Early MRI Could Mean More Expensive Claims
In a study of work-related lower back pain claims, patients who received an early MRI had medical costs $12,000 higher and were on disability about 120 days longer than those that didn’t have the test, on average.
“One out of every five people that has fairly benign lower back pain gets an early MRI that they really shouldn’t get,” said Dr. Glenn Pransky, director of the Center for Disability research. “They then have a much higher risk to go on to receive a lot of treatments that aren’t necessarily helpful.”
Most likely, physicians have not been well-educated in the proper application of evidence-based medicine and the judicious use of MRIs in assessing back pain.” — Dr. Rupali Das, executive medical director of California’s Division of Workers’ Compensation.
Evidence-based guidelines state that MRI should not be indicated for non-specific, non-radicular lower back pain. And even in instances where “red flag” conditions exist – like severe traumatic injury or possibility for cancer or infection – guidelines suggest a month of conservative treatment before revisiting the need for an MRI.
“This study came from earlier work we had done, where we surveyed providers, giving them case scenarios and asking what they would do as their initial management of acute back pain in a workers’ comp setting,” said Barbara Webster, lead author of the recent study from the Liberty Mutual Research Institute for Safety on the early use of MRI. “And we were struck. Despite what the guidelines said, many of them would order an MRI.”
“Most likely, physicians have not been well-educated in the proper application of evidence-based medicine and the judicious use of MRIs in assessing back pain,” said Dr. Rupali Das, the executive medical director of California’s Division of Workers’ Compensation. “Physicians may be unaware of false positives and lack of specificity with MRIs. It may be easier to order a test than to counsel a patient on proper exercise and behavior. Patients also may play a role in demanding tests and some physicians may find it easier to comply with the request than to explain why a test is not needed or may actually be harmful.”
Those tendencies mean workers’ comp payers end up taking on costs for unnecessary tests and subsequent treatments dealing with issues unrelated to the original claim. That means more time away from work and more expensive claims. Workers’ comp payers may be missing an opportunity to catch inappropriate tests through utilization review, which would help produce better outcomes and contain costs.
“Our studies suggest that requests for early imaging tests should go through utilization review,” Webster said. “It’s likely that if providers are following OEM and ACOEM guidelines, it won’t be certified within the first 30 days.
Das suggested that payers start with “a carrot approach” by providing education on the existing guidelines for treatment, including initial management, and the proper indications that may warrant an early MRI.
“With the involvement of a medical director, the usage of MRIs can be measured, and inappropriate usage assessed,” he said. “Outreach and appropriate intervention should be directed at providers with a pattern of ordering tests inappropriately.”
Fee-for service payment models may incentivize physicians to order more tests, but quality and outcome-based payment proposed by the Affordable Care Act should dampen that trend.
“Many organizations are now educating their members about the proper use of radiologic tests, including MRIs,” Das said. “Hopefully younger physicians will be better educated about evidence-based practices.
MRIs can reveal age-related abnormalities, like compressed and degenerated discs in the spine, that may have nothing to do with what’s causing the back pain, Webster and Pransky said.
“In one study, MRIs found significant abnormalities in 60 percent of people sampled,” Pransky said. “Human tendency is to point to the abnormality as the cause of the pain, and suggest surgery or injection to treat it. It can be hard to dissuade people from thinking that’s not the source of the problem.”
“The natural history of many conditions causing lower back pain is that half of them will resolve themselves without the need for further imaging or surgery,” Webster said.
Use a Multi-Step Approach to Improve Employee Health
Employers seeking to reduce their workers’ comp and other health care-related costs should consider wellness plans that go beyond simple programs, suggests a new report. It found that employers saw greater participation rates when they created a corporate culture that focused on healthy behavior.
The National Business Group on Health examined data from 105 large companies from 2012 to 2013. While most had key strategic elements in place, few had successfully incorporated wellness into the corporate mission.
“Employers should consider a multiple step approach to improve employee health,” the report concluded. “Creating an environment that supports health, providing the programs to support behavior change, and engaging the different levels of the workforce will help move employees to a healthier status.”
For example, they found that while more than nine out of 10 companies offered programs for employees to increase their physical activity, only 65 percent had policies that allowed them time to participate during the workday.
