Little Progress Reducing Shoulder Claims
While the nationwide frequency of workplace injuries impacting other body parts, such as lower backs, continues on a downward trend, workers’ compensation experts say they have not seen a corresponding drop in workers suffering from shoulder problems.
Shoulder injuries can require longer recovery times than do other body parts, diminishing the likelihood of a quick return to work, several medical experts said.
“Shoulder claims are huge now,” with the joints of an aging workforce wearing down, said Liz Thompson, CEO at Encore Unlimited LLC, a case management company in Stevens Point, Wisconsin. Treatment options are often expensive, particularly for older workers who are more likely to suffer accompanying comorbidities, she added.
Thompson recently analyzed the claims from one insurer client and found that 70 percent of those stemmed from extremity injuries, including many shoulder issues, she said.
Similarly, Judie Tsanopoulos, director of workers’ comp and loss control at St. Joseph Health System in Orange, Calif. said that beginning about three years ago she observed a rise in shoulder injuries and incidences of frozen shoulder.
“We see far more shoulders,” Tsanopoulos said.
When she drilled into her company claims data she found that women aged 40 to 60 years old accounted for many of those shoulder issues, she said.
Other workers’ compensation experts say they have not seen an overall increase in the frequency of shoulder-related injuries. Yet despite nationwide gains in reducing injuries to other body parts, shoulder injuries are not decreasing.
An NCCI Holdings Inc. report released on July 18 states, among other findings, that from 2008 to 2012 the frequency of lost-time claims for most body parts dropped an average of 13.9 percent.
“One notable exception is that the frequency of injuries involving the arm and shoulder, which represent more than 15 percent of all injuries, remained flat over the period,” dropping only 1 percent, according to NCCI’s frequency report.
In contrast, lower back claims dropped 15 percent during the period while upper back claims dropped 7 percent. Upper back claims showed the least amount of claims decline next to the 1 percent drop in arm and shoulders among body parts.
NCCI’s report stated that the flattening trend in arm and shoulder frequency “may be influenced by an older workforce, where rotator cuff injuries are not uncommon.”
Prior to the flattening in lost-time arm and shoulder claims seen from 2008 to 2012, injuries to those body parts had been declining. They decreased 13 percent from 2004 to 2008 while frequency for all lost-time injuries dropped 17 percent, said Jim Davis, an NCCI director and actuary.
In addition to an aging population more likely to suffer shoulder injuries, more treatments may be occurring today when workers complain about shoulder pain.
In contrast to 20 years ago, doctors are increasingly able to diagnose and address shoulder pain complaints that previously went untreated, said Ira Posner, an MD, orthopedic surgeon, and consultant to third party administrator Broadspire.
“So you are seeing a lot more people with a diagnosis now that we couldn’t make before,” Posner said. “People would present with shoulder pain and we didn’t know why they hurt — now we know why they hurt.”
The improved medical quality means doctors are able to help more workers while workers’ comp payers may now be feeling the increase in shoulder treatments.
“That is why you are seeing more pathology in the shoulder being treated, because we understand the shoulder better and we are able to do more for complaints of shoulder pain,” Posner said.
One cost mitigating factor, however, stems from a shift from conducting mostly open shoulder surgeries to performing more orthoscopic and outpatient treatments, added Jacob Lazarovic, senior VP and chief medical officer at Broadspire.
Still, shoulder injuries typically require more recovery time than do other body parts, experts said.
“Recovering from shoulder surgeries is a pretty prolonged process in the best of cases, but it would be even more prolonged for older workers,” Lazarovic said.
The complexity of shoulder joints adds to the problem, medical experts said.
In addition to a longer recovery time, shoulder injuries such as those requiring rotator cuff surgeries make it challenging for employers to return workers to certain jobs, such as those requiring overhead lifting, said Teresa Bartlett, senior VP and medical director at Sedgwick Claims Management Services Inc.
“Shoulder injuries in general are problematic,” Bartlett said. “Regardless of age, it’s the mechanism of the shoulder that tends to be very difficult.”
In response, Thompson at Encore Unlimited is seeing employers increasingly interested in shoulder protection and corresponding loss control programs.
“Anytime you have an injury group that is driving your claims costs, as an employer you have to evaluate what can you do to eliminate some of that risk,” such as making sure the worker fits the job, she said.
Workers’ Comp Laws Regarding Illegal Immigrants See Little Change
With immigration grabbing headlines, some state legislators may decide to once again push bills to disqualify illegal immigrant workers injured on the job from receiving workers’ compensation benefits.
“Is it plausible that elected officials who feel strongly about the immigration issue might use the current instability to make a political point?” asked Bruce Wood, workers’ comp director for the American Insurance Association (AIA). “You can connect the dots. But from me sitting here today it would be speculation to say that is going to happen.”
The immigration issue surged to the forefront recently with news stories of tens of thousands of Central American children flooding the U.S. border in recent months, an angry reaction by residents in one California town who blocked Homeland Security buses carrying illegal immigrants, and a political stalemate in Washington D.C. over immigration law reforms sought by business groups.
“There was definitely that wave [of legislation] four or five years ago and it has been pretty quiet on that front the last two or three [legislative] session cycles, but given the current news and political climate we are potentially expecting to see bills in 2015.” — Trey Gillespie, senior workers’ comp director for the Property Casualty Insurers Association of America
But with a history of businesses opposition to legislation denying workers’ comp benefits to illegal immigrant workers, any new bills could meet the same fate as those introduced in 2011 in Georgia, Montana, New Hampshire, and South Carolina.
