Susannah Levine

Susannah Levine writes about health care, education and technology. She can be reached at [email protected]

In Depth: Workers' Compensation

When Claims Go Off the Rails

Case managers and pharmacy benefit managers are key pieces of the puzzle for payers trying to rein in catastrophic claims before they’re too far gone.
By: | November 2, 2016 • 6 min read
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When a worker faces the rest of his life in a wheelchair or is relearning how to tie his shoes, most people wouldn’t be surprised if he battles anger, depression and maybe opioid abuse. But why do some people move on after a catastrophic injury and others do not?

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And why, after a garden-variety ankle sprain, can most workers return to work quite quickly, while 10 to 20 percent of them descend into a lifetime of unrelenting pain and disability?

“True catastrophic injuries” are medically very different from “migratory” or “creeping” claims, like the ankle sprain that devolves into disability.

Michael Coupland, a psychologist, rehabilitation counselor and network medical director with the IMCS Group, said a large body of data suggests that both creeping catastrophic and “runaway” catastrophic claims are characterized by complicated recoveries, higher costs and more medical complications when the patient presents with one or more of these psychosocial risk factors:

  • Tendency to catastrophic thinking.
  • Guarding or fear avoidance behavior.
  • Perceived injustice and disability mind-set.
  • Adverse childhood events, which weaken the immune system.
  • Psychological comorbidities.
  • Stressors and weak family and social supports.
  • Abdication of control.
  • Lifestyle and demographic risks.

Predictive modeling has advanced to the point that these factors can be identified and acted on earlier, said Dr. Michael Choo, chief medical officer, Paradigm Outcomes.

Once these factors are identified, Choo said, claims managers can put into place the necessary support systems and work with the injured worker to gradually ease them into a more productive recovery.

Michael Coupland, psychologist and rehabilitation counselor, network medical director, IMCS Group

Michael Coupland, psychologist and rehabilitation counselor, network medical director, IMCS Group

Behavioral therapies are also part of the protocol for traumatic brain injuries, said Zack Craft, vice president, rehab solutions with One Call Care Management. He said brain injuries predictably produce personality changes, including angry outbursts.

The frontal lobes, the part of the brain most vulnerable to injury, are the emotional control center and home to personality, according to the Centre for Neuro Skills. Damage can affect motor function, problem-solving, spontaneity, memory, language, initiation, judgment, impulse control, and social and sexual behavior.

In a historical departure, carriers have started to pay for behavioral therapy in migratory claims, said Maddy Bowling, principal, Maddy Bowling & Associates Consulting. “Payers had suspected malingering in migratory claims and were reluctant to pay for psychological treatments,” but they now assume motivational or psychological problems and recognize that these therapies could be helpful.

Chronic Pain Management

About two weeks after an injury, workers take a pain-screening questionnaire, scored from one to 10: How would you rate the pain that you have had during the past week? In your view, how large is the risk that your current pain may become persistent? A high score, said Coupland, predicts a high chance of chronic pain and delayed recovery.

“We don’t tell patients our goal is to get them off drugs. We say, ‘This is a way to manage your pain.’ ”  — Michael Coupland, psychologist and rehabilitation counselor, network medical director, IMCS Group.

In March 2016, the Centers for Disease Control called the nation’s prescription drug epidemic a “doctor-driven crisis” and offered new, non-binding prescribing guidelines. More doctors are weaning their patients from opioids and seeking non-pharmaceutical techniques to help them manage their pain.

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Predictably, Coupland said, patients who satisfy any or many of the identified risk factors are fearful of separating from their painkillers and of the debilitating pain that led them to opiate use in the first place. Most are not addicts, and most are compliant patients, following doctor’s orders perfectly.

Still, Coupland said, “getting off opioids is hard,” typically triggering depression, anxiety and withdrawal.

“We don’t tell patients our goal is to get them off drugs,” he said. “We say, ‘This is a way to manage your pain.’ ” He then introduces non-pharmaceutical techniques such as cognitive therapies, biofeedback or hypnosis.

“We have the patient say, ‘I can cope with my pain.’ When the brain hears that, even if the patient isn’t convinced, the words can stand down the stress arousal response, which is a pain generator.”

And he develops a weaning plan with the patient’s doctor. “We set a goal: Get pain down from an 8 to a 5 or 3. Even an 8 to a 7 is fine.”

Role of Pharmacy Benefits Management

Catastrophic injury claims are complex, with multiple providers prescribing multiple drugs, including painkillers.

Phil Walls, chief clinical officer, myMatrixx

Phil Walls, chief clinical officer, myMatrixx

A profusion of medications can cause a “cascade” effect, said Phil Walls, chief clinical officer, myMatrixx.

