Nurse Case Management

Targeted Nurse Assignment Boosts Outcomes

Nurses with the right skills and experience have been shown to have significant impact on red-flag claims.
By: | July 9, 2015 • 3 min read
Medical Exam700X525

Data analytics is not new to workers’ comp, but applying it more specifically to the decision to include nurses on a claim is a new and effective way to improve outcomes and lower costs. A new report from Helmsman Management Services, a third party administrator for Liberty Mutual that provides claims management and risk control services, describes a “decision-support model” that helps clients determine which cases can benefit from adding a nurse, and when.


To prove the advantages of including a nurse, Helmsman compiled 4,000 claims with similar profiles – except that half had a nurse and the other half did not. Their side-by-side comparison showed that claims that had a nurse involved were resolved about 15 percent faster, reduced overall costs by 26 percent and lowered future medical costs by 18 percent. The report dubbed this impact the “N-Factor.”

But this doesn’t mean every claim should automatically be assigned a nurse.

“Take the example of an injured employee who had no comorbid conditions and a positive relationship with the employer, was receiving appropriate medical care and was working in transitional duty,” said Mary O’Donoghue, vice president and manager, medical services, commercial Insurance, at Liberty Mutual. “Adding a nurse to this claim would not significantly impact its outcome but would increase its cost.”

Helmsman’s analytics program collects data on 25-30 variables, which include body part injured, the claimant’s motivation to return to work, bill payments for comorbid conditions, and above-average use of narcotics. It then alerts claims managers when a case is high-risk, and recommends assigning a nurse

Nurses can be instrumental when claims get more complicated, both by helping the worker stick to his treatment plan, and by keeping lines of communication between worker, employer and claims managers open.

“In talking with a claimant, a nurse might identify a comorbid condition, and get that injured employee into a management program to better control the condition so that the workplace injury can be more effectively treated,” O’Donoghue said.

“Or a nurse might question a proposed treatment plan — including the timing or quantity of powerful prescriptions — review his or her concerns with one of Liberty Mutual’s medical directors, and arrange for the medical director to speak with the treating physician about those concerns and the latest evidence based treatment options.”

Nurses can be instrumental when claims get more complicated, both by helping the worker stick to his treatment plan, and by keeping lines of communication between worker, employer and claims managers open.

Finding the right nurses to navigate a claim can be a challenge. The best candidates possess the “soft skills” of effective communication and attentive listening, as well as understanding of the workers’comp process and the goals and expectations of every party involved.


“The most effective nurses also have advanced case management/rehab certifications, as well as experience and education in mental health,” O’Donoghue said.

Finding and training the right nurses certainly requires an investment of time and resources, and applying data analytics to key decision-making is a trial-and-error endeavor, but the “N-Factor” is worth pursuing.

According to the report, “The N Factor: How Nurses Add Value to Workers Compensation Claims,” by 2019, “some insurance experts predict that medical care will make up two-thirds of workers’ compensation claim costs.”

Katie Siegel is a staff writer at Risk & Insurance®. She can be reached at [email protected]
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Insider's Perspective

What Lies Ahead for Healthcare Solutions

Healthcare Solutions CEO Joe Boures answers R&I's questions on client service, industry consolidation and the best Philly cheesesteaks.
By: | April 13, 2015 • 4 min read
Joe Boures2

Change is afoot for Healthcare Solutions, the parent company of Cypress Care, Procura Management, ScripNet and Modern Medical. The company’s acquisition by Catamaran closed on April 8. Catamaran, in turn, will be purchased by UnitedHealth, according to a late March announcement. Risk & Insurance® discussed the implications of the Catamaran acquisition with Joe Boures, CEO of Healthcare Solutions.


Healthcare Solutions made a major announcement recently, how do you expect this change to impact your clients?

The acquisition will have a positive long-term impact on our clients but our primary focus right now is making sure that we continue to service our customers with the same discipline and focus as we do today. Our client service model is staying the same so clients should not feel a disruption in service upon close of the acquisition.

