Archive for the ‘Guest Posts’ Category

The “K” Factor and EU and USA Cases

Friday, June 26th, 2020

The K Factor

Ever heard of the “K” factor? Neither had I. But in yesterday’s Work Fitness and Disability Roundtable, Dr. Jennifer Christian’s long-running and valuable daily roundup of workers’ compensation medical news and musings, we were introduced.

Turns out the “K” factor could be tremendously important in helping leaders figure out how reopening the economy should proceed.

I thought Jennifer’s Roundtable post was so important I asked her if we could reprint it in the Insider. She gave permission, for which I’m grateful. So, here it is:

Hey, nothing like a fact-based “aha” to sharpen the mind and help point the way forward. A thought provoking article in New York Magazine (https://nymag.com/intelligencer/2020/06/coronavirus-meatpacking-plants-america-labor.html?utm_source=fb&utm_campaign=nym&utm_medium=s1&fbclid=IwAR0jnJXCeUx_zYVQuayha1XSMpMtjT-TSXIv7-RfIFNCDtlrz1hn558Da2w) on the reason for major differences between the COVID-19 experience in meatpacking industries in the USA and Europe brought up the “k” factor in the COVID-19 pandemic.  Ever heard of “k”?

Until yesterday, I hadn’t noticed (or paid attention to) any discussion about the implications for action of SARS-CoV-2’s  “k” factor. The “k” factor is an infecting organism’s observed dispersion behavior. Now is the time to start paying attention to the “k” factor because it points us straight to the main cause of the majority of COVID-19 cases: superspreading events in crowded indoor settings. We’ve all known that a lot of the cases have occurred due to spread on board ships, in prisons, hospitals, nursing homes, nightclubs and meatpacking plants – but to be truthful, I’m not sure we’d gotten the take-home message: SARS-CoV-2 is heavily dependent on crowded indoor spaces for its spread.

So, I did a bit more Googling and found a good Science Magazine article (https://www.sciencemag.org/news/2020/05/why-do-some-covid-19-patients-infect-many-others-whereas-most-don-t-spread-virus-all) that lays it all out quite clearly.  In addition to the R value (the mean number of subsequent new infections resulting from each infected individual), epidemiologists calculate how much a disease clusters. The lower k is, the more transmission is coming from a small number of people. The k value for the 1918 influenza pandemic was estimated at 1.0 – clusters weren’t too important. But during the 2003 SARS and 2012 MERS epidemics the vast majority of cases occurred in clusters, and their calculated k values were therefore low: 0.16 and 0.25 respectively.

In COVID-19, most infected people are not creating any additional cases. Adam Kurcharski from the London School of Hygiene & Tropical Medicine has conducted an analysis of COVID-19 dispersion and says, “Probably about 10% of cases lead to 80% of the spread.” A pre-print of his paper (https://wellcomeopenresearch.org/articles/5-67) has a calculated k value of COVID-19 at 0.1. Previous studies have pegged it just a tad higher than SARS or MERS.

There’s no point in trying to figure out which people are shedding the most viruses – though some of us clearly do disperse more bugs than others.  We professionals need to focus most of our attention on the places and types of events that SARS-CoV-2 needs in order to spread efficiently: loud and crowded indoor spaces, where people are cheek by jowl and raising their voices or breathing deeply: talking, singing, or shouting or aerobically exerting themselves. Ventilation and air flow in these settings also plays an important role.

Almost none of the clusters have resulted from outdoor crowded events.  Chinese studies of the early spread of COVID-19 outside Hubei province identified only one cluster among a total of 318 that originated outdoors. A Japanese study found that the risk of infection indoors is almost 19 times higher than outdoors. And here in the USA people who participated in (largely outdoor) Black Lives Matter protests have not been getting sick. (I also saw some data earlier saying that the virus is almost immediately disabled by sunlight.)

As the Science Magazine article says, the low k factor is …..”an encouraging finding, scientists say, because it suggests that restricting gatherings where superspreading is likely to occur will have a major impact on transmission, and that other restrictions—on outdoor activity, for example—might be eased.” So duh, let’s make the hierarchy of risk much more explicit. We need to make it crystal clear to the public (and patients and workers and employers) that the worst thing a person can do is participate in events in loud, crowded, and  indoor settings without rapid air turnover.

