Archive for the ‘Best Practices’ Category

Workers’ Compensation’s Costly Psychosocial Issues (2)

Wednesday, February 1st, 2017

First, a review.

Yesterday, we described the challenges confronting claims adjusters and injured workers when psychosocial issues are present in a workers’ compensation claim. These issues impede recovery and exacerbate costs. We confidently picked up our saw and walked out on the proverbial limb to suggest this thesis:

Our nation’s current system for treating injured workers with mental health issues is uncoordinated, overly fragmented, highly wasteful and does not focus enough on speedy return to work. There is a critical need for a more systemic approach as well as an integrated coterie of clinicians and practitioners, trained in workers’ compensation, whose goals are to provide compassionate treatment with a steady return to work trajectory. 

Finally, we listed the serious factors that make finding a solution to this looming crisis tremendously difficult.

But early in 2015 in New Jersey two Neuropsychologists, Mary Ann Kezmarsky and Richard Filippone, had an idea. Over a couple of decades, they’d treated a number of workers’ compensation claimants and had been appalled by what appeared to be the lack of a coherent system to deal with the issues they saw in their patients. They weren’t exactly sure what to do about it – they didn’t know much about workers’ compensation – but they saw it as a business opportunity.

They contacted me, and over the next year we created a company, Work Comp Psych Net (WCPN), and built a systemically organized and integrated specialty network of workers’ compensation clinicians and therapists to treat injured workers in New Jersey who might have behavioral health issues delaying recovery. Here’s how we did it:

  1. Over the last half of 2015, we recruited, credentialled and vetted 44 mental health professionals covering 55 offices throughout New Jersey’s 21 counties. Providers within WCPN’s network include psychologists and neuropsychologists, as well as cognitive rehabilitation and biofeedback specialists. All of the clinicians and therapists gave up a weekend to attend Lynch Ryan training in workers’ compensation. They learned about the New Jersey law, as well as the way workers’ compensation works – how a premium is constructed and  what indemnity and medical benefits are. They now understand experience modification, maximum medical improvement and the law regarding injuries “arising out of and in the course of employment.” Further, they have been educated regarding early return to work and have agreed to work with employers, adjusters and nurses to effectuate modified duty wherever possible.
  2. We built (with difficulty, because it wasn’t easy) the nation’s first electronic Claimant Intake & Referral Portal that allows claims adjusters, nurse case managers and attorneys to refer a claimant instantly. The paperless portal’s referral system is geographically and specialty based, meaning that referrers are assured that claimants will not have to travel far to reach their assigned clinician. In the past, referrals and appointments took weeks, even months, to arrange, but they can now be finalized within minutes. In Beta Testing from May through October, 2016, the longest time from referral to Provider scheduled appointment was 27 minutes.
  3. We built (with even more difficulty) the nation’s first mental health Electronic Health Record system for workers’ compensation. The EHR is set up as a roadmap for all WCPN clinicians to follow, meaning reports have a consistently structured form. The EHR is paperless, HIPPA-compliant and cloud-based. Initial Psychological Evaluations and subsequent treatment reports reach claims adjusters in pdf form within five business days.
  4. Our clinicians are all highly qualified and experienced; they know how to treat workers with mental health issues delaying recovery. But to make the system work we needed to understand the needs of adjusters and defense attorneys who would be referring the injured workers the clinicians would treat. Consequently, we conferred with experienced adjusters and defense attorneys. After doing so we decided that every referral would begin with a thorough Initial Psychological Evaluation (IPE), which, although not technically an IME, would be done at the IME level (we priced the IPE at $450, and, since nobody’s complained, we now think that’s too low, but we’re sticking with it). If the Initial Psychological Evaluation determines the presence of one or more mental health issues which are deemed to be work-related and requiring treatment, the treatment prescribed is initially authorized for up to 12 sessions unless medically justified, extraordinary circumstances are present. Additional treatment requires the approval of the referring party.

We officially launched in November, 2016. Over the intervening three months  we’ve learned two things (among a lot of others): First, our solution works extremely well; referrers have been highly receptive and pleased. They appreciate the ease of referral and the EHR reports.  They appreciate even more the fact that our clinicians and therapists have been trained in workers’ compensation. We’ve signed contracts with insurers and TPAs. Second, this could be a national solution.

So, our solution is working in New Jersey, but every state workers’ compensation system is grappling with how to deal with psychosocial issues that frequently hobble recovery. This may be work comp’s final frontier. Time will tell whether our template and software could help others. Regardless, we will continue to improve our solution at Work Comp Psych Net, as well as report on our outcomes.

