Roberto Ceniceros

Roberto Ceniceros is senior editor at Risk & Insurance® and co-chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at rceniceros@lrp.com. Read more of his columns and features.

Workers' Compensation

The Balancing Act of Rehabbing Injured Workers

The demanding task of nurse case management grows ever more complicated.
By: | December 10, 2014 • 7 min read
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Putting injured employees at ease, educating cost-conscious employers, and tactfully questioning doctors’ treatment decisions are among the responsibilities workers’ compensation nurse case managers must balance. Added to that, their role has grown increasingly demanding.

More regulatory requirements and claims-payer demands, rising claim complexity, and more service providers involved in a claim’s management make it a very different job today than it was a few years ago, experts said.

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Despite the job’s heightened challenges, however, some things remain the same, said Anne Kirby, chief compliance officer and vice president of medical review services for Rising Medical Solutions.

“I find in hiring nurses that the one thing that hasn’t changed is their interest and their dedication to doing the right thing for injured workers,” said Kirby, a registered nurse.

“I don’t see that that has changed at all.”

Claims-Payer Representatives

While guiding injured workers through workers’ comp medical treatment is a primary job focus, the nurses also represent the interests of employers and other claims payers.

“You either love this [work], or you hate it.” — Kim Weaver, an RN and director of professional services at M Hayes

They often form the front line of claims management to ensure workers receive the proper care necessary to expeditiously return to the job, while making sure payers don’t fund unnecessary claim expenses.

That often requires advocating for workers while collaborating with doctors, attorneys, therapists and other service providers. Other times it requires questioning the necessity of those service providers or their decisions.

“In the world of comp you have people who are welcoming you,” including doctors and patients, said Kim Weaver, an RN and director of professional services at M Hayes, a case management company recently acquired by GENEX Services LLC.

“They want to work with you because they see you as an advocate or as a conduit [for their medical care].”

But there are also physicians who believe insurance industry nurses are only there to delay or stop their treatment plans, Weaver said.

Requesting that a doctor consider a different treatment path requires tact and careful wording to avoid offending egos, said Susan Mitchell, an RN and case manager at The Travelers Cos. Inc.

“It’s all a matter of how you present it to them,” she said. “If you come across saying, ‘Your decision on this treatment is not working,’ then they will get defensive and not want to talk to you.”

She carefully explains to doctors when she observes that a patient isn’t improving and asks the physician if they can “talk about something else that might help” the patient, Mitchell said.

Gaining Worker Trust

A key challenge is winning worker trust, particularly for telephonic case managers who don’t have the advantage of working bedside like a hospital nurse, said Amy Jeffries, an RN and nurse manager for Bunch CareSolutions, a unit of Xerox Corp. providing workers’ comp managed care services.

Injured workers are often scared and confused because they have never before suffered a work injury, so they don’t understand workers’ comp, Jeffries added.

“The biggest challenge is establishing a relationship by phone,” she said. “We don’t have that face-to-face contact so from the very beginning it is very important to work to establish trust.”

That requires following through with all promises.

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“If you tell the injured worker, ‘I am going to call you back two days after your [medical] appointment,’ follow through and do that because by doing that, you establish that level of trust,” Jeffries said.

The same occurs when workers’ comp nurses provide face-to-face care for workers who have suffered previous workplace injuries, according to Mitchell.

“Initially, they are cautious with me,” she said.

“A lot of people, especially if they have had multiple work comp injuries and they have a history with it, look at me like I am representing the insurance company and I’m going to tell them they can’t have this [treatment] or we are not going to approve that [procedure].”

Mitchell is a case manager working under Travelers’ ConciergeCLAIM nurse program that places nurses in medical provider clinics treating injured workers.

She wins injured worker trust with assurances that she is their advocate and by following through with any promises, such as to obtain answers to questions she can’t immediately answer.

Margie Matsui, western nurse case manager for employer LSG Sky Chefs, said she carefully explains to injured workers why she asks specific questions about their injury, prior health conditions and issues such as their normal sleep pattern.

Explaining the reasons for her questions helps build trust while she learns whether she can teach them about measures for improving their health and whether there are medical complications that need addressing.