The appropriate response, Walls said, is to reduce the drug causing the original problem, especially opioids. “They cause drowsiness. We see Ritalin, amphetamines, and other stimulants to counter the drowsiness.” Those in turn may cause sleeplessness, jitters or dry mouth, which could be addressed by yet another medication.

If the prescribing practices — such as dosages, possible drug interactions and duration of the prescription — fall outside guidelines published by the CDC and other health organizations, Walls may contact the prescribing physician.

Do they resent the interference? Not often, he said.

“Medical schools teach collaborative care. They’re taught to embrace interaction when other providers reach out to them.” Even when they give attitude, the post-intervention data Walls monitors shows they make the change anyway 79 percent of the time.

Using their data on providers, types of drugs, dosages and duration of a prescription, pharmacy benefits managers are in a unique position to identify trigger points where an intervention would benefit a claim, said Nikki Wilson, pharmacy product director, Coventry Workers’ Comp Services.

Regrettably, claims often have problems by the time pharmacy benefits managers get involved, she said, especially when the pharmacy benefit is a stand-alone product.

“Medical schools teach collaborative care. They’re taught to embrace interaction when other providers reach out to them.”  — Phil Walls, chief clinical officer, myMatrixx

Multi-product managed care organizations have access to more information about the patient’s and the claim’s history than stand-alone providers. Their risk models may trigger early alerts to potential issues.

For example, “the first opioid prescription we fill will trigger outreach to guide the claim to the best outcome,” Wilson said.

A Minor Claim Gone Awry

All claims require management, but not all runaway claims involve excessive pain or medications.

Eighty percent of excess carrier costs derive from migratory claims, said Zack Craft of One Call. He recalls a claim One Call inherited for a restaurant manager who rolled his right ankle on an oil drip on some stairs.

“He went to an urgent care center, then an ortho group, which gave him an orthotic shoe and a brace, and sent him home.”

That should have been the end of the story, but the man wore the hard orthotic shoes more than prescribed and developed a blister.

“Now he had a wound that didn’t heal right, and then he was diagnosed with diabetes.”

After a stay in the hospital with his foot elevated, he developed foot drop — a gait abnormality — which required more orthotic shoes.

And then he suffered a wound on his left ankle, which he neglected. That resulted in another hospital stay, with an almost 100-pound weight gain from inactivity, poor nutrition and medication. After more than a year, with a degrading condition, he underwent an above-the-knee amputation.

“Now he was into prosthetics, and the weight gain forced him into a power chair,” Craft said. His rental home required a ramp for the power chair, and he went on disability.

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“It’s good practice for a case manager to step in when a symptom like an unhealing blister emerges,” said Bowling, which could (and did) indicate a more serious condition.

A case manager could work with doctors on diet and exercise to control weight and avoid the abnormal gait and stress fracture.

“Field case managers go to the physician’s office with the patient, help with referrals, and meet with the family to make sure they understand the treatment plan and their role in compliance,” she said. &

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R10-1-16p40-42_3Catastrophic.inddFacing the Unthinkable: What happens in the hours, days and weeks following a sudden, disabling injury?

 

R10-15-16p38-40_4Catastrophic.inddRoad to Recovery: When it’s time to send patients home, there are new challenges to tackle, for both patients and payers.

 

Man on wheelchairCreeping Catastrophes: This final story of the series focuses on “creeping” catastrophic claims.

 

Susannah Levine writes about health care, education and technology. She can be reached at [email protected]
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In Depth: Workers' Compensation

The New Normal

Advanced care techniques and technologies are helping workers with brain and spinal cord injuries get back to living full lives.
By: | October 15, 2016 • 6 min read
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Four years after a firefighter sustained third degree burns over 95 percent of his body, he’s not just alive, but he’s counseling other burn victims.

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And several years after a 40-something forklift operator suffered a pelvic fracture, a traumatic brain injury and a spinal cord injury, the karate black belt returned to his dojo and hopes to teach karate from his wheelchair.

Five or 10 years ago, these injured workers wouldn’t have lived a week after their injuries, say their medical teams. Thanks to recent advances in medicine and technology, more catastrophically injured workers are surviving and, while not returning to their former functionality, are leading productive lives, said Sherri Hickey, director, medical management, Safety National.

As a result, the workers’ compensation community is “dealing with more, and longer, and more expensive claims,” Hickey said.

A virtue of workers’ compensation coverage, said Dr. Michael Choo, chief medical officer, Paradigm Outcomes, is that it “takes the long view” of the injured worker’s needs. “Generally, health care focuses on the first few weeks, a month, or a year, but effects from burns, spinal cord and traumatic brain injuries last forever.”