“Because time is an obstacle to maintaining a healthy lifestyle at work, corporate policies offering flexible work time for physical activity can make it easier for employees to take advantage of these programs and resources,” the report said. “Companies that had flexible work policies had a higher percentage of employees who engaged in physical activity regularly.”
The study, “Measuring the Impact of Wellness on Workforce Health,” is based on employers’ WISCORE®, a wellness impact scorecard developed by the NBGH to determine the effectiveness of their wellness programs on workforce health. It includes various healthy behaviors such as physical activity, eating nutritiously, achieving and maintaining a healthy weight, reducing stress, and eliminating smoking.
“For employers who make significant investments in improving employee health, it is critical to be able to show a positive outcome,” the report stated. “One of the critical ways to show improvement is by tracking the healthy behaviors and status of the workforce over time. After implementing various wellness programs, are employers seeing an increase in the workforce engaging in healthy behaviors on a regular basis?”
Employers’ greatest success has been around physical activity — engaging workers in regular physical activity and specific physical activity programs. Employers had a median of 62 percent of employees who were physically active, second only to the 93 percent who were non-tobacco users. Employers also saw a median annual increase in the percentage of employees who were physically active of 3 percentage points.
“The success around physical activity is likely due to the multi-faceted programs that include mobile technologies, social influence through team or individual competitions as well as multiple opportunities to be physically active,” the report noted.
Spouses and dependents are included in the health improvement efforts of the majority of WISCORE users. Employers were often likely to offer them access to wellness programs and most offered incentives for their participation.
Environmental tactics and policies to improve behaviors remain areas of opportunity for employers. For example, just 65 percent of employers subsidize the cost of health food options, and fewer than 55 percent had corporatewide tobacco-free policies. Companies that are able to have tobacco-free campuses had a higher percentage of tobacco-free workers than others.
Changing employees’ health habits remains challenging for employers, especially in getting employees to maintain a healthy weight. The median percentage of employees who were at a healthy weight was 35 percent.
Because time is an obstacle to maintaining a healthy lifestyle at work, corporate policies offering flexible work time for physical activity can make it easier for employees to take advantage of these programs and resources.
Stress management is another area where many companies offer interventions. Relaxation programs such as yoga and meditation are offered by 79 percent of the employers while others offered mindfulness-based stress reduction and resiliency or energy management programs. Many also offered job-related skill building courses dealing with problem solving, conflict resolution. communication, and flexible work policies to eliminate common job stressors.
“To drive significant changes in the health of the workforce, employers need to attain significant participation levels in their wellness programs,” the report said. “Yet, engaging employees, specifically the ones who need to change their behaviors, continues to be a challenge for employers.”
Companies are most successful at driving employee engagement when they use leadership support, including middle management, financial incentives, and communications, the report said.
“Employers whose senior leadership visibly supported their wellness strategy by sending out communications and participating in programs experienced higher participation rates for nearly all programs than those organizations whose leadership did not visibly engage,” according to the survey. “Companies that provided health and wellness metrics (e.g., wellness program participation and health behavior rates) to division heads and line managers were able to connect employee health to business success. These companies found higher participation rates in programs for all six programs measured.”
While employers are having somewhat limited success in increasing participation rates in various health improvement programs, they are seeing improvements in the health behaviors of their workers, the report concluded.
A Modern Claims Philosophy: Proactive and Integrated
According to some experts, “The best claim is the one that never happens.”
But is that even remotely realistic?
Experienced risk professionals know that in the real world, claims and losses are inevitable. After all, it’s called Risk Management, not Risk Avoidance.
And while no one likes losses, there are rich lessons to be gleaned from the claims management process. Through careful tracking and analysis of losses, risk professionals spot gaps in their risk control programs and identify new or emerging risks.
Aspen Insurance embraces this philosophy by viewing the data and expertise of their claims operation as a valuable asset. Unlike more traditional carriers, Aspen Insurance integrates their claims professionals into all of their client work – from the initial risk assessment and underwriting process through ongoing risk management consulting and loss control.