It’s taken us nearly two years to get to this point, so if any reader wants to take this issue on in another state, we’d be happy to offer the wisdom (and sometimes folly) of our experience.

 

 

Are We Only Paying Lip Service To Psychosocial Issues In Workers’ Compensation?

Wednesday, November 4th, 2015

It is a cliché in the workers’ comp industry that claims adjusters never want “to buy a psych claim.” Perhaps that’s why they rarely resort to psychologists until the horse is out of the barn and grazing four pastures over. By then it’s a last resort kind of thing.

I was reminded of this last week in Idaho at the Industrial Commission’s annual conference when Bob Wilson opined during his presentation that he considers the “psychosocial” issue one of the most difficult facing the workers’ comp industry today, one that will become even more problematic tomorrow, a veritable iceberg dead ahead.

I could not agree more.

So, why is it adjusters don’t want to “buy a psych claim?” Pretty simple, really. Most claims adjusters have had the unfortunate experience of referring an injured worker to a psychologist after all else has failed only to discover that the injured worker turns into the psychologist’s lifetime annuity and the adjuster’s worst nightmare. Treatment goes on forever. Also, it often turns into an attitude thing. Claims adjusters consider “going on forever” claims their “problem children.”

That’s a logical inference. The steady march of time is a formidable opponent as one tries to assist an injured person to return to the bosom of the workplace. The longer a worker stays out of work, the more difficult the problem becomes. Comorbidities begin to sprout like the weeds in my woebegone garden. In many cases, staying out of work becomes the new full-time job. What’s an over-burdened adjuster to do?

Perhaps on Day 1 of the claim giving strong consideration to the psychosocial would help. Unfortunately, as adjuster pros know, the First Report of Injury won’t give many clues here. Deep digging is required. If available, predictive analytics can be the adjuster’s best friend. Still, an even better bosom buddy is experience. Over thousands of conversations with injured workers, an experienced claims adjuster will acquire a profound recognition of nuance. Not settling for the basic questions, but rather peeling the injured person’s personality onion to discover what really matters will allow for early detection of those relatively rare cases where speedy referral to a qualified psychologist might make all the difference.

And psychologists need to shoulder some responsibility here. Most know not even the first thing about workers’ compensation and give every indication of being proud of it. The only insurance premium that matters is the one labeled “Malpractice.” Experience Modification is nothing more than an oxymoron. Many do not understand, and do not want to understand, that helping someone become as mentally healthy as the day of exiting the womb is not the same thing as maximum medical improvement.

And what if payers and psychologists could agree to the rules of the road right up front. For instance, coming to an understanding about qualitative and quantitative goals, about the need for a finite number of sessions, about agreeing that there are certain signs which, if manifested at the beginning of a claim, suggest that the claim would benefit from early psychological intervention? And what about the idea that entrance into a payer network should not be determined solely by a License to practice and the forced acceptance of a ridiculously low fee? Quality and results matter.

There’s a fair amount of education that ought to go on here. Payers would be wise to begin that education today. Why? Because identifying early and resolving quickly the factors that have the potential to turn physical injuries into mental health problems will save employers, the folks who pay the bills, a significant amount of money and adjusters, whose goal it is to put the toothpaste back in the tube, considerable otherwise wasted time.

Peter Rousmaniere’s Seismic Shifts in Workers’ Comp: A Thought-Provoking Call To Arms

Monday, February 23rd, 2015

In the mid-1980s, workers’ compensation underwent a management revolution. Until then, employers bought insurance policies, and when injuries occurred passed the baton to their carriers. Then they went back to making widgets trusting that the carriers would take care of everything.

That didn’t work out so well, and costs took a rocket ride to the moon. Across America, employers looked for help. Why would injured workers remain out of work long after it was medically necessary for them to do so. The answer, as we all know, was found in the mirror. Employers, themselves, were the key to getting injured workers back into the bosom of the workplace, but they’d never been taught how to do that. Didn’t know it was their job.

Thus was the workers’ comp management consulting industry born. My company, Lynch Ryan, was first out of the gate. We were the Pathfinders, and Peter Rousmaniere was Employee Number 3 in what was to become a 55 person firm. Peter – Groton School, Harvard BA, Harvard MBA – wanted to join us because he was looking for a challenge. I wanted Peter to join us because he was really smart, and his brain worked like nobody’s I’d ever met. Peter thought “outside the box” before there was an outside the box.

Peter still thinks like nobody else, and today Work Comp Central has published his Seismic Shifts: An Essential Guide for Practitioners and CEOs in Workers’ Comp, subtitled, How Technology and Demographics Will Impact Workers’ Comp From Today Through 2022. This self-funded, year-long venture looks out into the future and envisions another revolution, one that we ignore at our peril.