HOWEVER:  Many people are stuck. They live in crowded housing or congregate housing. The places where they live and work (ships, factories, office buildings, and medical facilities) already exist. People need to work, and winter is coming when we have to be inside.

I see this call to action: Are you, personally, confident that you are collaborating with all of the professionals whose input, cooperation, and contributions will be required? Think outside your silo. All of the various types of professionals who do event planning & commercial building design & engineering, industrial hygiene, HVAC, public health, and occupational health & safety need to join up and get deeply and rapidly involved in adapting / redesigning / re-configuring / re-engineering existing places and events to reduce the potential for superspreading.

A look at European Union and U.S. case statistics: Stunning

The following chart from the Johns Hopkins Tracker Project, printed in yesterday’s Statista Daily Alert needs no introduction or even analysis. It puts the period to Dr. Christian’s words.

 

Mike Manley On The Oregon Workers’ Compensation Premium Rate Ranking Study

Monday, October 10th, 2016

I have always tried to surround myself with people smarter than I. People such as Gary Anderberg, Peter Rousmaniere, Jennifer Christian, Joe Paduda, Bob Wilson, Mark Walls and Julie Ferguson, to name just a few of the legion. Mike Manley is in the group, too. Mike is Research Coordinator for the Oregon Department of Consumer and Business Services and co-author of what is known in the biz as The Oregon Study.

For three decades, the state of Oregon’s workers’ compensation research group has published this bi-annual study, which won the 2006 IAIABC Research Award. The executive summary of this year’s study is due to be released in the next few days, and the findings are closely watched in quite a few states. Unlike the National Academy of Social Insurance report, issued last week, the Oregon study takes the comparison beyond simple averages. Instead, Oregon derives average rates for what a hypothetical set of comparable employers would pay, thus factoring out much of the difference in states’ risk profiles.

With any comparison across states in the workers’ compensation arena, there are caveats and fine points to be considered. Naturally, there are questions that arise about the methods and interpretation of the findings.

At the Insider, it’s unusual  to have guest bloggers; we’ve only done it a handful of times over 14 years. But for important issues, we make exceptions. The Oregon Study is such an issue. So, I asked Mike if he would write something he wanted our readers to know about the upcoming study. He came up with a list of ten, and we’re going to publish every one of them right here right now. Who knows? You may be reading the latest study tomorrow, but if you are, you’ll be armed with Mike’s intelligent cheat sheet. What follows are the ten things to know about the Oregon Study, by Mike Manley.

           Ten things WC professionals should know about the Oregon Study

  1. This isn’t a report card! The study isn’t an overall evaluation of states’ workers’ compensation systems. There are other important aspects of workers’ compensation systems that are beyond the scope of this analysis. The study focuses on one aspect of workers’ compensation systems: rates paid by employers that purchase insurance.
  2. The study uses a consistent hazard mix across states. This is done by giving each state the same hypothetical distribution of risks, in order to control for the differences in risk across states. This distribution is most similar to Oregon (a national distribution doesn’t exist). Occasionally there have been concerns that this might create some kind of bias, so we’ve checked into that question. Looking at other methods that don’t use the Oregon risk distribution to standardize risk, we find no basis for this concern. The other studies have results that are very similar, once a consistent hazard mix is used.
  3. Rank values are useful, but they have major limitations for interstate comparison. So, we publish a second comparison factor, Percent of Study Median. We recommend using this measure, rather than rank values, for comparing states’ relative rate position over multiple studies.
  4. We study rates using a snapshot on January 1 of the study year. We look at where the rates are on the date of the snapshot, not whether they are going up or down.
  5. Index Rates are averages, sort of. The study’s Index Rate is different than a simple average rate. Premium rates within a state vary dramatically by the risk classification involved, and states’ economies have a different mix of these classifications. The study controls for these differences by looking at premium rates as if each state had the same mix of risks. This figure is the Index Rate, which is not the state’s actual average; instead it’s an average that has been weighted for comparability across states.
  6. High-wage or low-wage state? Don’t worry, wage rate differences across states have little or no impact on the results. Here’s why: rates in workers’ compensation are measured in dollars per $100 units of payroll. High-wage states may have higher benefit levels, but they also have higher wage bases. So, when both parts of the computation increase with higher wages, the resulting rate isn’t affected.
  7. Pure premium rates are a big part of the rate comparison, but only a part. The study also includes factors for insurer overhead and state administrative agencies’ assessments, when these can be put on a comparable basis.
  8. Study data don’t tell us why a state’s rates have been going up or down, or where they might be in the future. Nor do they tell us how effective a system is in minimizing disputes, getting injured workers back to work, paying out adequate benefits, or getting cost-effective medical treatment. Clearly, those are important performance areas too.
  9. The study doesn’t consider insurers’ profitability, discounts, dividends, or activity in the state’s assigned-risk plan. Those items aren’t available for all states, and even when they are available, they’re often incomplete during the year we’re studying. Employers that self-insure (or, in a few jurisdictions, opt not to insure) aren’t included in the study because they aren’t paying workers’ compensation premiums.
  10. Need more detail? We’ve got more! There are two publications that report Oregon’s findings in each study cycle:
  • a summary, typically published in the fall of even-numbered years, and
  • a full report with much greater detail, published the following winter.

