Hearing from Employers
Employer engagement and superior service provider performance are acknowledged keys to successfully managing workers’ compensation claims.
Those employers that care enough to produce great results for their injured workers don’t tend to beat their own drums, though.
But they will get an unprecedented chance to share their strategies and practices on a wide range of workers’ compensation topics at the National Workers’ Compensation and Disability Conference® & Expo at the Mandalay Bay Hotel & Casino in Las Vegas, Nov. 19-21.
Two speakers from Harley-Davidson, for example, will discuss claims-mitigation practices that saved their company millions of dollars. Those practices include integrating a variety of company resources including health services, safety and ergonomics expertise.
They will also tell how Harley-Davidson integrated the services of vendor partners, such as BTE Technologies, which helps return injured employees to the job and keeps others working with a post-offer employment testing program that assesses functional ability to safely perform work, said Beth Mrozinsky, the motorcycle manufacturer’s director of safety and health.
Their work has helped address challenges common in many U.S. workplaces, such as those driven by an aging workforce.
Harley-Davidson’s successes also come from integrating vendor partners to help explore loss-reduction processes. The company is increasingly applying those processes to non-occupational injuries after proving them successful in mitigating occupational issues, Mrozinksi said.
“We work really hard with our vendor partners to really pull this together,” Mrozinsky said. “We are almost like one unit that thinks through these processes.”
In another session, speakers Darin Hampton, workers’ compensation regional coordinator at International Paper, and Jodie L. Massingill, senior manager, casualty claims at Sysco Corp., will share their strategies for successfully overseeing a range of services and how they get the best possible support from vendor partners.
In addition to employers, presenters will include representatives from some of the nation’s largest workers’ comp insurers, third-party administrators, brokers, managed care companies and attorneys specializing in workers’ compensation.
Focus on Medical
A growing trend to improve the quality of medical care delivered to injured workers relies on measuring doctor performance to build networks limited to providers capable of producing the best claims outcomes.
Jane Ish, national networks director for Liberty Mutual Insurance, will present a conference session on outcomes-based networks.
“We believe if you start right with the right physician and his entire medical ecosystem — in terms of who he counts on for referring — then you are more likely to have injured workers go back to work quicker and reduced medical costs,” she said.
Randy L. Triplett, workers’ compensation and integrated disability manager for The Goodyear Tire & Rubber Co., will join Ish in the presentation.
Other current challenges and the tools being applied to mitigate them will also receive prominent attention at the conference.
Jim Andrews, executive VP of pharmacy services at Healthcare Solutions Inc., and David Smith, divisional VP of risk management at Family Dollar Stores Inc., for example, will talk about how analytics and predictive modeling help identify and prevent drug abuse.
The nation’s growing diversity and that dynamic’s impact on workers’ comp and disability management will be examined by Jennifer De La Torre, executive director of workforce diversity at AT&T and formerly the company’s director of risk management.
Elizabeth Demaret, executive VP, chief customer relationship officer at Sedgwick Claims Management Services Inc., will join De La Torre.
De La Torre said considerations of racial and ethnic diversity, treatment of veterans in the workforce and age differences are all impacting workers’ comp management strategies.
Expect to hear session topics not commonly offered at workers’ comp conferences, but that nonetheless have significant impact on the industry and employer programs.
Three private equity executives, whose firms owned well-known workers’ comp companies, will discuss the growing influence of private equity in this business. It is unusual for private equity leaders to address a workers’ comp crowd, said Joe Paduda, principal at Health Strategy Associates LLC.
“Private equity people speak at investor conferences and at some other conferences, but never to my knowledge in a workers’ comp-related conference,” said Paduda, who will moderate the session. “Especially folks like these who actually assess the business, follow the workers’ comp industry and really understand it at both a granular and strategic level.”
Paduda promised to allow plenty of time for audience questions.
“We are going to have an extended question and answer [time] just because there is so much interest in the role of private equity in the workers’ comp business,” he said.
Legal and regulatory issues are also on tap.
The Occupational Safety and Health Administration’s 2013 temporary worker initiative directed its field inspectors to place greater emphasis on assessing whether employers using temp workers comply with their responsibilities.
“There has been a lot of postulation about what the ACA’s impact is on the industry.” —Denise Zoe Gillen-Algire, director, managed care and disability corporate risk, Safeway Inc.
