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Savings Strategies

On-Site Chiropractic Care Offers Multiple Benefits

Employers that offer on-site chiropractic care are experiencing reduced costs related to musculoskeletal injuries as well as reduce injury frequency.
By: | September 28, 2014 • 2 min read

“Compared with off-site care, on-site chiropractic services are associated with lower health care utilization,” says a new study. “Although we did not capture costs in this analysis, we may infer that the lower amount of health care utilization in patients visiting the on-site clinic for their chiropractic care resulted in direct cost savings for the company health plan.”

Companies have increasingly turned to employer-sponsored work site clinics to control costs and improve health care for their employees. The researchers compared the utilization patterns of employees at a Missouri company who obtained chiropractic care on-site with those who went to community-based centers.

“Doctors of chiropractic promote wellness and injury prevention, and chiropractic care has been demonstrated to deliver effective treatment for the symptoms of musculoskeletal conditions,” the researchers wrote in an article published in the Journal of Occupational and Environmental Medicine. “Furthermore, on-site chiropractic care has been shown to deliver substantial value through convenience of access, high quality of care and delivery, and lowered overall costs.”


There were 876 on-site and 759 off-site participants of Cerner Corporation’s employee health plan who received chiropractic care from 2010 to 2012. The researchers measured utilization differences as having one health care event or more, including radiology or clinical visits.

“Off-site group patients had significantly higher outpatient utilization — 47.3 percent vs. 30.2 percent of on-site group members,” the researchers reported. “The number of repeat services was also higher in the off-site patient group: 29.5 percent of off-site group members had two outpatient visits or more compared with 18.5 percent of on-site group members. Emergency department visits were higher in the off-site group — 19 percent vs. 13.1 percent of on-site group members.”

In comparing specific radiological services, the off-site group had 14.6 percent receiving MRIs vs. 12.4 percent for the on-site group, 15.8 percent for ultrasounds vs. 10.7 percent for the on-site participants, and 46 percent for radiographs vs. 26.6 percent for the on-site group. The off-site group also had a higher percentage of patients with more than one ultrasound compared to the on-site group.

Nancy Grover is co-Chair of the National Workers’ Compensation and Disability Conference and Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at
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View From the Bench

Workers’ Comp Docket

Significant workers' comp legal decisions from around the country.
By: | September 28, 2014 • 9 min read

Employer Liable for Unauthorized Back Surgery

Marion County Health Department v. Hill, No. 93A02-1402-EX-69 (Ind. Ct. App. 07/09/14, unpublished)

Ruling: In an unpublished decision, the Indiana Court of Appeals held that an employer was liable for the costs of an assistant’s back surgery.

What it means: In Indiana, a worker is allowed to select medical treatment in an emergency if the employer fails to provide needed medical care or for other good reason.


Summary: An administrative assistant for the Marion County Health Department felt a muscle pull in his lower back while he was lifting and carrying tables. The department authorized medical treatment for the injury through an occupational health clinic. An MRI revealed a disk extrusion in contact with a nerve root. Physical therapy did not help with the assistant’s pain, and a steroid injection only helped temporarily. Later, the department’s physician released the assistant from his care without any restrictions. The assistant sought further medical treatment on his own with an orthopedic spine surgeon. The surgeon performed surgery. The Indiana Court of Appeals held that the department was liable for the costs of the assistant’s surgery.

The department asserted that it was not required to pay for the assistant’s back surgery because he did not seek prior approval for the surgery. The court concluded that the assistant was not required to seek prior approval because his decision to obtain unauthorized care fell under the “other good reason” exception.

The court found that the assistant acted in good faith when he sought treatment from the surgeon without obtaining the department’s approval. The record also showed that the course of treatment offered by the department was inadequate. Despite the efforts of two physicians and other health care professionals, the assistant still suffered pain which was getting progressively worse. At one visit to the clinic, the assistant used a cane even though the department’s physician concluded less than two months earlier that he was at maximum medical improvement and did not sustain a ratable impairment. The court also found that the surgeon’s treatment was “reasonable and necessary” and improved the assistant’s medical condition.

Officer Secures Total Disability for PTSD 12 Years After Incident

Duncan v. State of Michigan, 28 MIWCLR 47 (Mich. C.A.C. 2014)

Ruling: The Michigan Compensation Appellate Commission granted an open award of benefits to an officer for mental disability injuries due to being held hostage by inmates in 1990.

What it means: In Michigan, a worker’s delayed response to a traumatic event that led to her disability and need to leave work will support an award for benefits.

