The Next Answer to MSDs: Wearable Exoskeletons
Musculoskeletal disorders comprise nearly one-third of lost time workplace injuries and illnesses. The cost of injuries from overexertion involving an outside source was estimated to be $15.1 billion in 2012, according to Liberty Mutual Insurance Company.
Back belts and lifting belts are personal protective devices that have been used to reduce back injury risks during lifting. Robotic-like suits used mainly for rehabilitation are now becoming a reality in the effort to prevent injuries, according to a federal agency.
“According to a recent market research report, in 2016 the medical/rehabilitation applications will likely comprise 97 percent of the total market for wearable exoskeletons compared with only 3 percent for work-related/industrial applications.
This report projects that within five years the industrial market share will equal that of the medical/rehabilitation,” according to the National Institute for Occupational Safety and Health. “Market forecasts from this report suggest growth in the industrial market from $2.9 million in 2016 to $1.12 billion in 2021 — an average growth of 229 percent per year.”
The devices are now being used in the shipbuilding industry. Experts project increasing market share for the exoskeletons in the construction, warehousing, and manufacturing industries.
The devices are described as “a wearable, external mechanical structure that enhances the power of a person,” NIOSH said. “Exoskeletons can be classified as ‘active’ or ‘passive.’ An active exoskeleton comprises one or more actuators that augments the human’s power and helps in actuating the human joints. … A strictly passive system does not use any type of actuator, but rather uses materials, springs or dampers with the ability to store energy harvested by human motion and to use this as required to support a posture or a motion.”
“Market forecasts from this report suggest growth in the industrial market from $2.9 million in 2016 to $1.12 billion in 2021 — an average growth of 229 percent per year.” — National Institute for Occupational Safety and Health
There is some evidence that the devices can help reduce musculoskeletal loads. NIOSH pointed to a recent literature review of the issue.
“The majority of these studies evaluated these effects in a laboratory setting and several studies did report decreased back muscle activity and compressive forces in the lower spine,” the post said. “Because most of the studies have been in laboratory environments, more information on worker acceptance and adoption of the devices and long-term use in real work environments is needed.”
The preferred method of reducing exposure to musculoskeletal injury risk is to redesign work such as lowering the weight of tools or materials or changing the layout of the work space to avoid putting workers into certain postures that make them more at risk. However, personal protective equipment is often used when such controls are unavailable.
The government is trying to determine the effectiveness of exoskeletons in reducing injury risks to workers. A variety of programs are underway in the Department of Defense and other entities. NIOSH is seeking input from those with experience in using the devices for safety.
“In what industries and specific occupations have these devices been successful and in what industries/occupations have they not?” the institute asked. “Industry experience can reveal issues and barriers to worker acceptance that are not evident in a controlled laboratory environment.”
Focus on Sleep Apnea in the Transportation Industry
An estimated 22 million people in the U.S. may have undiagnosed obstructive sleep apnea. For workers in the transportation industry that can be deadly.
The government is looking at accidents that resulted in multiple fatalities as it considers whether to propose requirements specific to obstructive sleep apnea. In the Federal Register notice, the government referred to the condition as a “national health and transportation safety issue.”
“Undiagnosed or inadequately treated moderate to severe OSA can cause unintended sleep episodes and deficits in attention, concentration, situational awareness, memory, and the capacity to safely respond to hazards when performing safety sensitive service,” the notice read.
“For individuals with OSA, eight hours of sleep can be less refreshing than four hours of ordinary, uninterrupted sleep, according to a study by the American Academy of Sleep Medicine. The size and scope of the potential problem means that OSA presents a critical safety issue for all modes and operations in the transportation industry.”
“Undiagnosed or inadequately treated moderate to severe OSA can cause unintended sleep episodes and deficits in attention, concentration, situational awareness, memory, and the capacity to safely respond to hazards when performing safety sensitive service.” — Federal Register notice
OSA is described as a respiratory disorder in which there is a reduction or cessation of breathing while sleeping. Risk factors include obesity, male gender, advancing age, family history of OSA, large neck size, and an anatomically small oropharynx (throat).