In Seismic Shifts, Rousmaniere catalogues the nearly unnoticed, but drumbeatingly steady, changes in workers’ compensation since the early 1990s. He shows that since 1991 lost time injuries have declined by 60% and projects that by 2022 there will be a further decline of at least another 35%. He is perplexed about how the insurance industry has missed this decline in injuries and claims, what he calls ‘the elephant in the room,” and suggests that it has done so because for more than a decade it has been obsessively fixated on medical costs, an observation with which I agree. Rousmaniere contends that the insurance industry does not understand how this has happened or why.

His thesis is that this sea change, this seismic shift, is the result of employer improvements in safety engineering, information technology, telematics, robotic design, predictive modelling analytics and the continuous yearning for enhanced productivity. And most important, this natural gravitational movement will continue inexorably. Further, he believes that the workers’ compensation insurance industry has not considered where all of this will lead, how it can be part of and optimize this transformational movement and what kind of workforce it will need to take advantage of this new paradigm.

In Rousmaniere’s view, workers’ compensation practitioners, as well as occupants of the C-Suite, would be well-advised to understand what’s happening and embrace, rather than resist, these evolutionary developments. In his mind, the embracers will succeed and control the future; the resisters will be swept away. It’s as simple as that. He describes, as example, the profound employer movement toward total absence management, rather than merely occupational absence. The move toward total absence management is gathering steam at larger employers, and workers’ comp insurers don’t know what to do about that. Neither do they have a plan for coping with the “opt out” phenomenon. First Texas, then Oklahoma, and just last Friday legislators in Tennessee filed opt-out legislation built on the Oklahoma model. This is becoming a trend.

But the workers’ compensation industry has never distinguished itself in the race to the future. It will be interesting, indeed, to see if Rousmaniere’s clarion call is even acknowledged by today’s potentates. To help it along Work Comp Central is hosting a 4-part webinar series during which Peter will lay out his thesis and try to persuade others in the workers’ comp community to join him in his effort to drag the industry kicking and screaming into the future. Check with Work Comp Central for dates of the Webinars.

Seismic Shifts is an important work, one deserving of your attention and consideration.

LexisNexis: Furthering the Workers Comp Community

Monday, December 22nd, 2014

I am not a lawyer, thank you very much, but I am married to one. So, you may imagine that I am familiar with more than a few members of the breed. I’ve heard every lawyer joke there is (but if you want to send me a couple of your favorites, that would be OK).

In the mid-1980s, the early days of Lynch Ryan, I often heard my attorney friends saying they had to search “Lexis” for one thing or another. Since they were occasionally charging me for doing that, I wanted to know a bit about “that Lexis thing.” Over lunch one day I was educated about this remarkable innovation for the legal community, an innovation that was actually saving me money.

The whole thing began as a searchable database experiment of the Ohio State Bar in 1967. In 1970, the Mead Corporation’s Mead Data Central took it over and named it Lexis. In 1973, Mead made Lexis’s full text search available for all cases in Ohio and New York. In 1980, after a 7-year key punch effort (you read that right), Lexis went nationwide for all federal and state cases. That same year, Mead launched the Lexis sister, Nexis, which allowed journalists to search news stories related to law.

In 1994, Mead sold LexisNexis to Reed Elsevier for $1.5 billion. Not a bad return on investment from those Ohio State Bar days.

Starting in 2000, LexisNexis began to get into the risk solution business, primarily by acquisition: Riskwise in 2000 and ChoicePoint, a data aggregator, in 2008. By the time of the ChoicePoint buy, LexisNexis had become profoundly involved in risk, especially workers compensation. It became a leading publisher of workers compensation material, including Larson’s Workers Compensation Law.
The LexisNexis Senior Editor for all things workers compensation is Robin Kobayashi, a ridiculously smart and talented person (Phi Beta Kappa from UCLA — by contrast, the closest I ever got to Phi Beta Kappa was admiring Gary Anderberg’s pin).

Robin is the visionary who decided to recognize workers compensation bloggers, beginning in 2009. That year there was only one winner, and I’m proud to say we were it. However, beginning in 2010, Robin expanded the award to the top 25 blogs, realizing that there was a wealth of insightful Web commentary that cried out for recognition.

Recently, LexisNexis announced the top 25 workers compensation blogs for 2014, a most distinguished list, and we congratulate everyone on it. However, during this time of recognition, I thought it might be a good idea to shine the Workers Comp Insider arc light on the far-sighted professional who made this award possible, thus deepening and expanding the workers compensation community in a meaningful and long-lasting manner.