Prior studies, both summary and full reports, are available at: http://www.oregon.gov/DCBS/reports/Pages/general-wc-system.aspx

 

Predictive Modeling in Workers’ Compensation

Monday, September 17th, 2012

Today, we host a guest blog written by our good friend and colleague, Gary Anderberg, PhD (Stanford). In addition to being one of the smartest people I have ever met (and I’ve met a lot of smart people), Gary is an exceptionally interesting and imaginative person. Currently Broadspire’s Practice Leader for Analytics and Outcomes in its Absence and Care Management Division, Gary is quite the expert regarding predictive modeling.
Gary’s been a college professor, a management consultant, VP of a California TPA and Founder of another California TPA. He helped design Zenith National’s Single-Point Program and Developed Prudential’s Workers Comp Managed Care Program, as well as its Integrated Disability Management Product.
Gary went to college to become an astrophysicist, but along the way found himself with a passion for ancient languages and cultures. As he puts it, “Some of my best friends have been dead for a few thousand years.” If that’s not enough, he also writes mystery novels, short stories and screenplays, and is a member of the Mystery Writers of America. In his spare time (you may be forgiven for asking, “He has spare time?”), Gary can sometimes be seen driving his space-age motorcycle through the back roads of Pennsylvania, wearing enough protective gear to make him look like an intergalactic warrior.
Tom Lynch
Predictive Modeling in Workers’ Compensation
Predictive modeling (PM) appears to be the buzzword du jour in workers’ compensation. There are real reasons why PM can be important in managing workers’ comp claims, so let’s stop and take a look at the substance behind the buzz.
PM is a process. Put simply, we look at tens of thousands of claims and try to discern patterns that link inputs – claimant demographics, the nature of an injury, the jurisdiction and many other factors – to claim outcomes. Modelers use many related techniques – Bayesian scoring, various types of regression analysis and neural networks are the most common – but the aim is always to link early information about a claim with the most probable outcome.
Obviously, if the probable outcome is negative – a high reserve, a prolonged period of TTD or the like – modeling can prompt various interventions designed to address and ameliorate that negative outcome. In effect, we are predicting the future in order to change the future. Spotting the potential $250,000 claim and turning it into an actual $60,000 claim is how PM pays for itself.
There are two approaches to PM: (a) mining existing claims data and (b) using claims data plus collateral information that models claim factors not well represented in a standard claim file. Ordinary data mining uses the information captured as data points during the claim process – claimant demographics, ICD-9 codes, NCCI codes, location, etc. But the standard claim file is data-poor. Much of the most revealing information about claimant attitude, co-morbid conditions, workplace conflicts and the like is captured – if it is captured at all – as narrative. Text data mining is a complex and less-than-precise science at this point, thus conventional data mining is limited in what it can provide for PM.
The best PM applications based on conventional data mining can provide a useful red light, yellow light, green light classification for new claims, identifying those claims with obvious problems and those that are obviously clean, leaving a group of ambiguous claims in the middle. This is a good start, but two important refinements that ratchet up the usefulness of PM materially are becoming available.
Sociologists, psychologists, industrial hygienists and others have done a tremendous amount of research in the last 30 years or so into the many factors that influence claims outcomes and delay normal RTW. Many of these factors are not captured in the standard claims process, but they can be captured through the use of an enhanced interview protocol and they can be mathematically modeled as part of a PM application.
Systems are already in place that ask value-neutral but predictive questions during the initial three point contact interviews. Combining the new information from the added questions with the models already developed through claim data mining produces a more granular PM output, which can identify particular claim issues for possible intervention.
