker safety, human performance optimization and evidence-based, quantified-outcome physical therapy programs,” Nolan said.
There are dozens more products like the Motus Pro that could have a place in the workers’ comp industry, including some of the wearable technology currently being used in baby sensors and monitors to track fetal movement in the womb, said Zack Craft, vice president of rehab solutions, complex care education at One Call Care Management in Jacksonville, Fla.
Wearables could be used in the ergonomics space to potentially prevent carpel tunnel syndrome by monitoring the position of the elbow, total muscles used and the speed of muscles being used by employees during the workday, Craft said.
If a worker has already filed a claim for carpel tunnel, the tool could be used to monitor appropriate positioning and could validate recommendations and potential retraining by providing solid outcome data.
“The small sensor is easily attached using a plastic clip on a glove or through the use of a compression garment,” he said. “For individuals working in an office environment, a very simple postural device can really help them learn to avoid poor positions and improve their posture.”
Wearable technology also has the potential to benefit clinical studies, Craft said. An example is the impact wearables can have on paraplegic patients in the prevention of shoulder injuries such as rotator cuff damage.
Sensors could be used to evaluate the movements of paraplegics in wheelchairs to determine whether they are properly forming a full propelling stroke to avoid damage to their wrist or shoulders.
“This data could then be collected and used to educate the injured worker and any caretakers to prevent the development of bad habits, or to help them relearn appropriate movements,” he said.
“Prevention of these types of injuries is key for paraplegics since the use of their shoulders is critical to complete transfers and pressure shifts.”
Apple recently announced an enhancement to its new Health app to assist wheelchair users in tracking their wheelchair propelling strokes as well calorie burn, periodically reminding them to stay active and take a “roll” around the block, Craft said.
“Wouldn’t it be great if we were able to get an injured worker in physical therapy to upload their exercise information to their workers’ comp treating doctor and claims manager, to see if they were meeting their daily goals?” — Dr. Teresa Bartlett, SVP, medical quality, Sedgwick Claims Management Services
Kathryn L. Havens, assistant professor of clinical physical therapy at the University of Southern California’s Division of Biokinesiology and Physical Therapy in Los Angeles, said that sensors have many great applications, but the difficulty is processing and interpreting all of the data.
Havens has had many discussions with other biomechanists about how to detect certain movement patterns from these velocities and accelerations, because the output from sensors “isn’t so straightforward.”
“I think there is potential and engineers are developing better algorithms for this,” she said. “But at this point we still need trained movement scientists to analyze the data from these sensors in order for the data to be useful.”
Dr. Teresa Bartlett, senior vice president, medical quality at Sedgwick Claims Management Services Inc., believes that technology will eventually be interspersed throughout all of medicine.
“In fact, I am looking for a client that wants to engage some wearable technology in a workers’ comp setting,” Bartlett said. “There are large manufacturers that could benefit from a health and safety perspective.”
Bartlett believes there is a place for such emerging technologies in a manufacturing setting to help prevent worker injuries. For example, sensors could be used by people to prevent elbow and shoulder injuries, to understand mechanics, thrust and the amount of energy it takes to perform certain jobs.
Moreover, existing technologies like the Apple Watch or Fitbit could help mitigate low back strain by getting workers to walk more during the day, Bartlett said.
“Wouldn’t it be great if we were able to get an injured worker in physical therapy to upload their exercise information to their workers’ comp treating doctor and claims manager, to see if they were meeting their daily goals?”
It would also help practitioners better understand if injured workers are being compliant with the quality of their exercise programs and to understand duration and intervals, she said.
For example, practitioners could determine whether workers are walking only in small increments such as one-minute intervals to the bathroom, whether they are walking five miles in one exercise period, or whether they’re walking five miles in one-mile increments.
“This information could make a big difference in their treatment plan and discussion with their doctor or nurse case manager,” Bartlett said.
Attitudes Shift on Medical Marijuana
The tide is turning towards paying workers’ compensation claims involving medical marijuana, but many payers remain reticent.
Industry professionals would prefer that the federal government stop classifying the drug as an illegal controlled substance before paying such claims.
Four states — Connecticut, Maine, Minnesota and New Mexico — approved workers’ comp reimbursement for the use of medical marijuana, at least publicly, according to Mark Pew, senior vice president at PRIUM in Duluth, Ga.
Courts in New Mexico ruled that carriers must pay for marijuana if a doctor in that state recommends it as part of a claimant’s treatment.