Summary: The commission affirmed the magistrate’s decision granting an open award of benefits to a corrections officer for mental disability injuries due to being held hostage by inmates in 1990. She returned to work in 1991 but never felt safe in any of the job positions she was assigned. She left work in 2002 and eventually received a duty-related retirement. She alleged mental injury as well as an orthopedic condition. The magistrate found no evidence of a work-related physical injury in 2002. However, the magistrate found that a delayed response to the traumatic work event in 1990 led to the officer’s total disability and necessity to leave work in 2002 and was the cause of her post-traumatic stress syndrome. In affirming, the commission refused to disturb the magistrate’s reasonable choices of medical evidence.


The commission determined that the magistrate’s finding of total disability due to the 1990 work incident was fully supported by the medical witnesses, treating practitioners, and other examining expert witnesses. The majority of the medical expert witnesses fully supported a finding that the officer was totally disabled and not employable in any occupation suitable to her experience, training, and education.

Firefighter Files Claim for Injury Sustained When Rising from Chair

Chambers v. Monroe County Board of Commissioners, No. A14A0265 (Ga. Ct. App. 07/16/14)

Ruling: The Georgia Court of Appeals held that a firefighter’s knee injury was not compensable because it did not arise out of her employment.

What it means: In Georgia, an injury arises out of a worker’s employment when there is a causal connection between the employment and the injury.

Summary: A firefighter for Monroe County was sitting at a desk watching television. Her supervisor asked her to get up from the desk so he could use it. When she rose from the chair, the firefighter felt and heard a “pop” in her left knee. She underwent knee surgery. The firefighter sought benefits. The Georgia Court of Appeals held that she was not entitled to benefits.

The firefighter testified that she did not get up from the chair in an unusual manner. She offered no testimony to establish a causal connection between her employment and her injury. For example, she did not assert that the chair or desk configuration caused her to lose her balance or strain to reach a standing position, that a work-related emergency such as a fire alarm caused her to jump out of the chair in a hurried manner, or that she came into contact with any object or hazard such as the desk, stairs, or a piece of equipment. The court concluded that the firefighter’s injury did not arise out of her employment.

A dissenting judge opined that where the undisputed evidence shows that the worker was injured while undertaking a physical activity at the express direction of her supervisor, the injury arose out of and in the course of the employment. The judge opined that in this case, there was a sufficient causal connection between the conditions of employment and the resulting injury to warrant compensation.

Worker’s DVT Is Compensable ‘Spill-Over’ Injury

Architectural Wall Systems v. Towers, No. 13-1653 (Iowa Ct. App. 07/16/14)

Ruling: The Iowa Court of Appeals held that a worker’s deep vein thrombosis was a compensable industrial disability.

What it means: In Iowa, if a worker’s injury is not confined to one of the scheduled areas, the injury is compensated industrially by consideration of the worker’s lost earning capacity.


Summary: An industrial worker/glazier was injured when he twisted and fractured his right ankle while working for Architectural Wall Systems. He underwent surgery to repair the broken ankle. Six weeks after surgery, the worker experienced pain and swelling in his right leg, and he was diagnosed with deep vein thrombosis. A surgeon removed a blood clot and inserted a filter to prevent clots from moving to the worker’s heart or lungs. The worker sought benefits for his DVT. The Iowa Court of Appeals held that the worker’s DVT was a compensable industrial disability.

The court found that AWS was correct that all the medical evidence supported that the injury was confined to the worker’s lower extremity. Each doctor concluded that the DVT was confined to the worker’s right lower extremity. The clots did not travel elsewhere to the body, and the cause of the DVT — trauma to the ankle — restricted the condition to the lower extremity. The court pointed out that the permanent placement of the filter outside of the worker’s leg was evidence of an ongoing disability outside of the leg but still within the lower extremity. The court found that the worker’s DVT represented a “spill-over” injury, which was compensable as an injury to the body as a whole.

The court awarded the worker 60 percent industrial disability. Substantial evidence showed that the worker was on the path to becoming a glazier and was hired in that capacity. The injury substantially impacted his earning capacity. He was unable to reenter the apprenticeship program and become a glazier. Also, his permanent restrictions limited his capacity to perform manual labor, the only work for which he was reasonably suited.

Worker’s Horseplay Nixes Petition for Benefits

Barrett v. Service Management Systems, Inc., 29 PAWCLR 118 (Pa. W.C.A.B. 2014)

Ruling: The Workers’ Compensation Appeals Board affirmed the workers’ compensation judge’s decision denying benefits to a worker, who was injured when the utility vehicle he was driving rolled over. Evidence indicated the worker was not in the course and scope of his employment at the time of the accident.

