Treating the Whole Person
Recent research from Gallup and Healthways Inc. shows what claims payers already know: The percentage of obese Americans continues to increase. In their May 2015 report, Gallup and Healthways stated that the nation’s obesity rate rose again in 2014, reaching 27.7 percent, up from 27.1 percent in 2013.
Even more unsettling — and perhaps surprising to some — is that research indicates changes in diet and exercise are not enough to reverse the trend.
What’s needed, according to the studies, is a more holistic engagement that boosts a person’s sense of purpose and strengthens their community and social relationships; even their financial health.
Professionals that help injured workers address biopsychosocial issues say they agree with that assessment. They also say it is increasingly a factor in their work with employers and other workers’ compensation and disability claims payers.
Biopsychosocial issues refer to psychosocial factors impacting a person’s medical problems, said Michael Coupland, CEO and network medical director at Integrated Medical Case Solutions Group, which provides biopsychosocial assessments and interventions.
Most biopsychosocial approaches take into account that factors such as emotions, behaviors, social environments and culture all impact human medical conditions and performance.
Services addressing biopsychosocial problems are being applied more often when medical treatment alone fails to mend injured workers. They can help with depression, pain medication misuse and obesity, which can delay or even thwart successful return to work.
About 75 percent of the workers’ comp and disability claimants referred to his group are obese or morbidly obese, IMCS’s Coupland said. They are referred by claims payers, treating physicians, self-insured employers and others.
“They are the people that tend to have psychosocial factors that are delaying their recovery,” Coupland said.
IMCS Group specialists offer their patients cognitive-behavioral techniques for taking control of their health and wellness, Coupland said. The techniques include meditation, mindfulness and biofeedback.
Those practices can help, for example, with decreasing muscle discomfort so recovering workers are able to go for walks and reap the benefits of exercise.
Darrell Bruga, founder and CEO, LifeTEAM Health, agrees with the Gallup and Healthways findings that factors such as social interactions, financial well-being and a sense of purpose must be addressed.
Bruga said many of the injured and disabled workers his company sees are obese, although his organization does not directly treat obesity. LifeTEAM professionals provide services for reducing psychosocial and return-to-work obstacles.
Interventions that help people develop a sense of purpose, achieve financial well-being and develop community interactions “are exactly the sort of things we are focused on in helping people re-engage,” Bruga said.
“It makes sense that if you are having challenges from a psychosocial standpoint in life as a whole, that is certainly going to impact your well-being and potentially your body composition,” he said.
But it’s important to recognize that returning to work is part of the solution — it can help meet the needs the researchers outline because work is social and it also improves peoples’ financial position, Bruga added.
“It makes sense that if you are having challenges from a psychosocial standpoint in life as a whole, that is certainly going to impact your well-being and potentially your body composition.” — Darrell Bruga, founder and CEO, LifeTEAM Health
Bruga will speak on mitigating psychosocial risk factors with biopsychosocial measures during the National Workers’ Compensation and Disability Conference® & Expo to be held at Mandalay Bay in Las Vegas November 11-13.
Dr. John T. Harbaugh, occupational medicine physician director at Southern California Permanente, will join Bruga and share results from helping his organization’s injured employees overcome psychosocial risks with a biopsychosocial strategy.
What’s important to keep in mind in managing the biopsychosocial aspect of work injury and return-to-work is that any injury creates stress for both the employer and the employee. The mere fact that a once-productive employee is leaving work creates a host of issues.
“There is a stigma to going out of work. Nobody wants to go out on leave,” said Rebecca Moya, a behavioral health manager with Sun Life Financial.
“So if we can battle that, have employers manage that piece in a more empathetic, supportive and understanding way, that’s one less hurdle that insurers or benefit analysts or vocational rehabilitation consultants have to jump over to get there,” Moya said.
There is also psychological trauma that lives within a worker who associates pain and injury with their workplace.
“It’s hard to revisit and go back to that place,” Moya said.
“We’ve worked with employers to ask, ‘Are there other sites? Is it possible to have this person work at a different site?’ Because they’re ready to come back — it’s just that the emotional and psychological aspect of returning to the site of their injury is very challenging,” she said.
There are also the injuries to self-esteem and the sense of self-worth that a physical injury can bring about.