However, some carriers are defying the state court’s order, arguing that it’s illegal under federal law. Still, there seems to be an ongoing shift in risk management and insurance toward paying claims that involve marijuana use.
“I think increasingly, more people with whom I’ve spoken are open to the possibility — that includes physicians, nurses, claims adjusters, and those that influence decisions,” he said.
“They will review based on the clinical efficacy for that particular patient.”
However, not everyone is convinced, as the studies conducted on marijuana are not as definitive as those for FDA-approved drugs, Pew said.
Moreover, professionals still point to the fact that marijuana is classified as illegal by the federal government.
Paying claims for its use could create a legal quandary.
“I think those that not convinced are still the majority of the workers’ comp industry,” Pew said.
“It is a loaded question, because marijuana is a divisive and partisan issue, and personal biases of individuals within the workers’ comp system influence their perceptions on it.”
On top of this, payment decisions based on utilization reviews (UR) are problematic because there are no medical guidelines for medical marijuana, Pew said. In some states UR is the arbiter, in other states UR is but an opinion, and in still others, UR is not supported.
Within workers’ compensation, the two treatment guidelines most used by states are Official Disability Guidelines and ACOEM, although some states have created their own. None currently recommend the medical use of marijuana, regardless of condition.
As such, if UR decisions rely on those guidelines, “the answer would be ‘no’ ” on payment for the drug use, Pew said.
But when reimbursement decisions are made outside of UR, individual biases on the subject of marijuana could have an impact, he said.
“Some will absolutely not consider marijuana as medicine and refuse reimbursement,” Pew said.
“Others may have personal experience or know someone that cannabis helped and be willing to consider it.”
“At no time in our history has a state government required the reimbursement for use of a substance that is illegal under in the eyes of the federal government.” — Nichole Wilson, director, pharmacy product development, Coventry Workers’ Comp Services
When it comes to evaluating the clinical efficacy of medical marijuana, practitioners should look at whether benefits exceed the risks, level of function and activity, quality of life, and whether the addition of medical marijuana could help discontinue the use of such dangerous drugs such as OxyContin, Alprazolam, Xanax and Soma, he said.
“In other words, evaluate the appropriateness of cannabis as you would any other drug or treatment — does it work or not for that specific patient? That has been the case in the four states where reimbursement is being done, and the way in which the tide seems to be turning,” Pew said.
The use of medical marijuana for chronic pain is growing more and more popular — as of February 2016, 26 percent of all registered medical cannabis patients in New Mexico usde it for chronic pain, Pew said.
Moreover, 46 percent of registered patients use it for PTSD.
These numbers include all registered patients, not just injured workers, but those conditions are obviously applicable to workers’ comp.
Chronic pain is typically included as a qualifying condition for medical cannabis programs around the country, with Minnesota adding a very narrowly defined “intractable pain” to its list of approved uses as of Aug. 1.
“All of this means that medical cannabis is a burgeoning issue, with evolving science and opinions, and is absolutely pertinent to workers’ comp both now and into the future,” Pew said.
“And if marijuana is ever made legal and/or rescheduled at the federal level, the conversation changes dramatically.”
Lisa Anne Forsythe, senior consultant, regulatory business consulting and analysis, at Coventry Workers’ Comp Services in Sacramento, Calif., said “the tide is definitely turning.”
She has been working on the issue from a regulatory, legal and financial/billing perspective.
There were no medical marijuana claims whatsoever until after the recent appellate rulings in New Mexico, the first state in the country to allow medical marijuana as a compensable benefit.
“It simply wasn’t an issue from a legal, regulatory and financial standpoint until then,” Forsythe said.
Paucity of Evidence
Don Lipsy, Coventry’s manager, pharmacy regulatory communications in Tucson Ariz., said there are “burgeoning pockets” of utilization of medical marijuana related to workers’ comp injuries. While Coventry has not had claims, they’ve heard secondhand of claims being paid by others.
“We’re seeing an expansion of use as an alternative to opioids, and my concern is that we might be trying so hard to address the opioid epidemic that we are treating medical marijuana as a silver bullet,” Lipsy said.
“I’m not so sure we aren’t trading one issue for another.”
From a clinical perspective, there are still a lot of people on the fence on whether or not marijuana is useful, said Nichole Wilson, Coventry’s director of pharmacy product development in Omaha, Neb.
“The evaluation of benefits versus risks are on most clinicians’ minds,” Wilson said.
“Since it’s still classified by the federal government as an illegal Schedule 1 controlled substance, there is not a preponderance of clinical evidence evaluating the drug, and that is a challenge to the medical community.”
“The tide is turning towards public acceptance of medical marijuana, with 169 million people living in the jurisdictions that have legalized it.” — Gregory McKenna, vice president and counsel for governmental affairs, Gallagher Bassett Services
Moreover, there’s a lot of concern about possible interactions of medical marijuana might have with other treatments as well as its potential benefits, Forsythe said.
“But there is also comparatively little discussion on the practical, legal and financial implications associated with the adoption of medical marijuana as a compensable benefit at this time, and that is something that really needs to be talked about,” she said.
“That was definitely one of the larger topics within the New Mexico bill. When we tell an insurance company that medical marijuana is a mandated covered benefit, this is precedent-setting — at no time in our history has a state government required the reimbursement for use of a substance that is illegal under in the eyes of the federal government.”
The Federal Conundrum
The liability implications of paying for an illegal substance need to be more thoroughly examined, experts said.
For example, the use of the federal banking system to pay for the illegal drug could that trigger federal criminal action under the Racketeer Influenced and Corrupt Organizations Act (RICO), Forsythe said.
“Financial institutions are loathe to potentially run afoul of RICO and have avoided doing business with dispensaries, etc., due to liability concerns,” she said. “Insurance companies face a similar exposure.”
Gregory McKenna, vice president and counsel for governmental affairs for Gallagher Bassett Services in Itasca, Ill., said the TPA’s workers’ comp resolution managers “are on the front line,” since they decide whether medical marijuana is a compensable treatment.
First, since federal banking restrictions make it illegal for providers of medical marijuana to use FDIC-approved banks, payment to them has to be made in cash, McKenna said. As such, the claimant needs to pay the provider in cash, and then the claimant has to be reimbursed by check.
“Payors have to make decisions to proceed with a reimbursement to the claimant, which is further complicated by a series of federal criminal statutes related to marijuana transactions,” he said.
“This is out of the realm of what we do normally, so it is a new frontier.”
Another significant challenge lies in the fact that the industry has few decision-support tools for medical marijuana, such as clinical intervention to alert workers’ comp decision-makers to potential interactions between medical marijuana and other medications or medical bill review processes to ensure proper dosage or utilization.
“However, the tide is turning towards public acceptance of medical marijuana, with 169 million people living in the jurisdictions that have legalized it,” McKenna said.
“Because of that volume of people, now the DEA and other federal agencies are taking a very careful look at reclassifying medical marijuana to make it legal.”
The agencies are also looking at naming very specific components of marijuana, to determine whether there may be some additional benefits to those components. That could open up additional research to take a clinical look at the efficacy of medical marijuana.
“This and decriminalization could lead to more workers’ comp payments within the industry,” he said.
Craft Incentive Programs With Care
What kinds of safety incentives lessen injuries and illnesses, and what kinds inadvertently discourage workers from reporting?
Safety professionals say it’s all in how an incentive program is structured, and perhaps even more importantly, how the importance of maintaining a safe work environment – especially for workers and their families — is communicated.
In 2012, the U.S. Occupational Safety and Health Administration issued a memorandum calling for employers not to provide incentives that effectively discourage employees from reporting their injuries.
Disincentives include awarding paid time off to a unit that has the greatest reduction in incidence rates or maintaining an injury-and illness-free worksite for a period of time.
“If employees do not feel free to report injuries or illnesses, the employer’s entire workforce is put at risk,” OSHA wrote.
“Employers do not learn of and correct dangerous conditions that have resulted in injuries, and injured employees may not receive the proper medical attention, or the workers’ compensation benefits to which they are entitled.
“Ensuring that employees can report injuries or illnesses without fear of retaliation is therefore crucial to protecting worker safety and health.”
The agency last year issued an updated memorandum that detailed the differences between a positive incentive program and one that discourages reporting.
“A positive incentive program,” wrote the agency, “encourages or rewards workers for reporting injuries, illnesses, near-misses, or hazards; and/or recognizes, rewards, and thereby encourages worker involvement in the safety and health management system.”
The memorandum included examples of positive incentives such as “providing tee shirts to workers serving on safety and health committees; offering modest rewards for suggesting ways to strengthen safety and health; or throwing a recognition party at the successful completion of company-wide safety and health training.”