What it means: In Pennsylvania, a claimant’s injury that is caused by his horseplay, rather than a condition of the employer’s premises, is not compensable.

Summary: A worker testified he was returning to the work area with a lunch he purchased at a nearby gas station when the utility vehicle he was driving started “cutting out.” He hit the gas, and the vehicle started sliding on snow and ice. He hit a dry patch, and the vehicle flipped over. However, two witnesses testified that before the accident they observed the worker performing “fish-tails” and skidding. The WCJ denied benefits. Relying on the testimony of the two witnesses, the WCJ found the worker’s injury occurred while he was attempting to fish-tail the vehicle he was driving. In affirming, the board determined the worker was not acting in furtherance of the employer’s business as he was attempting to fish-tail the vehicle in an overflow parking lot, allegedly on his way back from picking up lunch.

Also, the worker’s injury was not caused by a condition of the premises. Rather, the injury was due to the worker’s horseplay. Therefore, the worker failed to establish an injury occurred in the course and scope of his employment.

Harassment by Co-worker’s Spouse Triggers Compensable Stress Disorder

Mosley v. Hannaford Brothers Co., No. 517175 (N.Y. App. Div. 07/03/14)

Ruling: The New York Supreme Court, Appellate Division held that a manager was entitled to benefits for the exacerbation of his post-traumatic stress disorder.

What it means: In New York, an award of workers’ compensation is appropriate if there is any nexus between the motivation for the assault and the employment.


Summary: An assistant store manager for Hannaford Brothers made a telephone call to a coworker at her home to discuss a work-related matter. The coworker’s husband became convinced that the manager and the coworker were engaged in a romantic relationship. The husband took threatening and harassing conduct against the manager, culminating in an unsuccessful murder-for-hire plot against him. Also, the coworker’s husband contacted the manager’s supervisor regarding the alleged affair, triggering an internal investigation by Hannaford and resulting in the manager requesting a transfer to another store. The manager’s preexisting post-traumatic stress disorder was exacerbated to the point that he was unable to continue to work. He filed a claim for benefits. The New York Supreme Court, Appellate Division held that he was entitled to benefits.

Hannaford argued that the manager’s claimed injury was not causally related to his employment. The court disagreed, finding a nexus between the threatening conduct that exacerbated his condition and his employment. The work-related phone call from the manager to his coworker’s home was the basis for the harassment at the manager’s place of employment, Hannaford’s internal investigation, and the manager’s request for a transfer that exacerbated his preexisting stress disorder.

Christina Lumbreras is a Legal Editor for Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at
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Sponsored: Lexington Insurance

The Re-Invention of American Healthcare

Healthcare industry changes bring risks and opportunities.
By: | September 15, 2014 • 5 min read

Consolidation among healthcare providers continues at a torrid pace.

A multitude of factors are driving this consolidation, including the Affordable Care Act compliance, growing costs and the ever-greater complexity of health insurance reimbursements. After several years of purchasing individual practices and regional hospital systems, the emergence of the mega-hospital system is now clear.

“Every month, one of our clients is either being bought or buying someone — and the M&A activity shows no signs of slowing down,” said Brenda Osborne, executive vice president at Lexington Insurance Co.

This dramatic change in the landscape of healthcare providers is soon to be matched by equally significant changes in patient behavior. Motivated by growing out-of-pocket costs and empowered with new sources of information, the emergence of a “healthcare consumer” is on the horizon.

Price, service, reputation and, ultimately, value are soon to be important factors for patients making healthcare decisions.

Such significant changes bring with them new and challenging risks.

Physician integration

Although physicians traditionally started their own practices or joined medical groups, the current climate is quite the opposite. Doctors are now seeking out employment by health systems. Wages are guaranteed, hours are more stable, vacations are easier to take, and the burdens of running a business are gone.

“It’s a lot more of a desirable lifestyle, particularly for the younger generation,” said Osborne.

Brenda Osborne discusses the changing healthcare environment and the risks and opportunities to come.

Given the strategic importance of successfully integrating acquired practices into a larger healthcare system, hospitals are rightfully focused on how best to keep doctors happy, motivated and focused on patient safety.

A key issue that many hospitals struggle with is how to provide effective liability insurance for their doctors. Physicians who previously owned their practice are accustomed to a certain type of coverage and they expect that coverage to continue.