This proactive and integrated approach results in meaningful reductions to the frequency and severity of client losses. But when the inevitable does happen, Aspen Insurance claims professionals utilize their established understanding of client risks and operations to produce some truly amazing solutions.
“I worked at several of the most well known and respected insurance companies in my many years as a claims executive. But few of them utilize an approach that is as innovative as Aspen Insurance,” said Stephen Perrella, senior vice president, casualty claims, at Aspen Insurance.
“We do a lot of trending and data analysis to provide as much information as possible to our clients. Our analytics can help clients improve upon their own risk management procedures.”
– Stephen Perrella, Senior Vice President, Casualty Claims, Aspen Insurance
Utilizing claims expertise to improve underwriting
Acting as adviser and advocate, Aspen integrates the entire process under a coverage coordinator who ensures that the underwriters, claims and insureds agree on consistent, clear definitions and protocols. With claims professionals involved in the initial account review and the development of form language, Aspen’s underwriters have a full sense of risks so they can provide more specific and meaningful coverage, and identify risks and exclusions that the underwriter might not consider during a routine underwriting process.
“Most insurers don’t ever want to talk about claims and underwriting in the same sentence,” said Perrella. “That archaic view can potentially hurt the insurance company as well as their business partners.”
Aspen Insurance considered a company working on a large bridge refurbishment project on the West Coast as a potential insured, posing the array of generally anticipated construction-related risks. During underwriting, its claims managers discovered there was a large oil storage facility underneath the bridge. If a worker didn’t properly tether his or her tools, or a piece of steel fell onto a tank and fractured it, the consequences would be severe. Shutting down a widely used waterway channel for an oil cleanup would be devastating. The business interruption claims alone would be astronomical.
“We narrowed the opportunity for possible claims that the underwriter was unaware existed at the outset,” said Perrella.
Risk management improved
Claims professionals help Aspen Insurance’s clients with their risk management programs. When data analysis reveals high numbers of claims in a particular area, Aspen readily shares that information with the client. The Aspen team then works with the client to determine if there are better ways to handle certain processes.
“We do a lot of trending and data analysis to provide as much information as possible to our clients,” said Perrella. “Our analytics can help clients improve upon their own risk management procedures.”
For a large restaurant-and-entertainment group with locations in New York and Las Vegas, Aspen’s consultative approach has been critical. After meeting with risk managers and using analytics to study trends in the client’s portfolio, Aspen learned that the sheer size and volume of customers at each location led to disparate profiles of patron injuries.
Specifically, the organization had a high number of glass-related incidents across its multiple venues. So Aspen’s claims and underwriting professionals helped the organization implement new reporting protocols and risk-prevention strategies that led to a significant drop in glass-related claims over the following two years. Where one location would experience a disproportionate level of security assault or slip & fall claims, the possible genesis for those claims was discussed with the insured and corrective steps explored in response. Aspen’s proactive management of the account and working relationship with its principals led the organization to make changes that not only lowered the company’s exposures, but also kept patrons safer.
World-class claims management
Despite expert planning and careful prevention, losses and claims are inevitable. With Aspen’s claims department involved from the earliest stages of risk assessment, the department has developed world-class claims-processing capability.
“When a claim does arrive, everyone knows exactly how to operate,” said Perrella. “By understanding the perspectives of both the underwriters and the actuaries, our claims folks have grown to be better business people.
“We have dramatically reduced the potential for any problematic communication breakdown between our claims team, broker and the client,” said Perrella.
A fire ripped through an office building rendering it unusable by its seven tenants. An investigation revealed that an employee of the client intentionally set the fire. The client had not purchased business interruption insurance, and instead only had coverage for the physical damage to the building.
The Aspen claims team researched a way to assist the client in filing a third-party claim through secondary insurance that covered the business interruption portion of the loss. The attention, knowledge and creativity of the claims team saved the client from possible insurmountable losses.
Modernize your carrier relationship
Aspen Insurance’s claims philosophy is a great example of how this carrier’s innovative perspective is redefining the underwriter-client relationship. Learn more about how Aspen Insurance can benefit your risk management program at http://www.aspen.co/insurance/.
Stephen Perrella, Senior Vice President, Casualty, can be reached at Stephen.firstname.lastname@example.org.