Even without obesity or some other comorbidity dogging them, a worker who faithfully performed a task for decades can suffer a loss of confidence or suffer depression when a work injury means they will never be as strong or able again.
“That’s hard for people. They don’t always want to go back and do something different. Even with accommodations, it’s hard for people to accept that’s going to be the way things are going to be going forward,” Moya said.
Overcoming those fears and that damage to self-esteem means focusing on the positive, Moya said.
“If an analyst starts off a relationship with an injured worker with a positive, ‘We’re going to work on your abilities, not your disabilities, and we are going to get you back to work,’ then people are really receptive to that.
“It’s all about the foundation you lay at the start of a claim,” Moya said.
IMCS Group’s Coupland agrees that helping people return to work and reclaim their sense of purpose is a key piece of the well-being issue that the Gallup and Healthways researchers raise.
“We get so much of our purpose from work,” Coupland said.
Data Drives Down Skepticism
Growing acceptance of paying for biopsychosocial approaches to wellness is being helped along by a significant shift that occurred in 2009, Coupland added.
Health providers in psychology gained the ability to provide health and behavior treatments under Current Procedural Terminology codes for physical medicine rather than having to provide them as treatments under psychiatric codes, he said.
Now, workers’ comp payers are much more accepting of the treatments, Coupland said.
Even so, some workers’ comp claims payers are skeptical about a concept calling for treating the “whole person” and are still reluctant to pay for providing injured workers with biopsychosocial treatment approaches.
But increasingly, sophisticated claims payers are funding such programs and their numbers will continue to rise, said Debra Levy, senior VP of workers’ comp product management and national workers’ comp practice leader for York Risk Services Group.
Payers funding those programs are doing so because their data shows a positive return on investment, Levy said.
“The earlier you can recognize those are factors and offer solutions or guided care … you see a positive impact as opposed to throwing away money,” she said.
An Unnecessary Death
Brandon Clark’s demise and his family’s victory in a legal battle for death benefits makes one wonder whether remedies among the expanding list of workers’ compensation claims services might have saved his life.
It’s an important question because the carpenter left behind a grieving family, including children. It also offers a chance to weigh the potential value those services might provide disabled workers, their devastated families and claims payers.
In the case of South Coast Framing v. Workers’ Compensation Appeals Board, the California Supreme Court laid out the lessons to be gleaned from the case, finding in favor of providing death benefits.
The court addressed issues expected to arise across more states, mirroring the industry’s concerns that too many injured workers have been prescribed an abundance of harmful drugs, including opioids.
Clark was 36 when he fell from a height of 10 feet in 2008, suffering a concussion and neck and back injuries that caused progressive pain until he died 10 months later of an overdose of prescription medications.
His family presented arguments about causation and the degree to which drugs prescribed by workers’ comp doctors and his personal doctor played a role in Clark’s death.
The court said the family met a standard that only required proving industrial causation is reasonably probable. There was evidence that Ambien, prescribed for pain-induced sleep problems, was causally related to his work injury while drugs prescribed by a workers’ comp doctor for depression and pain played at least some role in the death.
When you hear about the magnitude of a family’s loss, it makes one think that the value of all those workers’ comp services must be considered in more than just financial terms.
California claims payers now face a lower causation standard than they perhaps expected when multiple factors contribute to a worker’s death, including prescription combinations.
Since Clark’s 2008 injury, workers’ comp has seen an expanding list of services increasingly applied to address a rise in challenging disabilities, prescription misuse and increased medical expenses. I’m thinking of the growth in pharmacy benefit reviews, nurse case management and predictive analytics, to name just a few.
It’s always prudent to question the value of those services and whether inefficient application or overuse might drive unnecessary expenses.
But Clark’s death, among numerous other cases, also raises the question of whether a pharmacy benefit manager’s review of his prescriptions might have raised a warning. Or whether a nurse case manager’s discussions with Clark might have provided life-saving pain-treatment alternatives.
The court records don’t show whether Clark received such services, and my attempt to reach his family through their attorney failed. But considering several factors, including the accident year and his employment as a carpenter, I suspect there is a possibility he didn’t.
The attorney did tell me, though, that Clark’s family was his life’s focus and that they struggled to understand his demise.