Challenges and Rewards

Nurses on the front lines also hear from frustrated injured workers venting about the work comp system or their injury status. But unlike bedside hospital nurses working with an unhappy patient for a few days, a case manager may interact with a disgruntled injured worker for months.

You can’t take negative attitudes personally, nurses advised. Do that, and you may not last in the job.

“You either love this [work], or you hate it,” Weaver said.

The work hours and less physically demanding roles are frequently cited reasons RNs leave a hospital to become a case manager, several sources said. Unlike hospital work, case management typically does not require weekends, nights or holidays.

They also apply their professional skill set in a different manner.

Where hospital nurses provide direct care, nurse case managers spend more time evaluating patients to determine whether they are progressing under their current treatment regimen, Weaver said.

That may require collaborating with a physical therapist, for example, to learn whether the patient is improving and whether their physician needs notification that a different program may be in order.

Nurses say they like the job because of the reward of seeing injured employees progress after working to get them the best medical care for their specific needs.

“There is nothing better than at the end of the file when you are getting ready to close it, looking back and seeing the progress that has been made,” Jeffries said.
Jeffries cited the example of a young worker whose hand got stuck in a piece of equipment, causing extensive nerve damage.

“With this particular gentleman, I didn’t leave my desk at the end of the day without thinking about him and thinking about how he was doing,” Jeffries said.

With the right care “he ended up doing very, very well” with very few limitations.

“It was definitely a success given the extent of his injuries in the beginning,” Jeffries said. “That is definitely one I was very proud of.”

Observers commonly think that telephonic nurse case managers may be less caring than hospital bedside nurses, but such experiences prove differently, Jeffries added.

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Meanwhile, today’s nurses are under greater pressure to follow processes and protocols set by insurers, third-party administrators and employers, and they must show a return on investment from their services.

An employer may not immediately agree with a nurse’s care decision even when the decision is based on a professional opinion that spending additional dollars up-front for certain treatment could ultimately result in a speedier recovery, shorter claim duration, and fewer costs in the long run.

“Sometimes doing the right thing for the patient isn’t always seen as doing the right thing by the employer who pays for it all,” said Natalie Rivera, an RN and assistant vice president of clinical solutions at Bunch CareSolutions.

“It’s really balancing those two [demands],” she said. “Doing the right thing for the patient — if you do that, the rest falls into place. But sometimes it’s educating the employer on why this is the right thing to do.”

 

In addition to increased demands to reduce costs and follow processes, nurses now face medical cases that are more complex than in years past. Claims analytics currently help direct nurses only to patients likely to benefit from their services, but that means RNs will see a higher percentage of injured workers with complex claims.

There are also mandated state treatment guidelines that didn’t exist before, rapidly changing treatment practices, and increasingly complicated pharmaceutical regimens, Kirby said.

“It’s a level of complication that nurses just didn’t have to deal with before,” she added.

Yet that doesn’t change one key role for nurse case managers.

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They work to drive collaboration so injured workers, employers, doctors, insurers, and physical therapists, among others, aim for the same goal, said Liz Thompson, CEO at Encore Unlimited LLC, a case management company.

“Our job,” Thompson said, “is to say if this is our goal, and everyone is on the same page, then let’s keep our path real clear about how we are going to get there.”

Read the other installments of our three-part series on nurse case management:

10152014_04_indepth_series_nurse_150x150Part I: On the Case

Payers are looking for spirited nurse case managers who will be patient motivators and advocates, not slaves to process.

11012014_09_indepth_150x150Part II: How Much Is Too Much?

Nurse case managers can provide vital consultation, but contractual limits to the expenses associated with the service are advisable.

Roberto Ceniceros is senior editor at Risk & Insurance® and co-chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at rceniceros@lrp.com. Read more of his columns and features.
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Column: Workers' Comp

Do Not Fail to Care

By: | December 10, 2014 • 3 min read
Roberto Ceniceros is senior editor at Risk & Insurance® and co-chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at rceniceros@lrp.com. Read more of his columns and features.

The New Year may greet many employers with falling prices for workers’ compensation insurance.

But getting lulled into risk-management complacency by lower insurance policy pricing is a mistake, more now than ever due to the increased complexity of workers’ compensation claims.