Some acquisitions result in the need to re-implement a program as changes occur to the company’s technology platform. In our case, since Healthcare Solutions’ technology platform is already integrated with Catamaran, there is not a need to re-integrate with our customers as a result of the acquisition. This will allow us to stay focused on current initiatives to make our delivery of medical management services as impactful as possible.

How do you see this change playing out for the future of the company?

Without a doubt, the acquisition will have a positive impact on the future of the company.  It provides Healthcare Solutions a stable ownership structure in a rapidly consolidating marketplace, along with access to the resources of a $20 billion company.

Catamaran has a long history in the workers’ compensation space and this is an area of investment for the company. Customers will benefit from the combined organization.

Do you expect your role to remain the same?

Yes, I’ll move over as a senior leader of the workers’ compensation business, with similar functions as I have today.

The last few years saw a lot of consolidation in the workers’ comp industry.  Do you think we can expect to see more consolidation going forward and why?

Short answer, yes. The primary reason is that there are still a lot of private equity-owned companies with needed exit strategies.  There’s also competitive pressures that will ultimately lead to a consolidated marketplace.

You talk to a lot of customers.  What are the key challenges your customers tell you they are facing?

Customers continue to be challenged by medical cost inflation coupled with appropriate utilization controls. Healthcare Solutions’ customers are responsible for coordinating appropriate care for injured workers. They are concerned about injured worker safety and outcomes while also being mindful of spend.


If you just look at pharmacy as a microcosm of medical management, customers are concerned about the increase in compound drugs and physician dispensed drugs, as well as the potential over-prescribing of narcotic opioids. These issues alone are concerning to our customers from both a cost and safety point of view.

At the end of the day, customers are looking for how to do more with less. As businesses operate in leaner environments, they are looking for partners and technology solutions they can leverage to have the greatest impact on their programs.

You’ve been in this space for more than 20 years.  What is the most significant advancement you’ve seen?

Technology as an enabler to create seamless business processing, which allows many of our products to truly become programs within our customer base. Though we’ve come a long way, there are more efficiencies to be gained.  Both claimant-centric and process-centric technology solutions will continue to evolve and add value for customers.

How has your training as an accountant benefited you as a workers’ compensation executive?

The workers’ compensation industry has and will continue to focus on bottom line results. Having an accounting background allows me to deeply understand relationships around how to drive outcomes-based programs in ways others without that experience are at a disadvantage.

But while an accounting background allows one to understand the language of business, there’s so much more to being an effective workers’ compensation executive. Financial spreadsheets don’t allow you to hear the voice of the customer. I believe that you have to spend a lot of time meeting with and listening to customers.  Our business is a people business and top leaders need to have both financial discipline and as well as connectivity with their customers.


We know you’re from Philadelphia Joe, so tell us…where do you get the best cheesesteaks?

Without a doubt, Joe’s Steaks + Soda Shop on Torresdale Avenue. Although this isn’t really a fair question, given that my brother-in-law owns the restaurant.

You don’t have to rely on my opinion though, Joe’s Steaks + Soda Shop is consistently acknowledged as one of Philly’s best cheesesteaks by locals.

The R&I Editorial Team may be reached at [email protected]
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Sponsored: Healthcare Solutions

The Tools of the Trade

Opioid use is ticking down slightly, but high-priced specialty drugs, compound medications and physician dispensing are giving WC risk managers and payers all they can handle.
By: | July 1, 2015 • 7 min read

Integrating medical management with pharmacy benefit management is the Holy Grail in workers’ compensation. But getting it right involves diligence, good team communication and robust controls over the costs of monitoring technology.

Risk managers in workers’ compensation can feel good about the fact that opioid use is declining slightly. But experts who gathered for a pharmacy risk management roundtable in Philadelphia in June pointed to a number of reasons why workers’ compensation professionals have more than enough work cut out for them going forward.

For one, although opioid use is declining, its abuse and overuse in legacy workers’ compensation claims is still very much a problem. An epidemic rages nationally, with prescription drug overdose deaths outpacing those from the abuse of heroin and cocaine combined.