The Federal Motor Carrier Safety Administration and Federal Railroad Administration issued a joint Advance Notice of Proposed Rulemaking and will host three public listening sessions in Washington, D.C., Chicago, and Los Angeles.
“The collection and analysis of sound data on the impact of OSA must be our immediate first step,” said Scott Darling, acting administrator for the safety administration. “We call upon the public to help us better understand the prevalence of OSA among commercial truck and bus drivers, as well as the safety and economic impacts on the truck and bus industries.”
The FRA is also developing a rule that would require certain railroads to establish fatigue management plans.
The most recent fatal accident described in the notice occurred in the early morning hours in December 2013 when a Metro North Railroad commuter train derailed in New York City, killing four passengers and injuring at least 61 others.
The train had been traveling at 82 miles per hour despite the 30 mph speed limit when it came off a curved track. The engineer reported feeling dazed just before the accident and his wife complained about his snoring.
A subsequent evaluation determined he had severe OSA. Despite having multiple risk factors, the driver had never been screened for the condition. The National Transportation Safety Board said his undiagnosed OSA had been exacerbated by a recent circadian rhythm shift required by his work schedule, causing him to fall asleep.
“It is imperative for everyone’s safety that commercial motor vehicle drivers and train operators be fully focused and immediately responsive at all times,” said U.S. Transportation Secretary Anthony Foxx. “DOT strongly encourages comment from the public on how to best respond to this national health and transportation safety issue.”
To Better Control Total Workers Comp Costs, Manage Physical Medicine
Soaring drug prices get all the attention in the workers comp space. Meanwhile, another threat has flown under the radar.
More than 50 percent of lost time workers compensation claims involve physical medicine — an umbrella term encompassing physical therapy, occupational therapy, work conditioning, work hardening and functional capacity evaluation.
Spending on physical medicine accounts for 20 to 30 percent of total workers compensation medical costs, a percentage set only to increase in the coming years. Despite the rapid growth of this expense, very few employers are engaged in discussions around how best to manage it.
“Now is the time to take a look at physical medicine and think about how it impacts total cost of risk,” said Frank Radack, Vice President & Manager, Liberty Mutual Insurance, Commercial Insurance – Claims Managed Care. “Employers should investigate comprehensive solutions to keep costs manageable and to deliver quality, evidence-based care to injured employees.”
Liberty Mutual’s Frank Radack defines physical medicine and why it is so important in managing total workers compensation costs.
Upswings in both pure cost and utilization of physical medicine are driving the spending surge. State fee schedule changes are largely responsible for increases in cost. California, for example, has increased the cost of physical medicine services by 38 percent over the past two years, and will increase it a total of 64 percent by the end of 2017. North Carolina changed its approach to its fee schedule effective June 1, 2015, resulting in an almost 45 percent increase in the cost of the average physical therapy visit.
Increased utilization compounds rising prices. Low severity claims like soft tissue injuries typically involve physical therapy, especially when co-morbid conditions threaten to slow down recovery.
“When co-morbids are present, like obesity, more conditioning is necessary for recovery from injury,” Radack said. “With people staying in the workforce longer, we see these claims more often because these types of injuries and co-morbid conditions become more common as people age.”
De-emphasis on surgery also bolsters physical therapy prescribing as patients seek less invasive treatments that might enable a faster return to work, even in a light or transitional duty role. Sometimes, patients with a minor injury might seek out physical therapy on their own as a precaution after an injury or under the mistaken belief it will hasten recovery, even if evidence-based guidelines don’t call for it in every treatment plan.
“Now is the time to take a look at physical medicine and think about how it impacts total cost of risk. Employers should investigate comprehensive solutions to keep costs manageable and to deliver quality, evidence-based care to injured employees.”
–Frank Radack, Vice President & Manager, Liberty Mutual Insurance, Commercial Insurance – Claims Managed Care
“Without proper claims management procedures, some physicians might be inclined to prescribe physical therapy as a palliative measure, even when it doesn’t provide much benefit to the patient,” Radack said.