Corey Berghoefer, senior VP, risk management and insurance for Ranstad, a global employment services provider, will join two workers’ comp attorneys to discuss OSHA’s initiative and other risk-management considerations accompanying current growth in temp worker hiring.
“I’ll talk about the duties and responsibilities, and how OSHA will come in during an investigation and view each of the parties,” he said.
The Patient Protection and Affordable Care Act is another current topic that conference speakers will weigh in on at a session titled “Healthcare Reform: Strategies You Can Apply Now.”
“There has been a lot of postulation about what the ACA’s impact is on the industry,” said Denise Zoe Gillen-Algire, director, managed care and disability corporate risk at Safeway Inc. and the conference’s program co-chair. “We want to say, ‘OK, what is the takeaway? What does it mean to employers?’ We want to take that information and say, ‘What can you do as employers to manage your workers’ comp program and either prepare or mitigate some of the impacts?’ ”
William Wilt, president of Assured Research, will join Gillen-Algire.
Here are some other presentations:
Opening Keynote: Integrating Employees’ Health and Well-Being to Improve the Bottom Line
L. Casey Chosewood, M.D., is senior medical officer and director of the Office for Total Worker Health Coordination and Research Support at the National Institute for Occupational Safety and Health. Chosewood will demonstrate how to reduce employer costs by integrating occupational health and safety with health promotion and post-injury management.
Session: Modeling Managed Care for Program Impact
Speakers from two large, self-insured employers and a national workers’ comp consultant will explain managed care services and how to evaluate which ones deliver the best outcomes and greatest cost savings.
Speakers: Barry Bloom, principal at The bdb Group; John Riggs, manager of workers’ compensation, Disneyland Resort; and John Smolk, principal manager, workers’ compensation, Southern California Edison.
Session: Risk Financing: Selecting the Best Option for Your Company
Mark Walls, conference program co-chair and VP, communications and strategic analysis at Safety National, will cover a range of considerations for employers weighing various insurance arrangements. From buying first-dollar coverage and large deductible programs to self-insuring, he will lay out the key considerations for each.
Session: Loss Mitigation of High Value Workers’ Compensation Claims
Hear about risk analysis that can identify old claims previously considered incapable of being resolved. The session will seek audience participation while discussing several cost drivers such as treating-doctor issues and Medicare set-asides.
Speakers: Christianne Quinn, national workers’ compensation manager at Pep Boys; and David R. Kunz, managing partner at Kunz & Germick.
Session: Behavior-Based Safety Program: How You Can Prevent Injuries and Improve Product Quality
Safety and product quality go hand in hand, so a behavior-based safety program stands to improve loss prevention and high-quality production throughout a company.
Speaker: Julia Sfurm, corporate senior risk operations manager, Elkay Manufacturing Co.
Visit www.wcconference.com/agenda.html for a look at the conference’s complete agenda.
An improving job market brings opportunities for employees in the workers’ compensation industry along with challenges for their employers and their employers’ customers. One large third-party administrator is experiencing an “uptick” in employee turnover as the economy gradually improves, the organization’s leader recently discussed at a conference. Other TPA executives tell me their employee retention levels remain flat, but one can reasonably foresee a repeat of the first TPA’s experience as more job opportunities arise.
An improving economy is good for everyone and a worker’s ability to advance into a better job is a positive sign that the economy is functioning as it should, by efficiently allocating resources.
When the economy tanked, for example, a risk manager I have known for years reluctantly returned to a TPA adjuster job following a layoff. Her skills were under-utilized and she wasn’t happy about returning to a role she had held before advancing in her career.
As the economy improved, she landed a risk management position where she is now happier, fully applying her broader knowledge. Her new employer also benefits from her skill set that was under-utilized during the recession.
The catch is that even moderate employee turnover among TPAs is difficult for customers, industry leaders tell me, presenting challenges for customer service continuity.
Clients suffer when a new adjuster assumes a file they are unfamiliar with. Customers like the service consistency delivered by adjusters and other TPA employees familiar with their business practices and claims handling preferences. They want to keep adjusters they have developed solid working relations with.
Losing employees also concerns TPAs because they can see their recruiting and training investments walk out the door.
