Integration Is the Key to Managing Claim Complexities

In this session at the 2016 California Workers’ Compensation & Risk Conference, workers’ compensation medical-treatment experts explained how an integrated view of a patient’s medical history and treatment course can reveal the full spectrum of factors impacting claim costs and clinical outcomes to better guide claims management decisions. 

Speakers included: 

• Silvia Sacalis, Vice President, Clinical Services, Healthesystems
• Mary Reaston, Ph.D., Chief Science Officer, Founder, Emerge Diagnostics
• Dr. Adam Seidner, National Medical Director Claims, Travelers Insurance

There are several isolated complexities associated with claims, including comorbidities, multiple providers and stakeholders, psychosocial factors, adherence to therapy, patient medical history and complex medications regimens. All of these factors are going to increase costs in addition to providing an inferior outcome.

The two most important stakeholders in the workers’ compensation process are the employer and employee. The employer needs to provide the best-possible care for treatment of the injured employee. The patient then needs to realize that their function within the organization is critical and the employer wants him or her to return to work. In addition, the experience that the injured employee has with his or her doctors is also critical to success. This cannot be underestimated. It will dictate whether the patient will be compliant with doctor’s orders and, ultimately, his or her ability to heal.

Psychological aspects are a huge contributing factor to healing because they may exaggerate or predispose injured workers to chronic pain. There are catastrophic thinkers that magnify injuries, there is fear avoidance that causes the worker to be afraid of reinjury and there is perceived injustice where the injured worker blames the employer. 

Comorbidities like obesity, hypertension, diabetes and high cholesterol are becoming more and more common and heavily impact claims outcomes. For instance, sleep apnea has a negative impact on pain perception. Often these are non-compensable issues unrelated to the claim, however, they can have significant downstream effects. If a patient is diabetic, for instance, they can experience nerve pain that is completely unrelated to the actual injury.

Patients also might be taking several medications for other ailments or mental illness that can impact their healing process. Polypharmacy can complicate and worsen patient outcomes. Common, non-claim medications can actually cause pain. For example, Lipitor taken for high-cholesterol can cause musculoskeletal pain as a side effect.

These are all important factors to create a specific patient treatment plan. Everyone is going to differ, so approach must be tailored to the individual and monitored closely.