Workers’ Comp Doctors’ Prescription for Medical Intervention

Opportunities to manage workplace injuries to their optimal conclusions evaporate when claim handlers ignore medical intervention’s power. Important elements may be lost, including the potential to identify risk factors that can delay recovery, the ability to uncover non-work injury causations, and the efficient coordination of claims-service providers. In this session at the 24th Annual National Workers’ Compensation & Disability Conference, medical directors from two large workers’ compensation insurers and a self-insured employer provided strategies for unlocking medical intervention’s capacity.

Speakers included:

• Mel Belsky, M.D., Medical Director, Workers’ Comp Program at Safeway Inc.
• Marcos Iglesias, M.D., VP and Medical Director at The Hartford
• Adam L. Seidner, M.D., Global Medical Director at Travelers Insurance
• Denise Zoe Algire, MBA, NR, COHN-S/CM, FAAOHN, Corporate Risk Management at Albertsons Safeway, Inc. (moderator)

The workers’ compensation landscape has changes a lot over the years. With medical being a large contributor to costs, what do you think are the causes?

• Inflationary rates of wages do not match that of medical. Also, an aging population and the medical problems that accompany that also contribute.
• There is a RAND study that states up to 50% of diagnoses are incorrect. This is driving inappropriate utilization of certain resources.
• Drug prices and drug utilization are huge drivers and the inflation for drugs year-to-year is a big contributor. There are few workers’ compensation claims that include prescriptions of multiple drugs. It’s not just the direct cost of them, many times workers’ compensation calls for more expensive drugs and those drugs usually lead to the prescribing of other drugs to address their side-effects.
• Psychosocial issues are a critical contributor to cost. Lack of patient resilience leads to limited coping skills and inaccurate assumptions, which can be powerful drivers of utilization.

There has been a lot of debate on the Affordable Care Act (ACA) and its impact on the workers’ compensation system. What do you think its influence has been on the industry?

• So far, as a carrier, we have not seen any real trends developing. So many predicted that the ACA would be disastrous for workers’ compensation, but we are not seeing that. However, WCI did release a study that we will see more cases shifted to workers’ compensation and that is one of my fears.
• We still do not know at this point. As an employer, we are not seeing any real impact as of yet. There has been some discussion of classifying musculoskeletal injuries under workers’ compensation, which is scary.
• We have to determine what we need to measure to determine the impact of the ACA. Is it system usage? Is it appropriate classification of injuries? It’s hard to tell if we aren’t measuring appropriate outcomes.

What are some of the initiatives that organizations should take to combat trends like pharmacy utilization?

• Do you know how much you are spending on drugs? What’s the utilization? What’s the cost? You’d be surprised that most people do not. The first step in trying to address a pharmacy issue is looking at your data and determining if it’s accurate. You can only collect this if you have a centralized area for your data.
• You must apply the four A’s when it comes to data: access, analyze, application, assess. We are often asking the wrong questions and evaluating the wrong outcome measures.
• Early intervention is critical. You need to identify the problem early and get the proper plan in place to make a difference.

We only have four states that have formularies in workers’ compensation. How does that apply to evidence-based medicine?

• Formularies are helpful, but sometimes they can be too restrictive. We need to manage every claim on its merit, not just on the formulary.
• Utilizing a pharmacy benefit manager (PBM) has made a huge difference for us as an employer. 
• In the absence of a state formulary, there are tools that you can utilize. It is important to stay on top of new drugs and their uses. 
• One way to address this is to do a “stop and pause” to verify if the prescriptions are clinically appropriate.

How can we help offset creeping catastrophic claims?

• You must have an overarching philosophy on how you want to approach your employee population. Early intervention programs are important, but you must determine what your definition of “early” is and intervene appropriately. If you can reduce delayed recovery by even 10%, that has a huge impact to your bottom line.
• We have a number of early-intervention plans based on predictive models. The areas of opportunity we are seeing is that the timing of services is critical and missed opportunities for services is a big issue. It doesn’t stop there. Then your nurses must hone in on how to address the problem and a lot of that has to do with the injured employee’s willingness to change. Sometimes it is a psychosocial issue and has nothing to do with any medical adjustments we can make.
• Time is your enemy. The sooner an employee can return to work, the better that their quality of life will be and the less likely a creeping catastrophic claim will develop. You are only as good as your tools to identify what problems that will delay recovery. Your claim handling, at every level, must buy into this. Train your adjusters to ask the right questions to identify red flags for those who may be at risk for delayed recovery.