Even when operators find comparable liability insurance solutions for their doctors, getting buy-in from their staff is often an additional hurdle to overcome.

“Physicians listen to two things — physician leaders and data,” said Osborne. “That’s why Lexington provides assessments that utilize deep data analysis, combined with providing insights from leading doctors to help explain trends and best practices.

“In addition, utilizing benchmarks against peers helps to identify gaps in best practices. It’s a very powerful approach that speaks to doctors in a way that will help them improve their risk.”

Focusing on the “continuum of care”

There’s been a fundamental shift in how healthcare providers care for patients: Treatment is becoming more focused on a patient’s overall health status and related needs.

SponsoredContent_LexA cancer patient, for example, should have doctors in a number of specialties communicating and working together toward a positive patient outcome. But that means a change in thinking: Physicians need to work collaboratively with one another — not easy for individuals or groups that are used to being independent. Healthcare is a team sport.

“If there isn’t strong communication, strong leadership, and the recognition of proper treatment procedures between physicians, healthcare providers can increase the risk of error,” said Osborne. “The provider has got to treat the whole patient rather than each individual condition.”

That coordination must extend from inpatient to outpatient, especially since the ACA has led to a rapid increase in patients being treated at outpatient clinics, or via home health or telehealth to reduce the cost of inpatient care

“Home health is going be a growing area in the future,” Osborne continued. “Telehealth will become an effective and efficient way of managing and treating patients in their home. A patient might have a nurse come in and help the healthcare provider communicate with a physician through an iPad or computer. The nurse can also convey assessment findings to the physician.”

Metrics matter more than ever

Patients have not always thought of themselves as healthcare consumers, but that’s changing dramatically as they pay more out of pocket for their own healthcare. At the same time, there’s an increase in metrics and data available to the public — and healthcare consumers are drawing upon those metrics more and more when making choices that affect their health.

SponsoredContent_Lexington“Consumers are going to start measuring physicians against physicians, healthcare systems against healthcare systems. That competition will force everyone to improve the quality of care.”
– Brenda Osborne, Executive Vice President, Lexington Insurance

Think about all the research a consumer does before buying a car. Which dealership has the best price? Who provides the best service? Who’s offering the best financing deal?

“Do patients do that with physicians? No,” said Osborne. “Patients choose physicians through referrals from friends or health plans with minimal information. Patients may be putting their lives in the physicians’ hands and not know their track record.

That’s all going to change as patients’ use of data becomes more widespread. There are many web based resources to find information on physicians.

“Consumers are going to start measuring physicians against physicians, healthcare systems against healthcare systems,” said Osborne. “That competition will force everyone to improve the quality of care.”

Effective solutions are driven by expertise and vision

The rapidly evolving healthcare space requires all healthcare providers to find ways to cut costs and focus on patient safety. Lexington Insurance, long known as the leading innovative and nimble specialty insurer, is at the forefront in providing clients cutting-edge tools to help reduce costs and healthcare exposures.

These tools include:

  • Office Practice Risk Assessment: To support clients as they acquire physician practices, Lexington developed an office practice assessment tool which provides a broad, comprehensive evaluation of operational practices that may impact risk. The resulting report, complete with charts, graphs and insights, includes recommendations that can help physicians reduce risk related to such issues as telephone triage, lab results follow-up and medication management. .
  • Best Practice Assessments: High risk clinical areas such as emergency departments (ED) and obstetrics (OB) can benefit significantly from external, objective, evidence-based assessments to identify gaps and assure compliance with best practices. In addition to ED and OB, Lexington can provide a BPA for peri-operative care, prevention of healthcare-acquired infections, and nursing homes. All assessments result in a comprehensive report with recommendations for improvement and resources along with consultative assistance and support. .
  • Continuing Education: In an effort to improve knowledge, decrease potential risk and support healthcare providers in the use the most current tools and techniques, Lexington provides Continuing Medical Education credits at no cost to hospitals or their physicians.
  • Targeting the Healthcare Consumer: With Medicare reimbursement impacted by patient-satisfaction surveys, assuring a positive patient experience is more critical than ever. Lexington helps hospitals understand and improve the patient experience so they can continue to earn the trust of healthcare consumers while preserving their good reputation. .

To learn more about Lexington Insurance’s scope and depth of the patient safety consulting products and services healthcare solutions, interested brokers may visit their website.

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Lexington Insurance. The editorial staff of Risk & Insurance had no role in its preparation.

Lexington Insurance Company, an AIG Company, is the leading U.S.-based surplus lines insurer.
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