Identifying and Managing the Hidden Costs of Chronic Pain in Workers' Compensation Claims
Without the use of these tools, employers may face staggering medical bills--not to mention the costs associated with lost productivity, according to Maureen McCarthy, vice president and manager of the workers' compensation claim department in the area of Liberty Mutual that serves large companies. Liberty Mutual is based in Boston and the fifth-largest property and casualty insurer in the U.S.
McCarthy notes that workers' compensation claims involving chronic pain are among the principal drivers of total workers' compensation medical costs. That is because a claimant with chronic pain typically requires more medical treatment and is away from work longer. Experience shows that roughly 20 percent of all workers' compensation claims drive about 80 percent of total medical costs, and a large share of these claims involve chronic pain.
Spotting the problems
"Identifying these claims early is vital to getting injured employees back to a productive lifestyle while managing costs for employers," McCarthy says.
Liberty Mutual identifies claims involving chronic pain, and other factors that can cause a claim's cost to skyrocket over time, through:
A proprietary predictive model that identifies claims with the potential to have medical and indemnity costs grow significantly
A specialized report that identifies those claims likely to involve chronic pain
Clinical review by nurse case managers and regional medical directors on open claims to identify those heading in the wrong direction
"From the beginning of any workers' compensation claim, the primary focus must be on quickly identifying any situations--such as chronic pain--that may move a claim to a different track than it should normally take," McCarthy explains.
According to Mary O'Donoghue, Liberty Mutual's vice president of managed care services, there are many factors leading to chronic pain, and having the right tools and processes in place should uncover those factors well before a claim can get out of control.
Variables that flag claims that may involve chronic pain include multiple surgeries, pain pump use, multiple prescriptions for powerful narcotics, psychosocial factors, no clear diagnosis, and failure to respond to traditional treatments for the given injury. Payment patterns, including any costs not usually associated with a specific injury are another indicator that a claim may require a closer look.
"More than anything, it's important to look at transaction level detail, so that every possible factor that may cause problems is identified," she says.
Managing claims effectively
Once identified, these claims should be managed holistically, since chronic pain often involves behavioral health issues. Effectively managing outcomes for injured employees and costs for employers requires treating the whole patient.
To do this, Liberty Mutual directs these claimants into appropriate interdisciplinary rehabilitation programs. These programs help claimants confront and explore those psychosocial issues that are part-and-parcel of their chronic pain equation, O'Donoghue says.
"You have to get to who they are as people," she says. "Are they afraid of re-injury? If not, you need to determine what they are afraid of. You need to understand what the impact of the injury is and how they deal and think about pain. Beyond helping control employers' total workers' compensation costs, these programs can dramatically improve injured employees' quality of life, returning them to productive work, weaning them from powerful narcotics and helping them learn to effectively manage pain."
McCarthy and O'Donoghue cite two Liberty Mutual cases to help illustrate the benefits of identifying workers' compensation claims involving chronic pain, and getting employees the specialized care required, while managing employers' total costs.
The first case involved an employee with a low back injury. Over the course of two years, the claimant received multiple injections and was prescribed powerful narcotics, but showed little improvement.
When the injured employee's treating physician recommended a lumbar discography, the Liberty Mutual nurse case manager assigned to the claim reviewed the case with a Liberty Mutual regional medical director--a board certified physician experienced in treating work-related injuries. Given the claimant's history of not responding to medical procedures or powerful narcotics, the regional medical director recommended a comprehensive interdisciplinary rehabilitation evaluation, including a psychological assessment.
Based on that assessment, Liberty Mutual referred the injured employee to a qualified chronic pain management program.
After just one month in the program, the employee ? who had been in and out of work for three years since the injury--was cleared to return to work full time and weaned from the majority of narcotic medication.
Beyond returning the injured employee to a productive, positive life, the program saved approximately $20,000 in ongoing medical treatment.
The second case involved an office worker with bilateral wrist injuries. The claim seemed to be progressing normally and the injured employee's treatment and disability were within accepted guidelines.
Yet, one of Liberty Mutual's predictive modeling tools alerted the team to further review the claim. The resulting conversation with the injured employee revealed a worsening situation with many signs that the claim had the potential to become problematic. For example, the injured employee's pain medication had inched up, along with the employee's weight and complaints about life in general. In addition, the injured employee reported that hope for any return to work was quickly fading.
The Liberty Mutual claims manager assigned to the case developed a plan to get the claimant and claim back on track.
As a first step, a nurse case manager visited the claimant to assess his situation and discuss how he could best manage his pain.
Then she worked with the claimant to address other conditions such as weight control and possible depression that were impacting his overall recovery.
Early intervention and quick proactive action helped this injured employee avoid the downward--and very expensive--spiral of chronic pain.
Liberty Mutual helps brokers, agents and buyers better manage the total cost of workers' compensation risk. One way Liberty Mutual does this is by quickly spotting and effectively managing the small number of claims involving chronic pain that can drive total workers' compensation claim costs. These efforts help injured employees return to productive lifestyles and employers better protect their bottom lines.
More information on how chronic pain can impact workers' compensation claims management can be seen at http://www.libertymutualgroup.com/chronicpain
Please visit Liberty Mutual's booth at RIMS (#1331)
(The above piece is part of our continuing Insights series designed to highlight key products and services to our readers. This paid-for Insights was written and edited by Risk & Insurance®
on behalf of our marketing partner. Additional Insights can be found on our Web site at www.riskandinsurance.com/.)
April 21, 2010
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