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The troubling factors we have all heard about during recent years — an aging workforce, obesity, and pharmaceutical trends — are driving more complex claims that are costly and harder to manage.

That is part of the reason you see private equity’s continued purchase of workers’ compensation service providers. Investors are betting more complex claims will drive steady demand for a range of claims services.

Meanwhile, signs point to downward pressure on insurance policy pricing, at least in many jurisdictions.

During 2014, many states announced workers’ compensation rate decreases. Those falling rates will eventually exert downward pressure on the actual price employers pay during insurance policy renewals.

In addition, a Willis Group Holdings 2015 insurance market forecast released in late October reports that workers’ compensation insurance capacity remains abundant. Some workers’ compensation underwriters are cutting back their offerings or raising their attachment points while others are aggressively growing their market share.

Willis predicts workers’ compensation insurance price adjustments will range between a 5 percent decrease and a 5 percent increase. An 8 percent increase is predicted for California, although California rate increases are at their lowest in years, according to Willis.

With the predicted spread in pricing — as some insurers reduce policy prices to gain market share while others tighten up their offerings — it stands to reason that those employers that manage their claims experience well will receive the better policy renewal deals and a broader range of coverage choices when arranging insurance.

Employers that fail to support safety programs that prevent injuries, or fail to take care of their workers once they are hurt, will eventually pay the cost of more complex claims and the increased services those claims require.

It’s easier for employers to grow complacent about safety and claims mitigation practices when the price of insurance declines. Historically, it’s a common enough reaction to insurance market cycles.

But things are different now with the rise of more costly claims.

Those costlier claims will prevent insurers wanting to remain financially viable from cutting deals on accounts with poor loss histories.

Fortunately, I see more instances of large employers increasing their investments in employee health programs and claims mitigation measures. They are concerned about costs driven by today’s potential for claims to become increasingly complex and they are concerned with worker productivity.

Many of the employers I see taking such measures are larger, self-insured companies. They often, but not always, work harder than insureds to reduce losses because they directly feel their claims’ impact. They also have resources to spend on wellness offerings, ergonomists, corporate medical directors and the like.

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But employers with fewer resources can follow their example of taking care of workers.

Regular talks with employees and front-line managers about working safely shouldn’t incur great expense. Likewise, communicating with injured and absent workers to express concern, and hope for a speedy recovery and return to the job doesn’t require a large financial commitment.

Those types of practices do, however, require an employer that cares about its workers and their claims losses.

Employers that fail to care will miss opportunities to gain from a more productive workforce and they won’t be among policyholders enjoying preferred pricing during future policy renewals.

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Improving Outcomes

Taking the Psych Out of Psychosocial

A drive to mitigate psychosocial factors exposes questions about defining them.
By: | December 8, 2014 • 5 min read
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Could taking the “psych” out of the word “psychosocial” help advance emerging strategies for workers’ compensation claims that stubbornly defy resolution?

But without any doubt, workers’ comp payers are increasingly interested in strategies, and willing to pay for services, that mitigate psychosocial factors known to impede the recovery of injured workers and their timely return to work, experts said.

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Workers’ comp service providers, meanwhile, are increasing product offerings for mitigating psychosocial barriers that stall the recovery of workers with physical injuries. Expect the trend to continue as analytical capabilities improve for predicting which claims will benefit from such attention, said Michael Lacroix, a psychologist and director of behavioral health at Coventry Workers’ Comp Services.

“People think ‘psychosocial,’ because [it starts with] p-s-y-c-h-o, we are talking about psychological challenges, that we are talking mental and nervous conditions.” — Ruth Estrich, chief strategy officer, MedRisk

Although attitudes are shifting, workers’ comp payers have been reluctant to address psychosocial problems and there remains lingering confusion over the word’s definition.

Not all psychosocial factors are mental health problems or require the attention of a psychologist or mental health expert, explained Jennifer Christian M.D., president of Webility.md, a management consulting company specializing in workers’ comp and disability.

Psychosocial factors are much broader. They can include economic circumstances, an injured worker’s health illiteracy, cultural influences, coping skills or resiliency, and workplace situations, she added.