Consequently, TPA executives are talking more about improving career advancement opportunities for their workers and how they might reshape careers in their industry so they can retain employees. That’s going to mean getting inside people’s heads and understanding their motivations.
There are many reasons people switch jobs, including commute times, salary increases, workplace personnel issues and career advancement.
A founding member of the Disability Management Employer Coalition recently suggested I write a story about the job churn he now sees among the disability insurers, consultants, and employers he has known for years. He thinks the movement is caused by the corporate demands that emerged during the recession, as companies moved to do more with less.
He thinks workers are moving in hopes of a lighter workload. I can’t verify whether his theory about the cause of job changes is correct.
But given his position in the disability management community, I suspect his observation that more professionals are moving on as the business outlook improves is on target.
The labor market has not fully recovered from the Great Recession’s impact. But industry leaders would be wise to look ahead and rethink employee retention strategies.
This is a cyclical challenge TPAs have faced before. Pre-recession, when the economy was booming, employee churn was significant, I’m told. But TPAs won’t be the only ones wrestling with these issues as the economy continues improving.
On the Case
Chances are greater today than ever that a workers’ compensation claimant will speak with a registered nurse, either telephonically or in person.
There is also greater likelihood that an injured worker with an ongoing claim will interact with a nurse case manager earlier in the life of that claim than occurred in the past. Those with new injuries, meanwhile, are more likely to speak with a “triage” nurse to help determine whether they need further medical assistance.
Increasingly, nurses are being used in a variety of workers’ comp roles, from providing counseling for injured workers, to becoming more aggressive questioners and overseers of medical treatment.
Hence, the constant appearance of want ads placed by workers’ comp companies seeking registered nurses, usually with case management skills, capable of helping manage disabilities and returning injured workers to the job.
Expect to see the number of those want ads grow as workers’ comp payers look to stem increasing claims complexity and medical expenses.
Over the next several years, employment of U.S. nurse case managers is expected to grow 3.3 percent annually. At the same time, the medical case management industry’s revenue is expected to grow by 3.6 percent annually, to an estimated $6.7 billion in 2018, according to a September 2013 report by IBIS World, an industry intelligence and research firm.
Those statistics reflect an expected growth in demand for all nurse case managers, including those working in group health. But much of the growth will come from workers’ comp, as the number of workers in the U.S. increases, the report stated.
Historically, hiring trends for nurses in group health and workers’ comp are cyclical.
Efforts to hire workers’ comp nurse case managers plateaued about five to seven years ago following a “huge increase,” said Linda Walker, a board member of the American Association of Occupational Health Nurses.
The growth spurt came when workers’ comp insurers and third-party administrators found they needed more registered nurses to help comply with increasingly complex medical laws and to ensure medical providers followed treatment guidelines, she said.
The hiring run ended due to the Great Recession’s impact on employment, according to IBIS World.
Part of the reason case nurses are so much more in demand today is that claims are much more complex today than in years past, said Liz Thompson, CEO at Encore Unlimited LLC, a case management company in Stevens Point, Wisc.
Comorbidities, an aging workforce, and narcotic prescriptions are driving claims complexities. Nurses are also spending more time addressing behavioral and psychosocial issues beyond the original workplace injury, Thompson said.
“Nurse case managers are really needed to help the insurance community navigate through these complex issues,” Thompson said.
Burgeoning Job Rolls
The proof of that need is that workers’ comp insurers and third-party administrators interviewed for this story said they employ many more nurses today than they did a decade ago.
Sedgwick Claims Management Services Inc., for example, employs more than 400 nurses, double the amount of five years ago, said Teresa Bartlett, senior VP and medical director at the company.
Travelers employs more than 500 registered nurses servicing workers’ comp claims nationwide. Their use was made necessary as the ratio of medical expense to indemnity costs for an average claim increased, said Jim Wucherpfenning, VP of workers’ compensation for Travelers.
Assigning nurses with the knowledge and communication skills to interact with injured workers and doctors alike speeds the recovery process and gets workers back on the job sooner, he said.
“We believe you get the best medical case management when those pieces of a claim are handled by a medical professional,” Wucherpfenning said.
Other claims payers have also increased in-house nursing staff to manage medical care costs.
“The operational models of carriers or payers increasingly have some commitment to in-house nursing to supplement adjusting staff,” said Ronald J. Skrocki, VP, product management and development at GENEX Services Inc. “Maybe 15 years ago there was some of that.”