For her vision and dedication, we salute Robin Kobayashi.

Veterans Day 2014 – Hire a Vet

Tuesday, November 11th, 2014


Veterans Employment Toolkit
“…to help employers, managers and supervisors, human resource professionals, and employee assistance program (EAP) providers relate to and support their employees who are Veterans and members of the Reserve and National Guard.
In this toolkit, you can learn about Veterans and the military, such as what Veterans bring to the workplace and what the military structure and culture is like. You can also learn how to support employees who are Veterans or members of the Reserve or National Guard in the workplace, through reading about common challenges and how to help, reviewing communication tips, reading a report about Veterans in the workplace, or by downloading handouts to use with EAP clients. Finally, Veterans and their family members can find employment resources for Veterans.”
Veterans in the Workplace Project
Information for HR Practitioners – Statutes & Regulations
More employment resources for hiring vets
Veterans Crisis Line
crisis-line

Tom Lynch interviewed by Steve Schmutz at Claimwire

Wednesday, June 18th, 2014

Pardon us while we self promote for a minute… but many thanks to Steve Schmutz at Claimwire for featuring Tom Lynch in his interview series. For those of you who don’t know Tom and would like to learn a little more about him, you can read the interview here: Industry Spotlight: 20 Questions with Tom Lynch, CEO at Lynch, Ryan & Associates…and when you’ve read that, here is an archive of all Steve’s prior interviews with insurance leaders. They are interesting reading because they dig below the professional surface with some questions designed to reveal what makes these well-known insurance professionals tick – who influenced them, what their career paths have been like, who they admire and other interesting questions that give insight. Thanks, Steve, for including Tom in your series.
Since this is blog post with Tom Lynch as a topic, it gives me a podium to add my personal perspective. As someone who has known and worked with and for Tom for more than 20 years, I would add that he is remarkable visionary and has been a key influencer in our industry — as well as on the lives and careers of his many employees over the years.
Today. many of the day-to-day employer best practices in managing workers’ comp claims that we take for granted were nurtured in the Lynch Ryan “labs” in the early days of the company. In those bad old days, Tom brought the true entrepreneurial spirit to addressing a broken system. “Changing the paradigm” is a shopworn cliche that rarely plays out beyond press releases, but Lynch Ryan truly shifted the approach by focusing on managing the human event rather than the financial transaction, a change in focus that enabled better and healthier outcomes for worker and employer alike. Tom & team identified many of the flaws and friction points in a malfunctioning system: a system in which most employers had better plans in place to address their copy machine breakdowns than they did for their injured workers; a system that was essentially geared to treating the “bad apple” on the bell curve, but not the preponderance of honest and legitimately injured workers; a system in which employers took a hands-off stance at point-of-injury, a critical management/human juncture; a system in which employers were paying large sums of money for a service it knew little to nothing about. Tom applied common sense management principles and a human-focused approach to fixing these problems saving employers a bundle in the process. Treating people well and fairly was actually more cost effective than treating people suspiciously and punitively — who knew!
Tom hired a remarkable team in those early days (if I do say so myself, heh), inspired them with passion and gave them wide latitude to enact their ideas – effecting some out-sized industry-wide practices that continue to this day. I can say that it has been a true privilege to work with Tom.

Review: Work Safe: An Employer’s Guide to Safety and Health in a Diversified Workforce

Monday, November 18th, 2013

Review of work produced by Peter Rousmaniere, with support from Concentra and Broadspire.
Of the 15 occupations that are expected to see the largest numerical growth between now and 2020, foreign-born workers, immigrants, are currently over-represented in eight of them. And of those eight, six are classified as “low-skilled” for which a high school diploma is not required. The Bureau of Labor Statistics projects that these occupations will grow by 42% between 2010 and 2020. Odds are that they will continue to be over-represented by foreign-born workers.
Consider this:

  • Forty-nine percent of private household employees are immigrants;
    • Within the Construction industry, 65% of all “reinforcing iron and rebar” workers are immigrants, and they total 27% of all construction laborers;
  • Forty percent of maids and housekeepers in the Accommodation industry are immigrants; and,
  • While immigrants comprise 24% of all the workers in the Agricultural industry, they make up 61% of the field workers.