Yet the term psychosocial remains stigmatized by a common belief that it refers exclusively to psychiatric diagnosis, which workers’ comp payers historically spent heavily on without obtaining positive claims results, Christian said.

The experience and the word’s prefix drive a predisposition that hampers broader support for addressing psychosocial risk factors.

“Part of issue is confusion over the term psychosocial,” Christian said. “Some people read ‘psychosocial’ to mean mental health problems. In the workers’ comp industry and payer industry, they have poured resources down black holes of ineffective mental-health services so they don’t want do that anymore.”

A fading, but common myth holds that attempts to ameliorate an injured worker’s psychosocial complications will force workers’ comp payers to “buy” psych claims, agreed Ruth Estrich, chief strategy officer for MedRisk, a provider of physical rehabilitation and other services for the workers’ comp industry.

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“People think ‘psychosocial,’ because [it starts with] p-s-y-c-h-o, we are talking about psychological challenges, that we are talking mental and nervous conditions,” Estrich said.

Psychosocial factors include a person’s lack of knowledge about their injury, Estrich explained. For example, a person with a musculoskeletal injury may fear physical activity due to pain when movement would improve their condition and lack of movement cause further deterioration.

“That actually is a pyschosocial issue,” Estrich said. “It is not a biological issue. It has to do with knowledge and education.”

Overall, there is growing acceptance that psychosocial complications, including mental-health issues, are major factors in claimant recovery and drive costs by preventing speedier claim resolutions, sources said.

Several factors are driving growing interest in addressing psychosocial factors, including Americans’ increased willingness to discuss mental health problems and awareness that current measures for resolving difficult workers’ comp claims have reached their limit and more needs to be done, Lacroix said.

“We have probably reached the point where we spend a great deal of money in workers’ comp and we still have a whole bunch of people who are stubbornly not getting better,” Lacroix said. “When you look at that proportion [of claimants] what you find is what prevents them from getting better is not that physicians are incompetent. It’s not that they are malingering. It’s that there are these other comorbidities and among these other comorbidities are pysch conditions.”

Among other measures for addressing the psych component of claims, Coventry case managers now receive training in cognitive behavior therapy concepts and other techniques that help them identify psychosocial barriers preventing an injured worker’s timely return to the job.

There may be a broader array of factors beyond psychological or mental health issues hampering injured worker recovery, Lacroix added. But factors such as cultural influences on a worker’s recovery are harder to quantify than are psychological impediments, he said.

Meanwhile, treatment guidelines tend to focus on psychological issues rather than on the broader array of factors some experts consider psychosocial barriers to worker recovery. That drives insurers’ willingness to pay for psych treatments over paying for non-psych psychosocial factors impacting a claimant, Lacroix said.

But employers are increasingly interested in addressing a broader range of psychosocial problems as they seek solutions for claims that drag on, Estrich said.

“I think we are reaching the tipping point,” she added.

Estrich points to a breakout session held at the National Workers’ Compensation and Disability Conference & Expo this past November. The session on “Overcoming Psychosocial Barriers to Recovery” drew a standing-room-only crowd.

The presentation included Carrie Freeland, manager of integrated leave at Costco Wholesale. She discussed successes the employer has experienced with a Progressive Goal Attainment Program.

PGAP’s approach pairs injured workers displaying psychosocial risks with experts in fields such as physical or occupational therapy.

It is an evidence-based program, meaning it has been proven to work, Christian said. And it tightly limits the number of sessions an injured worker will spend with a professional.

PGAP is “not psychological” because it does not address an injured worker’s past and it is delivered by a variety of professionals such as physical therapists and vocational consultants, Christian said.

Such measures help PGAP assuage the concerns of payers who may otherwise balk at funding psychological services, Christian added.

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“They are trying to get the stigma of mental health providers off of it so payers will be more willing to pay,” she said.

So, could de-emphasizing the “psych” in psychosocial help advance emerging remedies for workers’ comp claims that stubbornly defy resolution?

Perhaps. But the problem remains that there is a lack of a good prefix to replace ‘psycho’ when defining the array of personal, social, and environmental factors which can influence human behavior, Christian said.

Roberto Ceniceros is senior editor at Risk & Insurance® and co-chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at rceniceros@lrp.com. Read more of his columns and features.
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