Brokers and buyers may not be able to do much about fee schedule changes, but they can partner with an insurer that better manages utilization through a multi-faceted claims system, qualified network vendors, data analytics, and peer interventions.
The keys to better managing the soaring cost of physical medicine.
“There is an opportunity to move physical medicine spending into network solutions and partnerships,” Radack said. A strong, collaborative network is key to maintaining direction over treatment decisions.
Liberty Mutual uses a proprietary data analytics program to study its providers’ prescribing and referral patterns and their outcomes. It then builds a network of point-of-entry general practitioners with a proven track record of optimal outcomes.
“The treating physician is a gatekeeper to other services, so it’s important to start there in terms of establishing a plan and making sure evidence based guidelines are followed,” Radack said.
Radack and his team use similar data analysis and partnerships to deploy networks pertaining only to physical medicine, so it can identify physical therapists who understand the occupational space and are focused on effective Return-to-Work (RTW). A provider who doesn’t understand RTW, or even know that the employer of an injured worker has a modified RTW program, may over-utilize PT. Getting employees with soft tissue injuries back into the work place is critical for delivering the best possible medical outcome and a timely recovery.
These therapists know the value of adjusting a treatment plan based on a patient’s progress, which often cuts unnecessary appointments and therapies.
“Our data analytics program is built internally by people who are aligned with the claims organization,” Radack said. “These insights drive our ability to shape networks and direct injured workers to providers with proven outcomes.”
Peer-to-peer interventions also play a big role in adjusting provider behavior and ensuring adherence to evidence-based guidelines. Liberty Mutual’s in house regional medical directors can bring their expertise to bear on challenging claims and discuss how to redirect treatment to meet these guidelines. Liberty Mutual also partners with experts to build networks of physical medicine and physical therapy providers who deliver quality outcomes cost-effectively and to asses a patient’s progress, working with providers to identify and resolve treatment issues.
Sharing information and measuring performance in these settings helps to change the environment around physical medical care. For example, interventions that steer physical therapists back to established, evidence-based medical treatment guidelines often reduce the use of passive therapy treatments, like hot and cold packs, which are not as effective and can slow down recovery.
“Active therapies that get people moving often help them get them back to work faster and at a lower cost,” Radack said. Utilization review also helps to identify unnecessary treatments and signals the insurer to communicate evidenced-based expectations with the therapist or prescribing physician.
Solutions in Action
Physical therapy offers great value in spite of rising prices — but only if it’s managed carefully.
An example of the benefits of managing physical medicine.
Take for example the case of a worker with a shoulder injury. In an unmanaged situation, a physical therapist may prescribe 12 appointments, and the injured worker will go through all 12 sessions with no pre-approval of the treatment plan and no interim checkup.
In a managed situation, the physical therapist may only prescribe eight sessions, because she understands the benefits of a faster return to work and sees that guidelines don’t dictate a full 12 sessions for this injury. Halfway through the eight sessions, she checks in on the patient’s progress and determines that only two more sessions are necessary given the recovery and the medical guidelines; and so adjusts the treatment plan to a total of six sessions.
In this scenario, managed care saves the cost of six sessions over the unmanaged situation, and the employee gets back to work faster with a healthy shoulder.
Ultimately, workers comp buyers can achieve cost savings by making treatment decisions that optimize patient outcomes, rather than cut pure cost. To achieve that, every player — point-of-entry physicians, physical therapists, medical directors, claims managers and patients — need to shoot for the common goal of shortening recovery time by following evidence-based medical guidelines.
“When medical experts and network vendors work in concert with each other, along with data analytics and research to back them up, we can drive down utilization while improving outcomes,” Radack said. “All of these working parts together are the solution to managing physical medicine costs.”
To learn more about Liberty Mutual’s Workers Compensation solutions, visit https://www.libertymutualgroup.com/business-insurance/business-insurance-coverages/workers-compensation
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Liberty Mutual Insurance. The editorial staff of Risk & Insurance had no role in its preparation.