Because catastrophic injury claims often last for decades, the goal should be the best functional outcome possible in each case, said Choo, both for the patient’s quality of life and as a claims management strategy. “The best functional outcome translates to the lowest level of disability,” which itself translates to greater independence and lower care costs.

Kevin Glennon, vice president, home and health care services, One Call Care Management

Kevin Glennon, vice president, home and health care services, One Call Care Management

The best care doesn’t come cheap, said Michael Coupland, psychologist and rehabilitation counselor, network medical director, IMCS Group, but it’s cheaper in the long run than cheap care.

“Carriers and employers typically want the best doctors, the best rehab facilities, the best equipment, the best care management because they want to do the right thing for their workers and because the best care prevents returns to the hospital for complications such as skin wounds and infections” — the kinds of ailments that arise from fragmented care, oversight or neglect, said Choo, formerly CEO of a for-profit hospital before joining Paradigm.

“The financial payoff comes down the road.”

Management of these cases can be infinitely complex, he said, as medical conditions may change constantly, affected by comorbidities (such as high blood pressure and obesity, secondary effects of physical inactivity), psychological/social health (which can decline with pain, depression and isolation) and past medical issues.

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They also involve a multitude of providers — all the physicians, therapists, home health aides, equipment suppliers and transport services — engaged in the patient’s care. A “big believer in teamwork,” Choo recommends keeping all stakeholders aligned to the same goal, an achievable degree of functionality.

When the financial payoff comes, Choo said, “we get five times better results at 40 percent medical cost savings,” than catastrophically injured patients who receive à la carte care.

The Technology

Because of the huge volume of traumatic brain injuries, burns, spinal cord injuries and amputations resulting from military engagements, companies have been researching and creating function-restoring technologies, Hickey said.

The results would stun a science fiction writer: skin grafts grown in the laboratory from the patients’ own DNA; drones launched from wheelchairs to conduct surveillance on the surrounding topography; brain-controlled robotic suits that restore some neurological function; exoskeletons.

Sherri Hickey, director, medical management, Safety National

Sherri Hickey, director, medical management, Safety National

Most technology is not the gee-whiz stuff. For example, the Apple watch will soon track fitness for wheelchair users. And a device called Pants Up Easy helps wheelchair users and people with spinal cord injuries get dressed.

Effective, low-cost technologies borrowed from smart phone fitness apps are producing a huge shift in patient monitoring, Coupland said.

For example, biofeedback apps measure heart rate variability, an indicator of stress and mood, and provide a mechanism for controlling them. Pain and mood diarizing are moving toward these technologies, as are sleep and activity tracking.

Telehealth technology can help providers manage vital signs all day, not just during an office visit by identifying changes from the baseline, said Kevin Glennon, vice president, home health and complex care services, One Call Care Management. And they’re useful for tracking medications.

“Patients hit a button when they take their meds,” he said, informing providers that they remain on schedule.

While technology can enable more independence, it can also contribute to more sedentary lives. Social media may contribute to inactivity — and obesity.

Obese people need greater doses of medications, and those who are also disabled may need a higher level of care for mobility, bathing and toileting. They may need bariatric or heavy-duty equipment. “If the patient weighs 300 pounds and the power chair weighs 325, the home would need assessment” for weight-bearing capacity, Glennon said.

“Generally, health care focuses on the first few weeks, a month, or a year, but effects from burns, spinal cord and traumatic brain injuries last forever.” — Dr. Michael Choo, chief medical officer, Paradigm Outcomes

On the other hand, technologies such as high-end prosthetics may allow greater independence and activity. “If the patient was a runner before the accident, we’ll buy running as well as walking prosthetics,” Hickey said.

Will carriers pay, especially for new technologies? With input from research and medical experts, payers review on a case-by-case basis, said Maureen McCarthy, senior vice president, claims, Liberty Mutual. “We seek input on experimental devices and treatments. Payment isn’t a barrier to care in the workers’ compensation environment.”

Beyond Medicine

Many factors contribute to a well-planned discharge plan, said Scott Peters, clinical director, neurorehabilitation and neurobehavioral system, ReMed: the worker’s abilities and prognosis, the medical and therapeutic treatment, home modifications, and family support as well as the worker’s outlook on life, ambitions before and after the injury, and likes and dislikes.

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For example, said Zack Craft, vice president, rehab solutions, One Call Care Management, while the injured forklift operator — we’ll call him Job for his tribulations and the vigor of his spirit — was still in his high-end inpatient rehab facility, One Call started planning for discharge.