As of 2010, 29% of immigrants between the ages of 25 and 64 lacked a high school degree, as opposed to 7.4% of the U.S.-born population. And, although immigrants make up 15.8% of all U.S. workers (something a bit hard to believe when you consider their ridiculous over-representation in those fast growing industries), they account for 20% of all reported injuries.
These facts, alone, make Peter Rousmaniere’s Work Safe: An Employer’s Guide to Safety and Health in a Diversified Workforce (PDF), published with support from Concentra and Broadspire, a timely and compelling read. Moreover, it’s free and is available as a pdf download at Broadspire.
Rousmaniere, publisher of the Working Immigrants blog since January 2006, and, until November 2013, a columnist for Risk and Insurance Magazine, has, until now, been a “voice crying in the wilderness.” He’s been banging the drum and sounding the alarm, saying that we, as a nation, and particularly as employers, are unprepared–indeed, are refusing to prepare–to deal with the needs and cultural differences presented by immigrant workers. A Harvard MBA, Rousmaniere believes that, although there is a moral imperative for doing so, making the effort to become sensitive to the language and cultural differences in our immigrant workforce just makes good business sense. And in this 57-page, 6×9 inch, handsomely produced Employer’s Guide he skillfully makes the point.
Although immigrants are also over-represented in high-skilled jobs, this book is really aimed at the vast underbelly, immigrant workers who lack the education and skill set to navigate through the thorny thicket of work rules and health care issues, immigrants who may speak wonderful Spanish, or any number of other languages, but nary a word of English. The theme running through the entire book is one that urges us not to assume that English-challenged immigrant workers understand what we say, even when we say it in their language. Rousmaniere makes this point over and over again, so much so that I thought the book could have been somewhat shorter without losing a thing.
To me, this sentence is the big pitch:

“…moderately or low-skilled immigrants working in jobs of average or above-average injury risk are likely to face greater safety issues even if they work alongside U.S.-born workers.”

The book has an excellent chapter on safety training in which Rousmaniere doesn’t so much suggest what to say, but rather how to say it. He writes about teaching through stories, role-playing, body mapping and pictures. He’s big on pictures, recommending that employers go so far as to hire cartoonists, because cartoonists have “a knack for telling a story in one or many panels.” He even describes how cartoonists get paid and offers “Tips for working with artists.”
In the Workers’ Compensation chapter, Rousmaniere offers a novel idea — the prepaid indemnity card. He points out that about a third of the people who earn less than $30,000 a year don’t have bank accounts and, consequently pay hundreds of dollars a year in check cashing charges. To help them, he suggests that claims payers contract with debit card vendors to pay indemnity benefits directly to injured workers via the card, which the vendor would arrange to have honored at ATMs. Interestingly, this isn’t a new concept. Rousmaniere says, “An increasing number of employees receive their wages via a payroll debit card.” Left unsaid is what that “increasing number” actually is, but if you think about it, his idea might have more than a little merit because of the inexorable gravitational movement of technology.
The book has an extensive chapter on “Medical Care Across Cultures,” and here Rousmaniere is writing about all medical care, not just work injury care. Again, it’s all about translation and culture. He gives an illustration: “In some societies, it’s believed that coughs are always fatal.” I found myself wishing he’d enlighten us as to which ones.
He writes about “Job-Specific Challenges in Cross-Cultural Care” and says that “Medical Case Managers are likely to have to confront a patient’s steep learning curve when it comes to understanding the American health care system.” I found that one a bit rich, as in – does any patient understand the American health care system, if you can call it that.
In fact, I found that much of the chapter on health care really applied, not only to immigrants, but also to many native-born Americans who are unskilled at navigating the health care maze and have what Rousmaniere calls “low health literacy.” For example, he offers a bullet list of “side effects” for this affliction: failure to seek preventive care, leading to more ER visits and hospital admissions; no written agenda for medical visits; missed appointments; lack of follow-through with imaging tests; misuse of medications; and so on.
Rousmaniere suggests an “Rx for Hospitals: Professional Interpreters.” Moreover, he points out, “The Civil Rights Act obligates medical providers to arrange for patient communication in the most suitable language for the patient.” I did not know that. He offers health care providers another bullet list of tips for overcoming language differences. In today’s health care world the first tip, “Slow down. Plan double the normal time,” might be hard to achieve. Trouble is, the tips all make good sense. They’re thoughtfully done, and, were it not for our health care assembly line process, they’d be the norm. My bottom line takeaway to Rousmaniere’s health care recommendations: they will take nearly dictatorial leadership to implement.
Then for good measure, in case we’ve missed the point, Rousmaniere throws in an entire chapter on translation and interpreting, entitled “Translate This!” But just when you know to the soles of your boots that this translation thing has gone way too far, he throws in this Case Study zinger that makes you think he might be right to concentrate so much on this:

“An English-speaking hospital staff once misinterpreted a patient’s complaint of “intoxicado” as an admission of being intoxicated, not that the patient felt nauseous. The mistake resulted in permanent paralysis and a multi-million dollar financial settlement.”

