Workers' comp adjusters in particular feel conflicted. As experts have said in the context of mental health conditions, we'd rather cope with them than treat them. And many in the field would rather just ignore them.
Yet their effects can be so pronounced that sooner or later we are going to begin dealing with them rather than ignore them. Several factors suggest that will occur sooner rather than later.
One such factor is the unremitting rise in medical costs, in which these largely nonoccupational problems clearly have a hand. Trying to contain medical costs without addressing key drivers of costs is like trying to bail out a boat with a sieve.
Surgeries are an expensive alternative to conservative care and carry with them some risks. Surgeons are supposed to select their patients carefully. Smoking and obesity raise the risks that surgery will fail. Yet many surgeons operate on patients who smoke and who are obese. UR review and second opinions could counsel a surgeon to think twice. Case managers can coach their claimants about the risks of surgery.
Even without surgery, the obese smoker is still compromised in their recovery. So what does the case manager do next?
More is now known about the effect of nonoccupational conditions and behaviors on claims costs. Duke University researchers found in 2007 that very obese workers were more likely to incur injuries and much higher medical costs.
The National Council on Compensation Insurance recently published a study on obesity and claims costs titled "Reserving in the Age of Obesity." This publication could turn out to be a landmark document. For the first time, the NCCI has marshaled its huge claims database to calculate how nonoccupational conditions (severe obesity) affects both indemnity and medical claims costs.
Bring your own statistician along for the read, as most of the text is dense. But the basic findings are accessible and well presented. They show how obesity drives up claims costs through the first 60 months of the claim.
This method of presentation aids the claims, managed care or consulting firm which has the challenge to address obesity. The firm can use NCCI's estimates to prepare a return on investment proposition for early intervention.
I'm not aware of an effective program that either reduces treatment risks or that crafts a recovery program specifically with a co-morbidity in mind. My guess is that such a program, however targeted, may include exercise and counseling.
Not to act can be much more expensive than to act. Plus, the workers' compensation courts are more inclined today to rule that insurers "own" the comorbidity that impedes recovery.Note recent court decisions authorizing weight reduction surgeries.
As we address the whole claimant more candidly, I predict that we will begin to comply with federal patient privacy (HIPAA) standards. Workers' compensation is exempt from these privacy standards. The exemption infers that occupational and nonoccupational conditions are separate or at most tangential, when in fact they are often inextricably linked through comorbidities.
PETER ROUSMANIERE is an expert on the workers' compensation industry.
November 1, 2009
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