Job wanted to go home and re-engage in the community — itself a predictor of success — not to a step-down facility. However, his return to the split-level home he shared with his wife was impractical because of the cost of modifications; it would require an elevator. Besides, his wife had left him, leaving him with a single income equal to 66 percent of his former salary.

One Call arranged for a year’s lease on an apartment that needed only minor modifications and for a 24/7 home health aide while he sold his house. He applied the sale proceeds to buy a new house.

And he needed transportation. The transport van, although medically justifiable, was very expensive and didn’t fit Job’s idea of himself as a motorcycle and pickup truck sort of guy. A new van would cost a prohibitive $70,000 to $95,000.

Using its network of used vehicles, One Call located a year-old, pre-modified van for $40,000. It applied for and received approval from the Washington State workers’ compensation regulators.

Was Job happy?

“He wanted to return home and get back to living,” Glennon said. “Often, when workers can’t get past the depression and denial, they lose their will to strive for independence.” &

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R10-1-16p40-42_3Catastrophic.inddFacing the Unthinkable: What happens in the hours, days and weeks following a sudden, disabling injury?

 

R10-15-16p38-40_4Catastrophic.inddRoad to Recovery: When it’s time to send patients home, there are new challenges to tackle, for both patients and payers.

 

Man on wheelchairCreeping Catastrophes: The final story of the series focuses on “creeping” catastrophic claims.

Susannah Levine writes about health care, education and technology. She can be reached at [email protected]
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In-Depth Series: Workers' Comp

In the Wake of Tragedy

The first story in a three-part series on catastrophic care looks at the crucial steps to be taken in the direct aftermath of a severe injury.
By: | October 1, 2016 • 6 min read
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When a forklift operator in Washington State left for work at a construction supply company one morning, he was a healthy, married, home-owning karate enthusiast in his 40s.

By the end of the day, he had a spinal cord injury that left him paralyzed from the waist down. He also suffered a fractured pelvis and a closed head injury.

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In well-managed workplace catastrophic injury cases, the above scenario triggers a rapid-fire series of events, both medical and administrative, said Gordon Padera, executive vice president, consultative, Gallagher Bassett Services Inc. The first and most urgent is getting the best possible care for the injured employee as quickly as possible.

Ideally, said Sherri Hickey, director of medical management at Safety National, this should be at one of the country’s approximately 200 Level 1 trauma centers, which are best equipped and most experienced with “catastrophic injuries” — multiple traumas, third-degree burns over 25-plus percent of the body, amputation of major extremities, spinal cord injuries and traumatic brain injuries.

The “true” catastrophic claims are the sudden, disabling accidents that change the course and quality of the worker’s life, said Maureen McCarthy, senior vice president, claims, Liberty Mutual.

The term catastrophic is also applied to slow-developing or “creeping” claims, such as a sprained back from a slip, trip or fall that devolves into unmanageable pain, loss of ambulation, permanent disability or opioid dependence due to obesity, diabetes, psychological/social or other comorbid conditions.

The Crucial Hours After

Organizations — employers, carriers, third-party administrators and vendors — with well-rehearsed disaster plans produce better outcomes for their injured workers, said Padera, with fewer complications, less recidivism and greater restored function.

A “good” outcome means “a return to as healthy and productive a lifestyle as possible,” McCarthy said, given the worker’s age, health, and extent and nature of the injuries. It seldom means a return to pre-injury functionality.

The National Council on Compensation Insurance estimates that catastrophic injuries account for only 0.4 percent of claims but 14 percent of total loss costs.

In the best-case scenario for a worst-case tragedy, McCarthy said, the employer immediately notifies state workers’ compensation authorities and the workers’ compensation carrier. A nurse case manager, either in-house or through a contracted vendor that specializes in catastrophic injuries, can either direct the ambulance and response team to a center of excellence or meet the worker and his or her family at the nearest hospital. There, the nurse starts a strategy discussion with the family and doctors.

“Once we’re involved, we can start to add value,” McCarthy said. “We ask, ‘Is this the right facility? Should he stay in this hospital until he’s stable? Should we medevac him to a facility that specializes in catastrophic injuries?’ We quickly bring in the right resources.”

Taking Away Lessons

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Estimates for the frequency of catastrophic workplace injuries vary widely. The U.S. Bureau of Labor Statistics has no mechanism for collecting data on permanent disability, said Jim Rice, a BLS economist; it measures a non-fatal injury’s severity by days missed from work, and stops counting at 180 days.

The National Council on Compensation Insurance estimates that catastrophic injuries account for only 0.4 percent of claims but 14 percent of total loss costs.
McCarthy noted that about 20 percent of workers’ compensation claims drive about 80 percent of total workers’ compensation claim costs. That includes slow-developing claims that can cost multimillions over their lifetime.