The translation and interpreting chapter lists a number of resources of which health care and insurance pros will likely be unaware. He compliments California for Senate Bill 853, which “requires that health insurance organizations provide free and timely translation and interpretation services for patients with limited English proficiency.” And Rousmaniere’s “10 Planning Steps for Translation and Interpreting” is spot on.
But for my money, the little jewel in this book is the last chapter – “Free Online Resources.” I loved it. He has hunted down a wonderful library of resources that every professional in the field should have at his or her fingertips. They come as General Resources, such as a number of truly excellent offerings from the State Compensation Fund of California, Spanish to English and English to Spanish dictionaries published by OSHA, and resources aimed at a number of industries, the ones with all those low-skilled, fairly uneducated immigrants. Excellent, indeed!
All this may be a bit much for middle and small market employers, who may not think they have the resources or time to invest in this level of acculturation. I suspect that this book may not be a big seller for them. Health care professionals, on the other hand, would be well-advised to study it closely.
But, here’s an idea: if insurance companies and insurance agencies were to distribute the book to their customers, that would go a long way toward educating employers and getting Peter Rousmaniere out of the “wilderness.” For, in the immortal words of that great American philosopher and discount retailer, Sy Syms, “An educated consumer is our best customer.”
The official launch of the Guide will take place at the National Workers’ Compensation Conference in Las Vegas, NV, November 20-22.

Back to the Future?

Monday, November 4th, 2013

If you’ve been following the blog-o-sphere and the LinkedIn-o-sphere, you know that the space is crowded. Lots of workers comp practitioners have glommed on to the idea that the way to get ahead is to write and post frequently. Connect with more than 500 others in the profession. Write something, anything, put your name on it and throw it up against the wall to see if anything sticks. Kind of the way Garrison Keillor used to say he changed socks on a book tour.
Every once in a while, something helpful and interesting appears and gains a bit of temporary caché for itself and for its author. Mostly, the topics center on the persistent rise in medical costs and, even more often, on the insidious and, some would say, criminal use of opioids, which a regrettable number of alleged doctors, having checked their Hippocratic Oath at the door, are prescribing at a hell-bent-for-leather rate at a hell-bent-for-leather profit. The poor, unfortunate souls for whom these scripts are written are nothing more than high-cost collateral damage.
Consequently, efforts to control workers compensation costs are now almost entirely dedicated to reining in costs associated with medical care with a huge emphasis on prescription drugs.
My colleagues and I have always believed (and, I add, have time and again been proven right) that the workplace is the best place to control and manage work injuries and costs. That, in order to do that, employers need to be educated so that they understand that they, not the vendors to whom they outsource payment responsibilities, are the hub of the workers comp wheel. In the mid 1990s, at the height of the worst workers comp crisis ever to hit the market, this hypothesis became fact. Our clients, as well as the clients of a number of our competitors, overcame the workers comp troubles of the day because they learned that treating workers compensation in a Management 101 kind of way reduces costs to a minimum and goes a long way toward bolstering profits as well as employee morale and productivity. This meant training supervisors in the proper response to work injuries, keeping close communication with injured workers, creating good relationships with treating physicians, bringing injured workers back to work under medical supervision, seeing that injured workers received full pay while on modified duty, and measuring success every month just as they measured success in every other business enterprise. These, and other program components, gave these enlightened employers a distinctive competitive advantage, and the results spoke for themselves.
Something has happened between then and now. I think of it as the “workers compensation dark ages.” There are still enlightened employers, but many have lost their way. We took a system that we had made relatively simple for employers to manage (and let’s not forget that it is employers who ultimately pay the bills) and we made it progressively more complicated. We made medical care into a haunted house maze that only experts can navigate (hence, the rise of medical experts). Employers, suddenly realizing that they are now the south bound end of a north bound mule, have relinquished control to a myriad of vendors, the “experts.” Not all employers, of course. Large, sophisticated organizations with well-oiled risk management departments, have not lost the focus, although they have to work harder to stay the course.
So, like Pogo, “We have met the enemy, and he is us.”
The question is: What are we going to do about it? Could it be that the way forward is by way of the way back?