In addition, increased use of compound medications and unregulated physician dispensing are resulting in price gouging and poor medical outcomes.

Although individual states are attempting to address the problem of physician dispensing of prescriptions in workers’ comp, there is no national prohibition against it: That despite substantial evidence that the practice can result in ruinous workers’ compensation medical bills and poor patient outcomes.

“The issue is that there isn’t enough formal evidence to indicate improved outcomes from the use of compounds or physician dispensed drugs, and there are also legitimate concerns with patient safety,” said roundtable participant Jim Andrews, executive vice president, pharmacy, for Duluth, Ga.-based pharmacy benefit manager Healthcare Solutions.

Jim Andrews, Executive Vice President, Pharmacy, Healthcare Solutions

Jim Andrews, Executive Vice President, Pharmacy, Healthcare Solutions

Andrews’ concerns were echoed by another roundtable participant, Dr. Jennifer Dragoun, Philadelphia-based vice president and chief medical officer with AmeriHealth Casualty.

“When we’re seeing worsening outcomes and increasing costs, that’s the worst possible combination of events,” Dr. Dragoun said.

Whereas two years ago, topical creams and other compounds with two to three medications in them were causing concern, now we’re seeing compounds with seven or more medicines in them.

How those medicines are interacting with one another, and in the case of a compound cream, how quickly they’re being absorbed by the patient, are unknowns that are creating undue health risks.

“These medicines haven’t been tested for that route of administration,” Dragoun said.

In other words, the compounds have not been reviewed or approved by the FDA.

Carol Valentic, vice president of cost containment and medical management with third-party administrator Broadspire, said her company’s approach to that issue is to send a letter to providers, through the company’s pharmacy benefit administrator, alerting them to the fact that compounds are not FDA-approved and could be dangerous.

Other roundtable participants said they employ utilization review of every prescribed compound medication. They’re finding that the inflation of the average wholesale price for prescriptions that pharmacy benefit managers are battling in the case of single medications is happening with compounds as well, to the surprise of probably no one.

“The cost of compounds is doubling every year,” Healthcare Solutions’ Andrews said.

Deborah Gleason, Clinical Resources Manager, ESIS

Deborah Gleason, Clinical Resources Manager, ESIS

Kim Clark, vice president of utilization management with Patriot Care Management Inc., a division of Patriot National, Inc., said Patriot has their own software, DecisionUR, and opioids as well as  compound prescriptions can be directed from the PBM to Utilization Review.

In the area of new worries in workers’ compensation, and there are plenty of them, Dragoun also pointed to the introduction of extremely high cost, albeit extremely effective specialty medications, such as those being used to treat Hepatitis C. Treatments in this area can run into the hundreds of thousands of dollars.

Domestic drug manufacturers, pressed to pursue profits as their product lines mature and their margins level off, are jockeying for dominance in this area.

“This seems to be a route that a lot of drug makers are going after. Very narrow markets but with extremely high cost medications,” said Deborah Gleason, clinical resources manager, medical programs, with ESIS, the Philadelphia-based third-party administrator that is part of ACE Group.

Tools of the Trade

Given how substantially the use of prescriptions can balloon the cost of a workers’ compensation claim and undermine outcomes, a number of tools are in the market that can help risk managers rein in costs.

One is urine drug monitoring, which can catch cases of drug diversion, or instances where an injured worker is ingesting unprescribed substances. But the use of that test can create its own problems, namely overutilization.

Gleason, with ESIS, Inc., and others use urine drug monitoring. But when the test is overused, say by being conducted every month instead of quarterly as is recommended, the members of the Philadelphia roundtable said its costs can outrun its usefulness.

Test results are frequently inconsistent, signaling that the injured workers aren’t taking the prescribed medication or are taking something they shouldn’t be. Drug testing shouldn’t be used in isolation but rather as a component of integrated medical management.

“What’s emerging today, and in some companies more prevalently, is the integration of managed care with pharmacy benefit management,” roundtable participant Valentic said.

HCS_BrandedContent“When we’re seeing worsening outcomes and increasing costs, that’s the worst possible combination of events.”

