Claims Trends

Treating the Whole Person

The biopsychosocial piece of workers’ compensation and return-to-work is getting more and more attention.
By: | August 3, 2015 • 6 min read
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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.

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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.R8-15p34-36 04Holistic.indd

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.

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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.

“No question.”

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.

 

Recovery Obstacles

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.

Rebecca Moya,  behavioral health manager, Sun Life Financial

Rebecca Moya, behavioral health manager, Sun Life Financial

“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.

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“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.

Debra Levy, senior VP, workers’ comp product management and national workers’ comp practice leader, York Risk Services Group

Debra Levy, senior VP, workers’ comp product management and national workers’ comp practice leader, York Risk Services Group

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.

Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.
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Column: Workers' Comp

An Unnecessary Death

By: | August 3, 2015 • 3 min read
Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.

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.

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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.

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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.

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Sponsored: Helmsman Management Services

The Quality Assurance Journey

Helmsman TPA is changing the claims management game with their enhanced quality assurance process, a welcome departure from the industry standard checklist approach.
By: | August 3, 2015 • 5 min read
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Not too long ago, if you were planning a trip, you would buy a map or an atlas and draw out the route you would take. If you continued to drive this route repeatedly, you might discover better ways to avoid a heavily congested area or take advantage of a new highway.

Similarly, a third party administrator (TPA) draws on years of experience to develop best practices for claims handling, discovering better routes and avoiding areas of delay. Payers trust their TPA to formalize these best practices, and to develop a Quality Assurance (QA) program that helps ensure claims are effectively managed. Like a roadmap, a QA program tracks the journey to the desired destination.

Mark Siciliano defines a quality assurance program.

With today’s technology, a cumbersome map is replaced with a GPS; just follow the step-by-step instructions. Sometimes the technology works flawlessly, and other times, it doesn’t deliver the best route.

Likewise, many QA programs have developed a checklist mentality, listing the steps to take. Such QA programs typically involve a small team reviewing a limited number of claims to ensure that key standards are consistently applied. While important, this doesn’t necessarily guarantee claims are optimally handled, or uncover ways to improve claim workflows and performance.

Mark Siciliano explains how Helmsman’s QA approach differs from the industry’s standard “checklist” mentality.

A New Process

Helmsman Management Services LLC, a third-party claims administrator and a member of Liberty Mutual Insurance, began to re-examine its QA program with the help of its clients several years ago. In doing so, they developed a new methodology that is a welcome departure from robotic checklist behavior.

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“Our QA program dives deeper to find actionable ways we can improve claims outcomes, the performance of claims professionals, and the entire claims management process,” noted Mark Siciliano, vice president and managing director of Helmsman Management Services. “We conduct more in-depth reviews on a higher volume of claims – more than 80,000 each year – at key points in the lifecycle. We involve over 800 field claims professionals and engage individual claims handlers and their managers through an online dashboard that reports performance and highlights opportunities to improve performance through additional training and coaching.”

Mark Siciliano discusses the Helmsman approach to quality assurance.

The new approach to QA was successful, enabling Helmsman to improve the overall quality of its clients’ claims by eight points in 2014. In fact, 92.7 percent of the claims Helmsman managed met or exceeded the TPA’s service standards in the fourth quarter of 2014, up from 84.5 percent in the first quarter of that year.

“Re-engineering our QA program and moving it beyond the standard industry checklist approach took our claims management from really good to great,” said Siciliano. “And, it is helping us drive further improvements.”

One of the reasons for that improvement is Helmsman’s QA process keeps adjustors focused on what works best.

“We looked at the common characteristics of really great outcomes and worked backwards,” said Siciliano. “We found that when our claims professionals start with an empathetic approach, they are better able to connect with the injured employee and deliver better outcomes, both for the claimant and her or his employer.”

Like blindly following GPS instructions, a claims professional can easily fall into a pattern of completing tasks and forget that an injured person may be experiencing a very challenging time in their life. Helmsman trains its claims professionals to treat the injured worker as if they are dealing with a family member. It’s not just asking questions and moving through a checklist; it’s answering an injured worker’s questions, providing important information, and doing so with a level of compassion.

Once a conversation has begun and the injured worker is more at ease, the claims professional can ask questions beyond what might be in the process to really understand the injury, the individual, and the claim, and to find that best route to the ultimate destination of return to work. This inquisitive nature of the claims professional also allows for early discovery of any specific challenges in the claim – such as co-morbid conditions or psycho-social issues – paving the way for intervention to get the claim back on track.

“We call it humanistic common sense,” said Siciliano. “We know we have to ask the tough questions and protect our clients’ financial interests, but when we do so through a positive and supportive lens, it permeates throughout the entire process, facilitating the journey.”

Building a relationship with medical providers using this same approach can also assist the claim.

Helmsman_BrandedContent“Re-engineering our QA program and moving it beyond the standard industry checklist approach took our claims management from really good to great. And, it is helping us drive further improvements.”
— Mark Siciliano, Vice President and Managing Director, Helmsman Management Services

In the case of light duty restrictions, instead of ‘check’ and move on after the initial call with the treating physician, Helmsman asks for more details on what the injured worker can do, and helps the physician understand the claimant’s duties and the temporary jobs available. Helmsman might ask the doctor to join them for a site visit to better understand the work environment.

As a result, light duty jobs become gainful and meaningful work for the injured worker because they are tailored to their capabilities.

“We’re not just asking for medical information and work capacity; we’re actually working with our clients and the physicians to create a return-to-work environment that works for the injured worker, employer, and physician,” said Siciliano.

 

Evolution of Change

Helmsman_BrandedContentA QA program that delivers a high level of value to the employer and improves outcomes for the injured worker is just the beginning. QA is more than a program—it’s a process. Quality assurance programs are critical for tracking and improving performance. It’s a continuous cycle of training, learning, client feedback, and process improvement.

“Our enhanced QA program helps us better service our clients, but we know it’s an ongoing process,” said Siciliano. “Our continuous improvement process is built around the investment that we put in our people, systems, and technology. It’s also response to the changing landscapes around us, and how well we adapt to them.”

Mark Siciliano describes characteristics of effective quality assurance programs.

As a result, quality assurance programs are not working towards just a destination; they’re working towards the evolution of change, and how risk managers, brokers, and TPAs respond to it. The QA process becomes that journey.

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




Helmsman Management Services (HMS) helps better control the total cost of risk by delivering superior outcomes for workers compensation, general liability and commercial auto claims. The third party claims administrator – a member of Liberty Mutual Insurance – delivers better outcomes by blending the strength and innovation of a major carrier with the flexibility of an independent TPA.
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