Annals of Claims Management: Full Catastrophe Denial

Tuesday, May 7th, 2013

In the Insider’s decade of exploring workers comp, we have encountered many unusual instances of compensability, legitimate claim denials and outright fraud. But rarely have we found cases where a claims administrator, in this case, a TPA, simply refuses to pay for medically necessary treatment. The saga of the late Charles Romano reminds us that the great bargain of workers comp is not just between employers and their workers; it includes the good faith effort of claims adjusters to carry out the letter – and spirit – of the law.
Charles Romano worked as a stocker for Ralph’s Grocery Company, a California-based operation that is part of the Kroger chain. It is worth noting from the outset that Kroger is self-insured for comp, with Sedgwick serving as the TPA. As a stocker, Romano presumably did a lot of lifting and reaching. He suffered a work related injury involving his shoulder and back in August of 2003.
A Solution Worse than the Problem
After conservative treatment failed to resolve the problem, he underwent surgery in December 2003. What had seemed like a relatively simple solution to a shoulder problem quickly descended into a grave, life-threatening situation: Romano contracted a MRSA infection following the surgery, which led directly to total paralysis. He suffered renal failure and several heart attacks, which were related to the MRSA infection. After enduring inadequate medical treatment directly related to the TPA’s denial of treatment, Romano died in May 2008.
Nearly three years after the initial surgery, a workers comp administrative law judge (WCJ) ordered that the TPA pay for all the medical expenses related to the infection. Without consulting with medical professionals, the TPA unilaterally refused all payments – totalling, by this time, hundreds of thousands of dollars. The TPA appealed the adverse ruling.
In February 2012, a workers comp administrative law judge imposed penalties for delay of treatment in eleven specific instances, finding that the TPA “failed in its statutory duty to provide medical care, egregious behavior which increased the suffering of a horrifically ill individual.” He imposed the maximum $10,000 fine for each denial of treatment.
Unappealing Appeal
The TPA appealed the penalties for delayed treatment. In what surely qualifies as a new definition of chutzpah, the TPA contended that penalties were not appropriate, among other reasons, because the claimant had died. Well, duh, the routine denial of treatment throughout the course of the illness was a significant factor in the death. Romano simply did not receive medically necessary treatments to address his formidable medical conditions.
NOTE: The penalties, even when maxed out at $10,000 per incident, is dwarfed by the suffering inflicted upon Romano.
The Workers Comp Appeals Board upheld the penalties [For a link to a PDF of the lengthy ruling, Google “Charles Romano Trust vs. Kroger Company]:

The WCJ’s Report makes it clear that he imposed the harshest penalties possible under section 5814 because of defendant’s extensive history of delay in the provision of medical treatment; the effects of those delays on a paralyzed, catastrophically ill employee; the lengths of the various delays; and defendant’s repeated failure to act when the delays were brought to its attention.

Lest the ruling be considered in any respect ambiguous, the court went on to say: “We have rarely encountered a case in which a defendant has exhibited such blithe disregard for its legal and ethical obligation to provide medical care to a critically injured worker.”
Risk Transfer, Risk Retention
It is tempting to conclude that the TPA’s actions were related to their customer’s risk assumption – otherwise known as self insurance. It is one thing to purchase insurance (risk transfer) and have the insurance company assume liability for a catastrophic loss. It is quite another for a self-insured company to absorb a loss of this magnitude on its own. (Presumably Kroger had some form of stop loss in place.) Despite the multiple findings of compensability, despite the judicial determination that the horrendous MRSA infection was indeed work related, the TPA persisted in denying treatments and rejecting payments, long after Romano’s untimely death.
As Mark Twain famously noted, “denial is not just a river in Egypt.” It’s also a poor strategy for managing claims. In his last years, the unfortunate Charles Romano certainly had to confront health issues beyond anyone’s worst nightmare; denial for him was not an option. For reasons that remain unclear, when it came to paying for Romano’s extensive and expensive care, the TPA chose a path of full catastrophe denial .
In the findings of the court, this denial was in itself an unmitigated disaster for the acutely vulnerable Romano, accelerating his precipitous decline and death. In the interests of saving their client some serious bucks, the TPA dug in its heels and refused to accept the compensability of a claim that had been adjudicated as compensable. In doing so, they violated the spirit and letter of the workers comp contract and earned themselves, in this particular instance at least, a place on the Insider’s Management Wall of Shame.