Paul Braun, managing director, Aon

Paul Braun, managing director, Aon

The growing use of robots, lifting devices and restraints contributes to a drop in injuries, said Paul Braun, managing director, Aon. On the other hand, the aging workforce could add more injuries.

“Older workers are more susceptible to injury, and they take longer to heal. Their injuries are more prone to complications from comorbidities.”

The initial investigation that a catastrophic injury triggers with most risk managers is in part responsible for the improving safety trend, said Padera. Gallagher Bassett documents the incident with witness statements and photographs. That information helps it work with its customers to minimize the chance of any recurrence.

Often employers hire safety consultants after an incident or OSHA citation, said Matt McCreery, senior safety consultant, Safety Resources. The frequency of preventive or after-the-fact safety audits, he said, should be determined by the hazards at the site.

For example, he said, a low-hazard pharmaceutical remodel with infrequent accidents would merit fewer audits, whereas a site with a worse record or a higher potential for disaster, such as a multi-employer skyscraper construction site, would demand weekly or daily inspections to demonstrate “reasonable care” and “teeth to the safety program.”

Some companies are “stuck in the old-school mentality of ignoring safety until there’s a crisis or regarding safety as less important than production,” McCreery said.

“The companies that employ us the most need us the least, but sometimes the light comes on, and they become more proactive.”

Better Call Saul

The safer the work conditions, and the more vigilant carriers and vendors are about best-in-class care, the less likely patients and families are to engage legal representation. All of the sources interviewed for this article reported few cases that reach litigation.

“When you provide the care that’s needed, you don’t see a lot of litigation,” Hickey said.

“There’s no misunderstanding of fraud, few issues of compensability. Some spouses immediately retain an attorney, but even then their cases seldom come to litigation.

Matt McCreery, senior safety consultant, Safety Resources

Matt McCreery, senior safety consultant,
Safety Resources

Since workers’ compensation is the sole remedy in most cases, Hickey said, injured workers and their families can’t sue the employer for benefits, but suits occasionally arise if the plaintiffs feel the employer put the worker at high risk, she said.

Civil cases may also arise against third parties, such as when a teenager collides with a truck driver on a delivery route, said Jeffrey M. Adelson, managing partner, Adelson, Testan, Brundo, Novell & Jimenez, a California law firm that defends workers’ compensation cases.

Nurse case managers’ bedside communications with workers and families after accidents — the comforting and management of expectations — deflect some litigation, Braun said.

“People litigate because they don’t understand workers’ comp. When someone communicates all the workers’ comp benefits properly, they have less reason to hire an attorney.”

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Carriers and vendors tend to be deeply averse to attorney involvement in catastrophic injury cases. “When the worker hires an attorney, it can drive up costs and delay communication and the overall progress of the claim,” said Zack Craft, vice president, rehab solutions, One Call Care Management.

But there are cases where “good attorneys on both sides can grease the wheels of communication by keeping their clients focused on the big picture,” said Adelson.

When issues arise, they tend to originate not in the workers’ compensation system but in the insurer’s ability to provide what the worker or family wants.

“Sometimes plaintiffs don’t understand why they don’t get a treatment for which there is no medical justification or certain home or vehicle modifications that aren’t covered under their benefits. And some defendants stubbornly focus on minor issues.” Attorneys can cut through that static, he said.

Some families hire attorneys to manage an injured workers’ funds or act as a patient advocate, especially if the case is going for a third-party or product liability settlement, said Ann Pereira-Ogan, director of marketing and communications at ReMed, a continuum of treatment program for people with traumatic brain injuries.
Attorneys may manage a client’s advance directive and health care proxies, said Pamela Popp, executive vice president and chief risk officer for Western Litigation.

“Carriers would love to see more advance directives,” she said, although society in general is squeamish about raising the subject of death.

“Carriers are caught with no decisions about health care at the most sensitive moments, so they take the most conservative route: sustaining life at a very high cost until someone makes a decision.” &

___________________________________________

R10-1-16p40-42_3Catastrophic.inddFacing the Unthinkable: What happens in the hours, days and weeks following a sudden, disabling injury?

 

 

R10-15-16p38-40_4Catastrophic.inddRoad to Recovery: When it’s time to send patients home, there are new challenges to tackle, for both patients and payers.

 

Man on wheelchairCreeping Catastrophes: The final story of the series focuses on “creeping” catastrophic claims.

Susannah Levine writes about health care, education and technology. She can be reached at [email protected]
Share this article: