Keynote Speaker Driven to Improve Health Care
2014 NWCDC opening keynoter speaker Dr. L. Casey Chosewood, senior medical officer and director of the Office for Total Worker Health Coordination and Research at NIOSH.
Employers and workers’ compensation payers have grown increasingly interested in delivering quality health care that mitigates the rising costs of chronic health conditions, lengthy disabilities, and stubborn claims.
Yet determining what defines quality health care remains a challenge.
That is why the National Workers’ Compensation and Disability Conference® & Expo selected Arthur M. Southam M.D. to deliver the opening keynote presentation at this year’s event scheduled for Nov. 11-13 at Mandalay Bay in Las Vegas.
Southam is executive VP health plan operations for Kaiser Foundation Health Plan Inc. and Kaiser Foundation Hospitals. He is known for driving measured improvements in medical care quality delivered by Kaiser, which serves 9.6 million health-plan members. As a speaker, Southam is also respected for captivating audiences with his passion for health care.
“Kaiser is an organization that has achieved multiple awards in terms of clinical excellence and the highest star rating from Medicare and medical group health programs,” said Denise Gillen-Algire, director, managed care and disability in corporate risk management for Albertsons Safeway Inc., and the conference’s program co-chair.
The keynote will focus on “leveraging what organizations have been able to do on the group health side and how we can use those tools in workers’ comp, and why that is important to employers.”
“So many organizations talk about either quality-focused networks or provider quality or quality outcomes, but how do you define ‘quality’ and how do you get there?” — Denise Gillen-Algire, director, managed care and disability in corporate risk management, Albertsons Safeway Inc.
Kaiser is the recipient of multiple awards from a variety of organizations, including the National Committee for Quality Assurance, U.S. News and World Report’s Top Hospitals, the Leapfrog Group, and J.D. Power and Associates.
“So many organizations talk about either quality-focused networks or provider quality or quality outcomes, but how do you define ‘quality’ and how do you get there,” Gillen-Algire said. “That’s how we came to Dr. Southam for the presentation.”
Several studies from leading workers’ comp research organizations have suggested that injured workers with comorbid conditions such as diabetes, obesity, and hypertension have higher costs per claim and longer disability durations. Thus, employers and other claims payers are increasingly interested in quality health care that can help improve claims outcomes when more injured workers suffer from those conditions.
“That’s the context. So if that’s the case, how do you check the quality of your providers, hospitals, your delivery system,” said Cyndy Larsen, area vice president for Kaiser On-the-Job, sales and account management. “Dr. Southam will discuss how did [Kaiser] get from where we were maybe 10 or 20 years ago to all these outside parties — like the NCQA, Leapfrog and J.D. Power and Associates — ranking us up there. What types of things had to be in place?”
Employers need to understand the importance of employees’ overall health and its impact on the workers’ comp system. Conference organizers say Southam’s experience on the group health side can demonstrate how workers’ comp can make similar improvements that lead to better outcomes.
“Really, group health is the bigger piece of the pie, and when you think of (the nation’s) total medical spend, workers’ comp is 2 or 3 percent,” Gillen-Algire said.
As Gillen-Algire explained, injured workers should be viewed in terms of their overall health, not just the occupational injury at hand.
“That’s absolutely a focus,” she said. “You can’t split a person into pieces. A person doesn’t come to you as a 2 percent problem over here and the rest over here in group health. [It’s important to] be able to tie what organizations are doing on the group health side and why that is important for workers’ comp in employee health outcomes.”
Southam will deliver the opening keynote address, Achieving Excellence in Medical Treatment, on Wednesday, Nov. 11 at Mandalay Bay.
Take a Proactive Approach to Reduce Opioid Liability Risk
Workers’ comp payers are increasingly on the hook for problems related to opioids prescribed for injured workers, according to a new report. The National Safety Council examined several recent cases and issued a warning and suggestions for employers and insurers to take steps to protect injured workers and themselves.
“Recent court decisions have determined that in certain circumstances, overdoses suffered by injured workers from opioid pain medications prescribed for occupational injuries are compensable by the workers’ compensation insurer,” the report noted. “Employers and their workers’ compensation insurance carrier have been ordered to pay for detoxification and medical-assisted treatment services as well as death benefits to surviving family.”
The NSC cited more than two dozen cases from state appellate or state Supreme Court decisions between January 2008 and March 31, 2015. “These cases demonstrate that it is not a regional issue but a national problem meriting employer and workers’ compensation program action,” the report said. “The courts relied on several key legal concepts.”
Proximate cause, for example, is identified as “any legally recognizable set of facts which, in natural or probable sequence, produced the individual’s injury.” If a worker slipped on spilled water at work and sustained an injury, the spilled water is the proximate cause of the injury.
The “chain of causation” determines whether any injury after the original is related to the workplace injury. Sometimes a separate action by the injured worker can be considered an independent intervening act, or superseding cause. In such a case, the intervening act breaks the chain of causation and ends the liability for the workplace injury.
“For the cases reviewed in this paper, the chain of causation is clear,” the report said. “A workplace injury occurred. The injured worker received treatment that included prescription pain medications and subsequently died of an opioid-related prescription drug overdose. The legal question at the center of all these cases is whether an intervening action broke the chain of causation to the workplace injury.”
States differ in their workers’ comp laws and rules of evidence. Nevertheless, in the majority of cases noted in the report overdose deaths of injured workers may be compensable “even when the medication is not taken as prescribed, taken with alcohol or inappropriately prescribed.”
Employers and insurers are advised to reduce their risks and potential compensable costs related to the use of opioid pain medications in workers’ comp claims by:
- Requiring workers’ compensation and network providers to use opioid prescribing guidelines issued by the American College of Occupational and Environmental Medicine. These include guidelines on opioid prescribing thresholds and recommend precautions for the prescribing provider. Among the precautions are undertaking thorough patient histories with a more detailed screening if the treatment is to continue beyond two weeks, urine drug monitoring, checking the state prescription monitoring database, avoiding co-prescribing benzodiazepines with opioids, and discontinuing treatment when patients have reached meaningful functional recovery.
- Using caution and requiring prior approval for the use of methadone to treat chronic noncancer pain.
- Screening injured workers for depression, mental health conditions, and current or prior substance use.
- Requiring all pharmaceuticals be purchased and managed by a pharmacy benefit manager.
- Educating all workers about the hazards associated with prescription pain medication use. “Many workers do not understand the unique risks and dangers posed by opioid pain medications,” the report said.
Many Small Businesses Hazy on Red Flags for Fraud
Nearly one-quarter of employers surveyed are unsure they can identify workers’ comp fraud. Even more say they have installed surveillance cameras to monitor employees on the job.
Those findings are included in a survey that showed more than 1 in 10 small business owners are concerned their employees would commit workers’ comp fraud by faking an injury or illness.
Employers Holdings, a holding company with subsidiaries that are specialty providers of workers’ compensation insurance and services, facilitated a telephone survey in May with a national representative sample of 501 small businesses that have fewer than 100 employees.
“There is no silver bullet when it comes to identifying claim-related workers’ compensation insurance fraud.” — Ranney Pageler, vice president of fraud investigations, Employers
“Workers’ compensation fraud is a serious crime that can strain business operations, lead to higher insurance costs for businesses, and even undermine honest workers who are legitimately injured on the job,” said Ranney Pageler, vice president of fraud investigations at Employers.
“When we look at fraud cases that result in criminal convictions, about half of them are caught within the claims process itself and the other half are tip-offs from the employee’s coworkers, friends, or family members, or from workplace surveillance video.”
Respondents to the survey cited various activities as potential indicators of workers’ comp fraud. More than half said “the employee has a history of claims,” “there were no witnesses to the incident,” “the employee did not report the injury or illness in a timely manner,” and “the reported incident coincides with a change in employment status.”
Pageler said within the claim examination process, common red flags include an employee using a false Social Security number, having previously undisclosed injuries or medical conditions, or having a permanent total disability claim with total medical costs of less than $500 over a 12-month period.
“There is no silver bullet when it comes to identifying claim-related workers’ compensation insurance fraud,” he said. “Instead, you’re looking for a pattern of events or multiple indicators that suggest something may be amiss.”
Additional warning signs may include:
- The alleged injury occurs first thing on Monday morning or late on Friday afternoon but is not reported until Monday.
- The reported accident occurs immediately before or after a strike, job termination, layoff, end of a big project, or the conclusion of seasonal work.
- An employee’s medical providers or legal consultants have a history of handling suspicious claims, or the same doctors and lawyers are used by groups of claimants.
- The employee’s description of the accident conflicts with the medical history or injury report.
- The allegedly disabled claimant is hard to reach at home and does not respond promptly to messages.
“Employers who suspect an employee may be committing claim-related workers’ compensation insurance fraud should first alert the special investigations unit or fraud unit within their insurance company’s claims department,” the company advised. “The appropriate law enforcement authorities will likely be brought into the investigation, as well.”