Workers’ comp professionals eyeing disease management
Opportunity seen to lower rate of future injury claims
Imagine trying to control injury claims by targeting employees with chronic illnesses. Strange as that may seem, it’s precisely the tantalizing prospect that is drawing some workers’ compensation professionals into the area of disease management.
Thought in recent years to be the exclusive province of wellness and managed health care professionals, disease management strategies may soon appear on the services menu of a number of workers’ comp carriers.
"Historically, workers’ comp has tended to be characterized by crisis intervention looking at a particular instance that has occurred without regard to follow-through," says B.K. Kizziar, RNC, CCM, CLCP, a case management consultant based in Richardson, TX. "But with all areas of health care coming under more scrutiny from the public, from providers, from carriers, and even the government, comp has had to take a real good look at what it can do to control claims outlay."
"If ill health affects a worker’s ability to function at 100%, that impacts on employers, and if someone’s ill health makes them susceptible to a workers’ comp injury, that directly affects us," adds Laura Martinez, BSN, MS, CRC, CDMS, a nurse consultant with the Chubb Group of Companies in Dallas. "As the working population continues to age and medical disease processes progress, we are directly affected."
Significant opportunities seen
Kizziar sees a broad range of opportunities to integrate disease management into workers’ comp, including the utilization of very specific disease management strategies. "For example, you can stratify the population to determine who is at risk for injury claims based on chronic illnesses or diseases they may have. An asthmatic in a construction environment will be more prone to comp claims that result from breathing problems than someone who doesn’t have a lung disease.
"Chronic back pain could also be looked at as a disease management category. In terms of the ergonomic seating environment, I’d address those employees with histories of back pain earlier."
Such strategies can extend beyond specific sensitivities or physical disabilities, Kizziar notes. "You can also target diabetics, or hypertensives anyone with an uncontrolled chronic illness will have more sick days than someone without it," she adds. Martinez says other relatively common situations in which such a new workers’ comp strategy could apply include obesity and carpal tunnel syndrome.
In some sense, most workers’ comp professionals are already involved in a form of disease management, says Jennifer Christian, MD, MPH, vice president and chief medical officer at ManagedComp, a Waltham, MA-based organization providing managed care services in the workers’ comp environment. "Let’s say someone has an injury that does not appear to be overwhelming, but you discover they are at high risk of future permanent disability or a major job disruption. That is our [workers’ comp disease management] analog."
Christian gives the example of a 37-year-old welder with 17 years on the job and chronic knee pain. He has had the pain on and off for a year, but it is now really making him uncomfortable, so he seeks treatment.
"The medical diagnosis is bursitis, but in talking to the guy, you find he’s stressed because he has no other transferable skills in the job market; you see evidence of what looks like an unhappy marriage, excessive drinking, and problems with his supervisor," Christian says. "Also, he’s a macho kind of guy who never had a problem with his body before, and his confidence is shaken."
This gets into the workers’ comp area Christian calls high-risk management. "He’s not high-dollar yet, but he’s at a fork in his life," she says.
Workers’ comp professionals may intervene not only with medical treatment for the knee, but also with job analysis, modified hours, knee pads, alternative tasks, and referral to the Employee Assistance Program (EAP) for counseling.
"He could learn to type and become a computer operator," Christian says. "Or [without appropriate intervention], he could end up on long-term disability, spending his life in [recliner] and beating his wife. That’s what our challenge is."
But does she envision disease management strategies that can be implemented before the employee has ever been seen by a workers’ comp professional for an injury claim? "I think what you have today is a lot of people dreaming [about preventive disease management]," she says.
Not so, says Martinez, who reports that Chubb is already implementing such strategies. "What we’re doing is utilizing managed care strategies, presenting comprehensive programs to educate our insureds," she says. For example, Chubb’s technical services (safety) division offers ergonomics presentations and sets up safety programs to make employees aware of situations that predispose them to injuries.
"Our managed care nurse consultants are working closely both with that department and our claims department," she explains. Chubb has created what they call CWCs (commercial workers’ comp units), consisting of an underwriter, a workers’ comp claims supervisor, a technical services division representative, and a nurse consultant. "As a team, we conduct account visits face to face meetings with our insureds," she says. "Then we assess as a team what their needs are and assist in implementing the necessary programs."
The next step in this evolving process, she says, is to offer a wider range of presentations for workers, such as disability management, safety, and ergonomics. "If the company has a wellness coordinator, we will integrate with their system to do anything they need, like working together to put on an educational program."
Chubb is providing these additional services under their current premium structure at no extra cost to the client. Martinez admits that while her company is one of the most aggressive in this area, the workers’ comp/disease management paradigm has hardly taken the country by storm.
Making it happen
The key to successful integration of workers’ comp and disease management in the future is "not putting up any self-imposed barriers over what we can’t do," says Kizziar. "We have to be open as to how to provide that total continuum of care."
She sees a significant role for wellness professionals in this process. "Historically, insurance companies in general have been reactive participants in health care. Now, we have to look at prevention, which is totally contrary to the way we were educated, and we have to draw from the expertise of wellness professionals as to what we can do to integrate their expertise. After all, the best way to deal with either injury or chronic diseases is to prevent them in the first place."
She is optimistic about the future. "Several major health care carriers are talking to what have historically been comp companies. Larger companies that are self-insured in both group health and comp have the ability to integrate the two, as can large carriers who provide both types of coverage. I think [the trend] will begin with those companies."
But eager workers’ comp professionals should tread carefully in this new area, Christian advises. "This should be regarded as a refinement of existing workers’ comp strategies," she insists. "Where the first managed care emphasis should be is on primary prevention. There are a heck of a lot of people who are diabetic who don’t have carpal tunnel syndrome. So, the predictive power is not that strong."
She agrees with Kizziar, however, that a large, self-insured company with integrated benefits management would be "the perfect place" to attempt a marriage between disease management and workers’ comp. (For more on the difficulties of disease management and workers’ comp integration, see story, above.)
[Editors Note: For more information about workers’ comp disease management strategies, contact: Laura Martinez, The Chubb Group of Insurance Companies, 1445 Ross Avenue, Suite 4200, Dallas, TX 75202. Telephone: (214) 754-8168.]