— Dr. Jennifer Dragoun, Vice President and Chief Medical Officer, AmeriHealth Casualty

In other words, it’s not enough to flag a script or pick up a urine drug monitoring test result. There needs to be a plan or a system in place that says what action should be taken with the patient once that information has been received.

Identifying a potential problem early and taking action on it is key, said ESIS’ Gleason. She added that the patient’s psychological state, including how they react to and perceive pain, is something that more risk practitioners should consider.

Obstacles to assessing someone’s psychological or psychosocial state, according to roundtable members, include a lack of awareness or acceptance of its possible advantages on the part of patients and physicians. After all, we’re talking about an assessment, a list of questions, that should take no more than 15 minutes to carry out.

If a treating physician or case manager doesn‘t conduct a psychological test but is still concerned about the potential for pain medication abuse, there is one key question they can ask an injured worker, according to AmeriHealth Casualty’s Dragoun.

“There is one question that predicts far more than any other attribute of a patient whether they are likely to abuse narcotics, and that is if they have a personal or family history of substance abuse,” Dragoun said.

Kim Clark, Vice President of Utilization Management, Patriot Care Management

Kim Clark, Vice President of Utilization Management, Patriot Care Management

“You know they may ask that about the patient, but I don’t know how many ask it about the family,” Patriot Care Management’s Kim Clark said.

Pharmacogenetic testing, that is testing an individual for how they might react to certain drugs or combinations of drugs, and not — let’s be clear about this — whether they are predisposed to addiction, is also entering the market.

But as is the case with urine drug monitoring, the use of pharmacogenetic testing is no cure-all and the cost of it needs to be carefully managed.

Some vendors are pitching that it be applied to every case in a payer’s portfolio. The roundtable participants in Philadelphia agreed that it should be used with far more discretion than that.

Regulating the Regulators

It’s a given in the insurance business and in workers’ compensation that regulators in all 50 states call the shots. There are few national laws that regulate the hazards faced by workers’ compensation risk managers and injured workers.

Having said that, is it really such a pipe dream to think that the federal government could step in and provide leadership in an area that is so prone to confusion, risk and self-serving behavior on the part of some vendors and medical practitioners?

If the Philadelphia roundtable as a group could point to one place where federal regulators could do some good it would be in the area of physician dispensing. Many states have enacted legislation to curb the practice, as there is no data to prove better outcomes, and regulation by the federal government would be of benefit, the Philadelphia roundtable concluded.

Another area would be to require FDA oversight for compounds.

“The minute you need to have FDA approval of a compound, that’s going to stop it,” Broadspire’s Valentic said.

It’s a notion worth considering. After all, lives are at stake here.

Given the lack of oversight from the federal government, the roundtable participants pointed to measures in a number of states that are worth emulating. The Texas closed formulary, which limits the range of medications that can be prescribed, is one example.

The requirement in the State of New York that a prescribing physician check a state registry — what’s known as a prescription drug monitoring program — to check whether a patient is already taking or has a prescription for a controlled substance, is another good example of a state government stepping in to ensure the safety of its residents.

“The minute you need to have FDA approval of a compound, that’s going to stop it.”

— Carol Valentic, Vice President of Cost Containment, Medical Management, Broadspire

Pennsylvania also earned praise from the roundtable for recently passing a measure limiting the amount of medication that a physician can dispense to an initial supply.

With different regulations in every state and with the average wholesale cost of prescriptions constantly on the rise, pharmacy benefit management is an art requiring constant vigilance.

“It’s not an original thought, but if you stop and think about all the things that are happening in society with the addictions and the costs, the cost of doing nothing is greater than the cost of doing something.

I think that’s why everybody is doing something,” Healthcare Solutions’ Andrews said.

For more information about Healthcare Solutions, please visit

Opinions of the roundtable participants are the opinions of each individual contributor and are not necessarily reflective of their respective companies.


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

Healthcare Solutions serves as a health services company delivering integrated solutions to the property and casualty markets, specializing in workers’ compensation and auto liability/PIP.
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