Skrocki said it is hard to find a major payer today that isn’t using more nurses either in-house or in an outsourced function. No matter how the industry accesses the talent, it needs more of it, he said.
Melinda Hayes, president and CEO of managed-care company MHayes, said that while some large workers’ comp insurers employ hundreds of nurses, they also contract with her company for nurse field case managers and to bolster their telephonic nursing staff.
For older, complex claims, she has seen her nurse field case managers called in earlier today, with the average time from injury to referral dropping from 2.53 years in 2011 to 1.84 years in 2014, Hayes said.
Predictive analytics also plays a role, as it helps adjusters determine which cases will benefit from nurse oversight of medical care. The technology also helps ensure nurses are not unnecessarily assigned to cases that won’t benefit from their involvement, preventing wasteful expenses, experts said.
Slaves to Process
Insurers and other companies providing case managers and other nursing services also have best practices, treatment guidelines, protocols and client handling instructions that their nurses must follow. The measures are intended to help deliver proper care to speed recovery.
But some workers’ comp observers express concern that today’s case managers spend their workday adhering to those processes, rather than critically evaluating claims and applying their medical expertise to improve outcomes.
“I don’t need to pay for you to scribe. I need a critical thinker and a decision-maker and to challenge what is happening in the exam room.” — Judie Tsanopoulos, director of workers’ comp and loss control, St. Joseph Health System
Field case management nurses are now far less likely to engage in critical practices such as questioning a doctor’s treatment decisions when necessary, said Sherri Hickey, director of medical management for workers’ compensation insurer Safety National.
Instead they focus on following protocols and processes, such as making sure patients find their way to a contracted medical provider network. She doesn’t see as many nurses with the “more aggressive, challenging attitude” she believes is necessary.
“I find some of the nurses now are a lot more process-oriented,” she said.
“They get a little busy with all that work and they are not really focusing on what is the best outcome for the patient. It is more processing than it is looking at the best outcome and how to facilitate that best outcome.”
Hickey is a registered nurse supervising two other Safety National nurses. Hickey and the Safety National in-house nurses in turn police the field case managers assigned to claims by TPAs to make sure the field case managers are doing their jobs properly.
“We are calling those case managers and having discussions on the phone and saying, ‘Have you asked the [medical provider]this question, have you pursued this theory, have you asked them why they are doing this versus that,’ ” she said.
“We force them into that a little more.”
Judie Tsanopoulos, director of workers’ comp and loss control at St. Joseph Health System in Orange, Calif., agreed that some field case managers have become increasingly process-oriented to the detriment of good patient care.
“Absolutely,” she said. “We have had difficulty finding good nurse case managers.”
She discontinued relations with some field case management companies because their nurses merely accompanied claimants to medical appointments and took notes, but did not ask enough probing questions.
“I would get their reports and all they did was scribe,” Tsanopoulos said.
“I don’t need to pay for you to scribe. I need a critical thinker and a decision-maker and to challenge what is happening in the exam room,” she said.
“That is what I want to pay for and I want them to take their technical skills and clinical skills and utilize them.”
Done right though, nurse case management can have a huge impact on resolving claims.
Tsanopoulos said she spends significant sums for the liberal use of nurse case managers. It increases spending up-front but ultimately reduces claims durations and the costs of ongoing claims.
Over the years, the roles and training of workers’ comp nurse case managers has evolved, experts said.
Today’s nurses, for example, are more likely to be trained in “motivational interviewing,” said Susan DeMarino, vice president of accreditation services at URAC, a Washington, D.C.-based nonprofit that accredits case management and other health care programs.
The training includes best practices for eliciting information from claimants and empathizing with patients who may be mistrustful of the workers’ comp system.
“Case managers are getting additional training and education on how to ask questions to better engage the injured worker,” she said. “We started hearing about it about five years ago, but we are starting to see it being applied more.”
Of course, how well nurse case managers perform will be up to the individual. Rest assured, the workers’ compensation risk management industry needs as many of the good ones as it can get these days.
Read more of our three-part series on nurse case management:
Part I: On the Case
Payers are looking for spirited nurse case managers who will be patient motivators and advocates, not slaves to process.
Part 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.
Part III: Available in the December 2014 issue.