When you hear about the magnitude of a family’s loss, it makes one think that the value of all those workers’ comp services must be considered in more than just financial terms. It’s not just a question of whether they reduce claims costs, eliminate litigation or improve worker productivity.
There are also families needing someone to deliver the right care that will spare them the painful financial and emotional devastation that comes with prolonged disabilities and the loss of a loved one.
Specialty Drugs Show No Signs of Slowing Down
A decade ago, high-cost specialty drugs were commonly referred to as “injectable drugs” and were used to treat conditions not typically covered in workers’ compensation, such as cancer, rheumatoid arthritis and multiple sclerosis.
“Today, however, new specialty drugs are emerging that will be used to treat other chronic and inflammatory conditions,” said Joe Boures, president and CEO of Healthcare Solutions, an Optum company providing specialized pharmacy benefit management services to the workers’ compensation market.
“Payers in the workers’ comp market are just beginning to feel the cost impact of greater utilization of these drugs, which come with expensive price tags.”
Specialty drugs are often manufactured using biologic rather than chemical methods, and they are no longer just administered by injections. New specialty drugs can also be inhaled or taken orally, likely contributing to the rise in their utilization.
“There isn’t a standard definition of specialty drugs, but they are generally defined as being complex to manufacture, costly, require specialty handling and distribution, and they difficult for patients to take without ongoing clinical support or may require administration by a health care provider,” said Boures.
In 2014, more than a quarter of all new therapies that the FDA approved were through its biologics division. Biologics, and similar therapies, are representative of a future trend in prescription drug spend.
“As the fastest growing costs in health care today, specialty drugs have the potential to change the way prescription benefits are provided in the future,” said Jim Andrews, executive vice president of pharmacy for Healthcare Solutions.
Workers’ Compensation payers may not recognize how specialty drugs are affecting their drug spend.
Specialty drugs like Enbrel®, Humira® and Synvisc® can be processed in conjunction with other medical procedures and, therefore, not recognized by payers as a pharmacy expense.
This leaves payers with little visibility into the costs of these medications within their book of business and a lack of tools to control these costs.
Due to the high costs of specialty medications, special due diligence should be utilized when claimants receive these medications, up to and including utilization review, said Andrews.
“Healthcare Solutions recommends that claimants using specialty drugs are monitored for proper medication handling and that the medication is administered appropriately, as well as monitoring the claimant to determine whether the medication is having its desired results and if there are any side effects,” he said.
“At $1,000 per pill for some of these specialty medications, making sure a claimant can tolerate the side effects becomes vital to making sure the claimant achieves the desired outcomes.”
Hepatitis C drugs have made their way to the workers’ compensation market, largely through coverage of healthcare workers, who have exposure to the disease.
“Traditional drug treatments that began in the 1990’s had a success rate of 6% and costs ranging from $1,800 to over $88,000,” said Andrews.
“The new Hepatitis C specialty medications have a treatment success rate of 94-100%, but cost between $90,000 and $226,000.”
Although the new treatments include higher drug costs, the payer’s overall medical costs may actually decrease if the Hep C patient would have required a liver transplant as part of the course of treatment without the drugs.
While the release of new Hepatitis C medications in 2014 demonstrated the potential impact specialty medications can have on workers’ compensation payers, there are some specialty medications under development that target more common conditions in workers’ compensation.
Pfizer Inc. and Eli Lilly and Company are currently developing tanezumab, a new, non-narcotic medication to treat chronic pain, which is common in workers’ compensation claims.
Tanezumab has demonstrated benefits of reducing pain in clinical trials and may provide non-addictive pain relief to claimants in the future. This may change how pain management is treated in the future.
Healthcare Solutions has a specialty medication program that provides payers discounted rates and management oversight of claimants receiving specialty medications.
Through the paper bill process, Healthcare Solutions aids payers in identifying specialty drugs and works with adjusters and physicians to move claimants into the specialty network.
A central feature of the program is that claimants are assigned to a clinical pharmacist or a registered nurse with specialty pharmacy training for consistent care with one-on-one consultations and ongoing case management.
The program provides patients with education and counseling, guidance on symptoms related to their medical conditions and drug side effects, proactive intervention for medication non-adherence, and prospective refill reminder and follow-up calls.
“The goal is to improve patient outcomes and reduce total costs of care,” said Boures.