The agency warned that incentive programs that focus on injury and illness numbers often have the effect of discouraging workers from reporting an injury or illness.
Disincentives to reporting, it said, “may range from awarding paid time off to a unit that has the greatest reduction in incidence rates to rewarding workers with a celebration for achieving an injury/rate reduction goal or maintaining an injury-and illness-free worksite for a period of time.”
“There are also programs that actually defeat the purpose, by telling people that they can get paid if they don’t have accidents. But that sends the wrong message.” — Brent Jones, safety officer, Red River Army Depot
But these are just memorandums, and since there are no hard and fast rules about such programs, many employers are confused about what is now acceptable to OSHA, said Don Enke, director of risk control services at Safety National.
Enke recently spoke about OSHA’s view of incentive programs in a webinar, “Out Front Ideas with Kimberly George and Mark Walls,” sponsored by Safety National and Sedgwick.
“I think what OSHA is looking for is, does your program have characteristics that would compromise safety, discourage reporting a claim, or even delay reporting a claim?’” Enke said.
“They definitely don’t want anything delaying reporting. And they don’t want anybody retaliated against if they report a claim.”
Traditional safety incentive programs often reward employees for having a certain number of days without any injuries. However, that could discourage employees or their supervisors from reporting an injury, a key concern of OSHA’s.
“What I’m seeing in the workplace with various clients is more of a progressive program of leading indicators vs. lagging indicators,” Enke said.
“It’s recognizing employees for various proactive safety behaviors. That is where I’m seeing more progressive programs or employers moving in that direction, where it’s part of their safety culture.
“They’re getting employee buy-in and ownership, and they’re making employees part of the program where they are involved with hazard indications, reporting near misses, reporting unsafe conditions, even involved with audits, training programs — even taking online training courses.”
Tamara Ulufanua-Ciraulo, director of insurance at Stater Bros. Supermarkets in San Bernardino, Calif., said that safety professionals need to review their incentive program to make sure the organization is not pushing people to not report.
For example, at Stater Bros., no single store carries the sole burden of its own claim costs, Ulufanua-Ciraulo said.
Costs are now spread out across all stores, and each store has a pro rata share of the cost based on man-hours and how injuries are reported.
“That way, no one injury can hurt a store’s profit and loss statement, which minimizes a manager’s desire to not report,” she said.
For its employees, Stater Bros. rewards them for engaging in safe practices that minimize injuries. The grocer holds annual recognition parties, with raffle prizes of gift cards, gas cards and apparel, and catered breakfasts for certain years of no reported injuries.
But Ulufanua-Ciraulo believes incentives like these don’t result in employees not reporting, because the company has also changed the culture about safety, with bulletins saying that what’s most important is the employee — not the organization.
“We recognize employees’ good intentions by giving them positive recognition for staying safe,” she said. That has helped dispel any misunderstanding about reducing injury costs being the company’s top priority, which leads workers to not report.
Brent Jones, safety officer at Red River Army Depot in Texarkana, Texas, said it comes down to how safety incentives are structured and then communicated to employees: “The right tools in the wrong hands can always be detrimental to the organization.”
“We do offer safety incentives, but we don’t tie them to injury rates or anything like that,” Jones said. “Instead, we reward for good behavior in trying to reduce injuries.”
The depot has an “on-the-spot” incentive program, in which supervisors can recognize employees for going above and beyond the standards.
For example, supervisors wouldn’t recognize an employee for wearing personal protection equipment, “because that’s what they’re supposed to do.”
But if an employee reports potential safety hazards, that goes above and beyond, so their supervisor can hand them a ticket that can be redeemed at the safety office for a gift, such as glasses, coffee mugs, backpacks, coolers, chairs, umbrellas.
These all have the depot’s safety logo on them, which also helps the safety team’s communication efforts by publicizing the depot’s commitment to safety when employees use these items outside of the workplace.
The program only works if there is good communication, Jones said.
“A lot of programs are poorly communicated and, in my opinion, don’t work,” he said. “There are also programs that actually defeat the purpose, by telling people that they can get paid if they don’t have accidents. But that sends the wrong message.”
If leadership of an organization thinks incentive programs are only there to encourage fewer accidents, then that’s likely going to give OSHA cause to view their incentive program merely as a way to discourage injury reporting, Jones said.
“The message to employees is that they should keep themselves safe so they can go home to their families without injury,” he said.
“That brings it home a little bit with a whole new outlook. How that message is delivered probably means the most, even with an incentive program.”