Treating injured workers’ whole health

Making injured workers whole again has become a goal in workers compensation circles, with stakeholders trying to address injuries caused in the workplace together with other issues that might impede return to work.

But managing comorbidities is difficult, and workers comp insurers and employers remain reluctant to pay for medical issues that arise independently of a compensable injury, experts say.

The term “whole health” generally refers to programs that go beyond just paying for injuries, with an enhanced focus on the overall health of injured workers, according to a January report by the Boca Raton, Florida-based National Council on Compensation Insurance, which cited whole health as an emerging trend in the comp sector.

“The way people are thinking about whole health today is starting to gain more momentum than it ever has,” said Matt Zender, Las Vegas-based senior vice president of workers compensation strategy and product for comp insurer AmTrust Financial Services Inc.

Comorbidities ranging from diabetes and high blood pressure to depression and anxiety can complicate an injured worker’s recovery, experts say.

“In the ideal world, we want to take care of everything, but this is a work comp system that doesn’t really allow for that,” said Dr. Marcos Iglesias, Sunrise, Florida-based chief medical officer for Broadspire Services Inc., the third-party administrator unit of claims manager Crawford & Co. “The nature of a comp claim is time-limited, and a lot of the issues we have as human beings are chronic.” 

Yet more insurers are paying attention to issues such as anxiety, depression, fear of pain and fear of reinjury that can complicate claims, he said. “Those things aren’t part of the injury, but it behooves us to help them overcome these barriers.” Insurers and employers might end up paying less on an uncomplicated claim with a comorbidity that is better managed at the onset than a claim that malingers, often due to issues outside of the injury.

“Some of it (requires a) bigger view of what the total cost of risk is,” said Kimberly George, Chicago-based senior vice president of corporate development, mergers and acquisitions, and health care for Sedgwick Claims Management Services Inc.

NCCI found whole health to be an industry focus that could lead to less spending overall.

“Looking at it in the whole scheme of things and the whole cost equation, it’s beyond what payments are made, it’s successful outcomes,” said Bill Donnell, president and CEO of NCCI. “There may be a greater investment in the short term, but in terms of the life of the overall claim and in terms of claim duration, there are improved outcomes there. The total focus on our product line and the industry, I believe, is in getting the injured worker back to work.”

The newer approach moves the advocacy model a few steps forward: asking questions and connecting the dots on a picture that won’t improve unless a worker is healthy, experts say.

“I don’t think the issue now is, is work comp going to be paying for this? Those are the comorbid (conditions) and they are not specific to the injury, but some of it might become embroiled in the claims, and how do we address those issues?” said Randi Urkov, Chicago-based managing director with Marsh Risk Consulting, a unit of Marsh & McLennan Cos. Inc.

The “progressive employers” are putting in place protocols with nurse case managers and adjusters so that “when these flags come up, (they) can say, ‘Did you know your employer has a program in place in disease management that can help you?’” said Ms. Urkov.

A simple push toward an employer’s employee assistance program embedded in a group health plan offering can be used to address issues such as depression and anxiety, she said, adding that the “critical (issue) is getting those linkages in place.” 

The task could be as simple as reframing the approach and avoiding an upfront denial for care, said Mr. Zender of AmTrust.

When outside issues that are not a part of the compensable injury emerge, “rather than starting off with a denial, if that employer can say, ‘You are not eligible for this, but here’s what you are eligible for,’ (that) gets the discussion going and it isn’t negative,” he said.

“Many of these employers already have these programs in place” on the benefits side, said Carolyn Turpin, Rocklin, California-based vice president and regional manager for workers compensation claims with Liberty Mutual Insurance Co. “We have tried to be more helpful and cognizant… in getting the injured worker the

health care they need.”

Larger insurers who have both benefits and workers comp in their programs and are contracted with the same employer have an advantage, said Dr. Adam Seidner, Hartford, Connecticut-based chief medical officer for Hartford Financial Services Group Inc., which is integrating models by flagging claims and introducing early interventions, often on the benefits side.

“It’s not just what’s compensable and what would be covered by the claim, but it’s looking at what is going on with the individual,” he said. “We view this worker as a whole person.”

To insurers, that brings up the conversation about “silos,” or the challenge of workers comp falling under risk, which falls in line with finance, and benefits and wellness falling under human resources — and the lack of connections, said Mr. Zender.

Employers “are starting to realize that, if you think of this as a benefit as opposed to a spend, it changes the paradigm on how they recognize” the costs of getting an injured worker healthy, he said.