Strategies to Manage the Pandora’s Box of Comorbid Conditions
Originating from Greek mythology, the phrase “to open Pandora’s box” calls to mind how a seemingly innocuous act, such as opening a box, can unleash a plethora of negative consequences. That’s how many workers’ compensation (WC) program managers feel about covering injured workers who incur relatively minor workplace injuries that quickly spiral out of control due to the claimant’s comorbid conditions.
Perhaps the fear associated with covering claimants with comorbidities has prevented adjusters from understanding the scope of these conditions, how they impact their WC programs, and how they can use such insights to enhance the clinical management of their claims.
Being aware of conditions—beyond the work-related injury—allows us to have a holistic view of the patient’s health and to provide a more comprehensive care approach that can truly impact outcomes.
I’ll be addressing this topic on April 25 at 1:30 p.m. EST at the RIMS Conference in Philadelphia, Pa. If you’re headed to RIMS, be sure to attend this presentation. This article provides a preview of comorbidities and risk management strategies to address them.
Comorbidities in Workers’ Compensation
According to an NCCI report released in October 2012, the number of WC claims with a comorbid condition nearly tripled from 2000 to 2009. This report also showed that claims with a comorbidity had about twice the medical costs of otherwise comparable claims. Comorbid conditions commonly found in WC include:
- Obesity. Obesity is defined as a condition in which a person’s body mass index (BMI) is 30 or higher. Excess body fat accumulates and has the potential to adversely affect a person’s health. By 2030, 51 percent of the U.S. population may be obese, according to Trust for America’s Health. Generally, obese workers file more WC claims as well as experience higher medical costs and require more time away from work than their non-obese counterparts.
- Diabetes. In 2012, the Journal of the American Medical Association reported that more than half of American adults either had diabetes or prediabetes—and one-third of those with diabetes were unaware they had the disease. People with diabetes are unable to use insulin to properly balance their blood sugar levels. When diabetes is a comorbidity, it can delay the healing process, increase the risk of infection, extend recovery time and cause other medical complications.
- Hypertension. Nearly one in three adults in the U.S. suffer from hypertension and only about half of them have their blood pressure under control1. This condition often goes undiagnosed due to the fact that it causes minimal or no physical symptoms. Within the body, however, it causes stress to arteries and can lead to serious health problems, such as stroke or heart attack.
- Mental Health. Nearly one in five adults may suffer from a mental health issue in any given year2. According to a survey of chronic pain suffers conducted by the American Pain Foundation, 77 percent of the patients reported feeling depressed3. Injured workers may experience depression, as their injuries lead to decreased daily activity, concerns over money, and feelings of hopelessness.
- Tobacco Use. Smoking is considered a comorbidity because it can cause other diseases and medical conditions. While tobacco use has decreased significantly over the years, according to the CDC, 15 percent of the adult population still smoked as of 2015,4 and it remains the leading cause of preventable deaths.5
- Substance Abuse. Substance abuse might occur in relation to alcohol or drugs—even opioid painkillers. Alcohol abuse impairs a person’s ability to perform the physical activities necessary to recover and it could bring about or worsen feelings of depression.
The use of opioid painkillers has increased, resulting in safety issues. Patients often build up a tolerance and require increased dosages; prolonged use can lead to addiction and even death. In 2013, there were 16,235 overdose fatalities related to opioid painkillers, according to the CDC.
Impact on WC Claims
In general, comorbidities impede an injured worker’s ability to heal, recover and return to work. As a result, these claims on average experience:
- Longer claims duration
- Higher medical and indemnity costs
- More temporary disability (TTD) days
- Increased litigation rates
- Increased surgery rates
With an aging workforce, comorbidities may soon become a complicating factor on most claims. We may even see an increase of claims with multiple comorbidities, such as obesity anddiabetes, or diabetes and hypertension. In 2016, Harbor Health Systems, a One Call company, performed a study of comorbidities and found that claims with multiple comorbidities experienced a 341 percent increase in total incurred costs and 285 percent more TTD when compared to the control group.
Currently, states have varying requirements on how to handle claims with comorbidities. In California, employers are required to pay for treatment of a comorbidity, if the condition is hampering the worker’s recovery. In Florida, disability benefits may be allocated between the WC injury and pre-existing conditions.
Employers should be aware of the requirements in their specific jurisdictions. They should also assess the impact comorbidities are having on their unique set of claims and develop strategies to handle them.
Proactive Clinical Management Strategies
Early identification of comorbidities in the claims process is a positive trend, as it can allow for safer and more effective, holistic care. It also gives the employer, provider, injured worker and payer more realistic expectations for recovery and return to work. Here are a few proactive strategies being deployed today:
- Telephonic nurse case managers help to assess injuries at the onset of a claim. In this way, they can help to identify comorbidities that may require clinical intervention or ongoing oversight throughout the case.
- Use of analytics. Predictive analytics help payers screen claims for a host of characteristics, including the existence of comorbidities, that may lead to claims escalation. By applying clinical management to these cases, payers can reduce the risk of rising medical and indemnity costs.
- Wellness programs. The International Foundation of Employee Benefits Plans (IFEPB) reports for every $1 spent on wellness, employers can expect to save up to $3 in healthcare costs. Similarly, Harvard concluded for every $1 invested in wellness, employers can expect to save approximately $3 in absenteeism costs. Whether these programs include bike-to-work, nutritional counseling or weight management initiatives, they can help to reduce the risk of a number of comorbidities, including obesity, diabetes and hypertension.
- Clinical Coordination. Catastrophic or complex claims that include comorbidities must be assessed from multiple perspectives to ensure the injured worker is receiving the clinical coordination required, whether this is home care, medical equipment or transportation.
Claims with comorbidities are expected to create significant and continued challenges for the WC industry. We need a more comprehensive, system-wide approach to identify and oversee these conditions. More research can help us understand how these conditions create complications. However, employers also need to assess how comorbidities affect their own claims and determine what they can do to mitigate and manage these conditions within their workforce.
About Eric Patten
Eric Patten, RN, BSN, is Senior Director of Clinical at One Call. He has over 24 years of nursing experience in critical care, emergency care, diabetes education and catastrophic case management. Prior to joining One Call in 2011, Eric served as a catastrophic nurse case manager for 12 years. This position provided him with a rich understanding of the daily challenges workers’ compensation adjusters and nurse case managers face and a unique ability to offer them support on complex, high-exposure files. In his current position, Eric oversees a team of RN and PT Clinical Specialists. He and his team review large-loss complex files, helping to address issues related to comorbid conditions and identify opportunities for savings and improved care.
About One Call
One Call (www.onecallcm.com) is the nation’s leading provider of specialized solutions to the workers’ compensation industry. One Call has six locations across the United States with its corporate headquarters located in Jacksonville, Florida. One Call’s solutions enable faster, more efficient and more cost-effective claims resolution with a focus on injured workers’ needs across the continuum of care. One Call provides reliable, consistent connections to care with expertise in high-end diagnostics, physical therapy and transportation services, post-discharge home care and durable medical equipment, dental and doctor specialty services, complex care management, and the language services required for today’s multicultural workforce. Visit the event page (www.onecallevent.com) to get more information on One Call presentations at RIMS.