The New Normal
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.
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.
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.
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.
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.
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.”
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.
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.” &
Facing the Unthinkable: What happens in the hours, days and weeks following a sudden, disabling injury?
Road to Recovery: When it’s time to send patients home, there are new challenges to tackle, for both patients and payers.
Creeping Catastrophes: The final story of the series (coming in November) focuses on “creeping” catastrophic claims.
The Case for Exoskeletons
I hope more workers’ compensation insurers seriously evaluate paying for exoskeletons that allow patients with certain spinal cord injuries to rise from their wheelchairs and walk.
Exoskeletons are assistive devices often described as “wearable robots” or “Segways with legs.” Since 2014, the Food and Drug Administration has approved two models for personal use, including one earlier this year.
Some workers’ comp insurers have already approved a few claims for the motorized devices and the cost of training. Other underwriters have declined to fund them.
The battery-powered devices cost at least $80,000 plus additional training. Safety questions remain and some doctors who agree on the medical benefits they provide are still wary of certifying them as “medically necessary.”
But the products are among technological advancements in patient care — like increasingly sophisticated prosthesis — that payers should learn about to adequately weigh the exoskeleton’s price tag against potential medical care and medication expense reductions resulting from their benefits.
“Psychological benefits also result from standing, walking and looking others eye to eye. Well-being impacts claims expense.” – Clare Hartigan, physical therapist, exoskeleton clinical trail leader at Shepherd Center
Attendees at the National Workers’ Compensation and Disability Conference® & Expo in New Orleans can watch an injured worker’s exoskeleton demonstration during a session titled “The Bionic Claimant: Emerging Medical Technology’s Impact on Care and Cost.”
Clare Hartigan, a physical therapist who will speak during the session, has led clinical trials on exoskeletons at the Shepherd Center, a rehab hospital in Atlanta. She will be joined by Mark Sidney, VP of claims at Midwest Employers Casualty Co.
Exoskeletons’ well-documented medical benefits for spinal injury patients include improved bowel and bladder function, weight loss and better glucose test results, Hartigan said.
“Psychological benefits also result from standing, walking and looking others eye to eye,” Hartigan said. “Well-being impacts claims expense.”
Apart from clinical uses and workers’ comp, other exoskeleton applications are emerging. The military is testing robotic-like suits that could help soldiers carry more weight and reach the battleground less fatigued.
The National Institute for Occupational Safety and Health expects rapid growth in industrial wearable exoskeleton suits that can help workers lift greater loads or hold up heavier tools for longer periods.
But it would also be great to see more workers who have lost their mobility in workplace accidents benefit from the health and quality-of-life improvements exoskeletons offer. Perhaps that will come as more insurers learn about exoskeletons and begin evaluating their unit costs against their impact on medical expenses.
We can also hope for decreases in exoskeletons’ cost as commonly occurs with most technology products. But the companies offering them will need to recoup their R&D expenses. &
Hot Hacks That Leave You Cold
Thousands of dollars lost at the blink of an eye, and systems shut down for weeks. It might sound like something out of a movie, but it’s becoming more and more of a reality thanks to modern hackers. As technology evolves and becomes more sophisticated, so do the occurrence of cyber breaches.
“The more we rely on technology, the more everything becomes interconnected,” said Jackie Lee, associate vice president, Cyber Liability at Nationwide. “We are in an age where our car is a giant computer, and we can turn on our air conditioners with our phones. Everyone holds data. It’s everywhere.”
Phishing Out Fraud
According to Lee, phishing is on the rise as one of the most common forms of cyber attacks. What used to be easy to identify as fraudulent has become harder to distinguish. Gone are the days of the emails from the Nigerian prince, which have been replaced with much more sophisticated—and tricky—techniques that could extort millions.
“A typical phishing email is much more legitimate and plausible,” Lee said. “It could be an email appearing to be from human resources at annual benefits enrollment or it could be a seemingly authentic message from the CFO asking to release an invoice.”
According to Lee, the root of phishing is behavior and analytics. “Hackers can pick out so much from a person’s behavior, whether it’s a key word in an engagement survey or certain times when they are logging onto VPN.”
On the flip side, behavior also helps determine the best course of action to prevent phishing.
“When we send an exercise email to test how associates respond to phishing, we monitor who has clicked the first round, then a second round,” she said. “We look at repeat offenders and also determine if there is one exercise that is more susceptible. Once we understand that, we can take the right steps to make sure employees are trained to be more aware and recognize a potentially fraudulent email.”
Lee stressed that phishing can affect employees at all levels.
“When the exercise is sent out, we find that 20 percent of the opens are from employees at the executive level,” she said. “It’s just as important they are taking the right steps to ensure they are practicing what they are preaching.”
Locking Down Ransomware
Another hot hacking ploy is ransomware, a type of property-related cyber attack that prevents or limits users from accessing their system unless a ransom is paid. The average ransom request for a business is around $10,000. According to the FBI, there were 2,400 ransomware complaints in 2015, resulting in total estimated losses of more than $24 million. These threats are expected to increase by 300% this year alone.
“These events are happening, and businesses aren’t reporting them,” Lee said.
In the last five years, government entities saw the largest amount of ransomware attacks. Lee added that another popular target is hospitals.
After a recent cyber attack, a hospital in Los Angeles was without its crucial computer programs until it paid the hackers $17,000 to restore its systems.
Lee said there is beginning to be more industry-wide awareness around ransomware, and many healthcare organizations are starting to buy cyber insurance and are taking steps to safeguard their electronic files.
“A hospital holds an enormous amount of data, but there is so much more at stake than just the computer systems,” Lee said. “All their medical systems are technology-based. To lose those would be catastrophic.”
And though not all situations are life-or-death, Lee does emphasize that any kind of property loss could be crippling. “On a granular scale, you look at everything from your car to your security system. All data storage points could be controlled and compromised at some point.”
The Future of Cyber Liability
According to Lee, the Cyber product, which is still in its infancy, is poised to affect every line of business. She foresees underwriting offering more expertise in crime and becoming more segmented into areas of engineering, property, and automotive to address ongoing growing concerns.”
“Cyber coverage will become more than a one-dimensional product,” she said. “I see a large gap in coverage. Consistency is evolving, and as technology evolves, we are beginning to touch other lines. It’s no longer about if a breach will happen. It’s when.”
About Nationwide’s Cyber Solutions
Nationwide’s cyber liability coverage includes a service-based solution that helps mitigate losses. Whether it’s loss prevention resources, breach response and remediation expertise, or an experienced claim team, Nationwide’s comprehensive package of services will complement and enhance an organization’s cyber risk profile.
Nationwide currently offers up to $15 million in limits for Network Security, Data Privacy, Technology E&O, and First Party Business Interruption.
Products underwritten by Nationwide Mutual Insurance Company and Affiliated Companies. Not all Nationwide affiliated companies are mutual companies, and not all Nationwide members are insured by a mutual company. Subject to underwriting guidelines, review, and approval. Products and discounts not available to all persons in all states. Home Office: One Nationwide Plaza, Columbus, OH. Nationwide, the Nationwide N and Eagle, and other marks displayed on this page are service marks of Nationwide Mutual Insurance Company, unless otherwise disclosed. © 2016 Nationwide Mutual Insurance Company.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Nationwide. The editorial staff of Risk & Insurance had no role in its preparation.