By DR. RACHNA HAJELA, medical director of the workers' compensation division of Best Doctors Inc., which serves more than 260 insurers, employers and health plans in 30 countries.
Occupational injury and illness cost carriers and employers more than all cancer-related illnesses combined. Non-fatal occupational injuries and illnesses requiring days away from work occur at a rate of 122 per 10,000 full-time workers. Back injuries accounted for 43 percent of the more than 1.3 million injuries and illnesses in private industry that required recuperation away from work.
A complicated healthcare system, compounded by misguided medical care and employee lifestyles, are driving up the cost of claims. There are risk factors associated with every workers' compensation injury that can increase the medical and lost time costs. Understanding these risk factors and creating aggressive strategies to address them are key to breaking the cycle.
Critical risk factors include comorbidities, recurring infection, accuracy of clinical issue assessment and appropriateness of injury treatment.
Perhaps the two most significant risk factors are obesity and chronic pain. Obesity is an increasingly chronic condition in the United States.
In the United States, 3.8 million people weigh more than 300 pounds and more than 400,000 people carry more than 400 pounds.
--Between 1962 and 2000, the percentage of obese Americans grew from 13 percent to 31 percent.
--63 percent have a Body Mass Index (BMI) in excess of 25.0 (normal is 18.5-24.9)
--31 percent are obese with a BMI in excess of 30.0
--According to experts, obesity is responsible for 300,000 deaths every year.
Obesity increases risks of heart disease and diabetes, both of which impact workers' compensation cases.
Chronic pain is the most common cause of long-term disability and affects more Americans than diabetes, heart disease and cancer combined. More than 25 percent of U.S. adults have experienced pain lasting more than 24 hours, according to a 2006 survey by the National Center for Health Statistics.
While managing pain is an important factor in workers' compensation, heavy use of opiates is a key concern. According to the National Institute on Drug Abuse, prescription abuse has increased. For example, U.S. prescriptions for opiates increased from 40 million in 1991 to 180 million in 2007.
A CASE EXAMPLE
A 48-year-old male, let's call him Tom, slipped on the job and cut his ankle. Tom, who weighed more than 300 pounds, waited more than six months to seek treatment. By then, his wound required significant medical intervention, including drainage. He had a staph infection and needed antibiotics. In addition, he had a chronic condition, venous stasis, leading to edema and skin breakdown.
Over the next two years, Tom was hospitalized for recurring infections. His pain became chronic, and he started taking hefty doses of painkillers. His weight reached more than 500 lbs.
In addition to obesity and chronic pain, there were several risk factors at play here.
1. Treatment Delay
In this case the delay between the injury and treatment was significant and should have prompted action.
2. Injury Treatment
Lymphedema sepsis could have been treated earlier to prevent future complications. Edema control garments would have prevented swelling and further infections.
3. Recurring Infection
Recurring infections inhibit recovery and return to work. Early intervention with a specialist would have prevented recurring infections.
Significant costs were associated with the late stages of this injury. Had treatment for the lymphedema and infections begun early, the chronic pain cycle could have been prevented.
This case was referred for expert medical consultation when limb amputation became a possibility. However, bringing medical expertise into the case sooner would have ensured appropriate care. This would have prevented chronic pain and infections which led to skyrocketing costs.
Misguided care and misdiagnosis happen far more than one would imagine. A recent analysis of clinical cases warranting review by Best Doctors uncovered alarming error rates:
--Wrong treatments: 61 percent
--In appropriate surgery: 38 percent.
--Insufficient work-ups: 31 percent.
--Misinterpretation of pathology or diagnostic tests:12 percent.
As much as 30 percent of U.S. healthcare costs are attributable to misguided medical care. To address these concerns, companies should instill a cross functional approach when dealing with workers' compensation claims. It should cover:
--Communication between medical, claims and legal teams
--Collaboration to design an early intervention process
--An essential focus on follow through
--A commitment on the part of the claims professional to refer cases to medical experts based on risk factors and medical treatment decisions.
November 1, 2009
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