Those legislative efforts failed to pass into law amid insurer opposition and concerns they would harm employers, including by allowing claimants to seek redress in civil courts rather than through workers’ comp systems where employer liability is limited.
“There was definitely that wave [of legislation] four or five years ago,” said Trey Gillespie, senior workers’ comp director for the Property Casualty Insurers Association of America (PCIAA), “and it has been pretty quiet on that front the last two or three [legislative] session cycles, but given the current news and political climate we are potentially expecting to see bills in 2015.”
That lull doesn’t apply to all state legislation regarding immigration-related issues, which rebounded in 2013 after falling off the prior year, according to the National Conference of State Legislators.
Lawmakers in 45 states and the District of Columbia enacted 437 immigration-related laws and resolutions during 2013, affecting issues such as education, drivers’ licenses, and budget appropriations, according to NCSI. That compared to 267 in 2012, and included resolutions praising immigrant contributions.
AIA’s Wood recalled a 1999 Virginia’s Supreme Court finding that illegal immigrants in that state could not receive workers’ comp benefits when injured.
“The employer community took a victory lap after that and then AIA and others reminded them that this opened them up to tort exposure because there was nothing precluding an undocumented worker from filing a tort suit,” Wood said.
That new exposure pushed Virginia employers to support the successful adoption of a law requiring workers’ comp benefits, with the exception of vocational rehabilitation benefits, to be paid to undocumented workers.
Overall, despite legislative attempts over the years to prevent providing workers’ comp benefits to illegal immigrants, state laws on the matter have remained unchanged, Wood said.
“Notwithstanding all of the bills introduced there haven’t been a whole lot that actually got through and were signed into law,” he said.
But that has not stopped attempts, even recently.
In North Carolina, Sen. Thom Goolsby (R-Wilmington) amended House Bill 369 in late June to disallow workers’ comp benefits being paid to workers “not lawfully employable in the United States and [those who] knowingly made a false representation to the employer as to his or her legal work status.”
But on July 8, the bill was removed from the state Senate’s calendar and referred to a Senate Rules and Operations Committee, meaning it had stalled.
Insurers oppose such legislation because in addition to stripping employers of worker’s comp exclusive remedy protections, there is a public policy concern. Such laws could incentivize certain employers to hire illegal workers and ignore safety practices because they would not be obligated to purchase workers’ comp insurance.
Those employers would gain an unfair advantage over other employers paying workers’ comp premiums.
“There is a concern,” said PCIAA’s Gillespie, “as to whether you are rewarding employers for knowingly hiring illegal aliens at the expense of employers who do their best to follow immigration and employment laws and pay benefits to their injured workers, as opposed to other employers who may get a benefit from hiring illegal aliens because they wouldn’t have to pay workers’ compensation claims arising out of injuries.”
Better Prescribing Through Technology
Doctors are increasingly turning to the genetic testing of workers’ compensation claimants to evaluate their tolerance for prescription medications such as opioid pain relievers, observers say.
Pharmacogenetics, or the study of genetic variations among individuals, has found broader use to test how patients suffering from cancer and other diseases metabolize prescription drugs and whether they are likely to derive therapeutic benefits or are at higher risk of suffering harmful side effects.
Now, more physicians are turning to pharmacogenetics to similarly evaluate how workers’ comp claimants will respond to prescription drugs based on a patient’s genetic makeup.
It is not yet a mainstream practice for workers’ comp claims, nor is it appropriate for all claims, said Candy Raphan, director of medical services for Broadspire, a third party administrator.
But the practice is taking hold, and a recent review of injured worker claims managed by Broadspire revealed “quite a few incidences where this was used in the last year,” Raphan added.
Doctors turning to pharmacogenetics are doing so to determine how workers’ comp patients might metabolize opioids and other pharmaceuticals used for “adjunct pain management,” Raphan said. They are looking to identify patients that may not respond positively to certain drugs or experience a “heightened response,” placing them at a high risk for an adverse drug reaction, such as overdose and death.
Physicians may also use it — by taking a swab from inside a patient’s cheek — as a tool for learning why patients may not respond to the “pain-relief intention” of a drug, despite dose escalation, Raphan said.
“If you are giving someone a medication and they keep saying, ‘I took twice as much because I didn’t get pain relief,’ it may be as a result of them not having one of those [genetic] factors so they can break that drug down to get that therapeutic benefit,” she elaborated.
Advocates say pharmacogenetics could shorten injury and disability durations among workers’ comp claimants by eliminating common trial-and-error doctor attempts to find which prescriptions will benefit patients most.
It can also reduce treatment durations by eliminating harm caused when providing drugs a patient will not tolerate well, they add.
“We have seen providers say, ‘Let’s do some genetic testing to identify which drugs you are more likely to have side effects from, or are least likely to respond to or to tolerate, and let’s use that as a roadmap to guide our therapy,’ ” said Jennifer Strickland, VP and pharmacogenetics business leader for Millennium Laboratories L.L.C.
San Diego-based Millennium launched in 2007, providing urine-drug testing services for patients suffering from pain. The company moved into pharmacogenetics testing about two years ago.
There is interest in applying pharmacogenetics in worker’s comp cases because doctors are often attempting to address pain, which is a “very subjective condition,” Strickland said. It is difficult for them to find the right drug, especially while trying to meet the goal of returning employees to the job as soon as possible.
Most requests for testing are now coming from doctors, but Millennium has also held discussions with pharmacy benefit managers evaluating the practice and considering its application for cases where patients have not responded to medications prescribed to them, Strickland said.
For now, plenty of doctors remain hesitant about using a new technology.
But as the technology enters the mainstream, Raphan said she expects to see more doctors turn to it, “as long as the costs and the benefits align.”