Opioid Catastrophe: The Data Leads to Doctors

Monday, March 4th, 2013

After two stimulating days at the Workers Comp Research Institute conference, the Insider is ready to solve the opioid problem. To be sure, WCRI is a research-driven organization and makes no claims of solving problems; it simply reveals them through stark, powerful data. However, in a series of presentations ranging from improving the way doctors prescribe drugs through the mobilization of entire communities to tackle the problem, the conference has illuminated the path toward a favorable resolution of this increasingly dire problem.
Dr. Karin Mack of the Centers for Disease Control established the parameters of the problem: death from drug overdoses – mostly involving prescribed medications – now kills more people than traffic accidents. While heroin and cocaine account for about 4,000 deaths annually, opioids kill four times as many people – more than 16,000 in 2010. Most of the drug overdoses involved people of working age (between early 20s and 60). Dr. Mack identified the population most at risk:
– “Doctor shoppers”
– People receiving high daily doses of opioids and those using a variety of drugs
– Low income people and those living in rural areas
– Medicaid populations
– People with mental illness or a history of substance abuse
When the discussion shifted specifically to workers comp, the data becomes even more alarming. In some states, over 80% of injured workers receive opioids for pain relief – way too many! The prescribed doses are often much higher than is medically necessary. For many workers, the prescriptions extend for many weeks, even though pain usually subsides relatively quickly. And finally, very few doctors are monitoring patients who have been prescribed opioids.
Doctor Problems
Given that drug abuse has reached catastrophic proportions, and given that most of the problem involves prescribed – as opposed to illicit – medications, it is becoming increasingly clear that doctors are a big part of the drug problem. They are too quick to prescribe opioids; they prescribe them for too long; and they fail to monitor injured workers who are on these medications. The first red flag, in other words, is raised over the heads of our medical practitioners.
Dr. Dean Hashimoto outlined a Massachusetts initiative that significantly reduced doctor mistakes in prescribing opioids (a summary of the state’s approach can be found here). The guidelines:
1. Distinguish between acute and chronic pain. For acute pain, doctors should explore ady and all alternatives before prescribing opioids and then carefully re-evaluate before extending the initial prescription.
2. For chronic pain [in itself a red flag], doctors should run urine screens to determine whether the prescribed drug is being used properly and whether other drugs have been taken; they should meet fact to face with patients as frequently as needed; and they should try to focus on function rather than pain.
Note that these are steps that doctors should, but all-too-often don’t take. Combine that with the fact that a small number of doctors are generally responsible for a huge number of prescriptions: in California, 3% of doctors prescribe over 50% of the opioids. Once again, doctors are at the root of the drug problem.
PDMPs
In addition to improving best practices in the medical use of opioids, we need to know more about prescription practices. This involves the evolving tool of prescription drug monitoring programs (PDMPs), which track prescription practices of doctors across a given state. Because the programs are state based, they vary widely on how they work: what is tracked, how often data is submitted, how it is analyzed and what is done with it. Ideally, to be effective, the data should be collected on a real-time basis, but in practice, it’s generally submitted weekly. Ideally, there should be standards across all state PDMPs: everyone collecting the same data, in the same form, generating information on prescription practices and “hot spots” with consistency.
Brandeis University’s Center for Excellence identifies the best practices for PDMAs. But we live in an age where uniform standards are anathema. It’s just not going to happen, so we’ll have to live with the current chaos – which, however inadequate, is better than nothing.
Community Mobilization
While there is much that can and should be done at the doctor-patient level to fix the opioid problem, such efforts cannot solve the problem. We can actually map the crisis across the country and identify specific communities that have been devastated by drug abuse. The conference highlighted efforts in eastern Kentucky, where in some counties half the children are being raised with no parents in the home (the parents being dead from overdoses, incapacitated by addiction or in prison). Under Operation UNITE, the community has responded with a combination of drug enforcement, coordinated treatment, support for families and friends of abusers, education and mentoring for young adults. They teach kids archery and fishing, among other things, surely an example of putting the beautiful natural surroundings to good use.
It is hardly surprising that one focus of UNITE is the pill mills that are frequently found in poor, rural areas. One doctor prescribed over 100,000 pills a month (!) by issuing 40-50 scripts each day (!). Don’t bother asking whether Dr. Hashimoto’s standards of treatment were followed.
The Path to a Cure
The WCRI conference illuminates the path toward solving the opioid abuse catastrophe: teach doctors how and when to use these powerful drugs and how to find alternative treatment forms; carefully monitor injured workers on opioids to ensure proper use; severely limit the use of these drugs over the long term; monitor prescription practices to identify doctors who are not with the program; and provide support, mentoring and education to young people in high risk communities.
There are many obstacles to implementing a comprehensive and effective program, but in those areas where key elements have been established, the incidence of opioid abuse has been dramatically reduced. It is ironic, of course, that the stakeholders who must “do no harm” are in fact in the forefront of the problem. They can and must do better. Medicine got us into this mess and it is medicine, with its highly trained and presumably well-intentioned practitioners, that must lead the way out.