For example, development is now underway to include a likelihood of litigation component in an existing PM system by adding a few interview questions and combining those responses with information already captured. Predicting the probability of litigation has a clear value to the adjuster and others in the claim process. Can potential litigation be avoided by changes in how the claim is managed? Do other factors in the claim make running the risk of litigation a worthwhile gamble? Better predictions make for more effective claim management.
Most of the PM systems in development or online are front-end loaded and look at the initial claim data set. But some trials are already underway to perform continuous modeling to look for dangers that may arise as the claim develops. The initial data set for a new claim can predict the most probable glide path for that claim, and in most cases the actual development of the claim will approximate that glide path. In some cases, however, the development can go awry. A secondary infection sets in or the claimant unexpectedly becomes severely depressed or lawyers up. This new, ongoing PM process monitors each claim against its predicted glide path and warns whenever a claim seems to be in danger of becoming an outlier – or a reinsurance event.
But wait a minute: isn’t an alert adjuster supposed to catch all of these factors from the initial interviews on? The use of PM is predicated on the idea that the best adjuster can have a bad day or miss a clue in an interview. A claim may have to be transferred to a new adjuster due to vacation, illness or retirement. Claim adjusters may well have invented the concept of multitasking and we all know that oversights can happen in a high-pressure environment.
A good PM application is the backstop, and it can be set up to alert not just the adjuster, but also the supervisor, the unit manager and the client’s claim analyst all at the same time. This brings new power and precision to the whole claim process, but only if the PM application becomes an integral part of how clams are handled and is not relegated to after-the-fact reporting. Several presentations at a recent Predictive Analytics World Conference in San Francisco made it clear that, in a wide range of business models, PM is still a peripheral function which has not yet been integrated into core processes.
To make the best use of PM in managing workers’ comp claims, two conditions have to be met: (a) adjusters have to understand that PM does not replace them or dumb down their jobs and (b) claim managers have to trust the insights that PM offers. When the PM system tells you that this little puppy dog claim has a very high potential to morph into a snarling Cujo based on how the claimant answered a handful of non-standard questions . . . believe it. Taking a wait and see approach defeats the whole purpose of PM, which is to get ahead of events, not trail along after them in futile desperation.
Remember, the purpose of PM is to avert unfortunate possible outcomes. This is one job at which you can never be too effective. Progress catches up with all of us – even in workers’ comp (one of the last major insurance lines to go paperless, for example). It is unlikely that, in another five years, any claim process without a robust PM component can remain competitive. If you can’t predict how claims will develop, you will be throwing money away.

Calculating Indirect Costs of an Injury

Tuesday, September 20th, 2011

The following is a guest post by Frank Pennachio of The WorkComp Advisory Group
In the September 7th edition of the Workers’ Comp Insider, I noticed a reference and link to a tool known as the OSHA $afety Pays Program. I find value with the process of determining how many dollars of revenue is required to pay for an injury, but have serious reservations with the tool’s calculation of indirect costs. Calculating the indirect costs of an injury is far more complex than the OSHA tool would indicate, and reliance on such a tool may erode credibility with an employer.
For example, let’s look at two employees who work for a Franchised Auto Dealer that experience the exact same injury, medical costs, and lost time. One of the employees is a top notch auto technician who frequently outperforms the manufacturers allotted time for warranty work, thus generating significant profits for the dealership. This employee is difficult to replace and each day of lost time is costing the business substantial profits.
The other injured employee is an auto detailer who is much easier to replace and train. Profits are not affected at the same level for the detailer as they are with the loss of a highly productive technician.
So, we have the same injury, medical costs, and lost time, but dramatic differences with indirect costs to the employer. According to the OSHA tool, both would have the same indirect costs.
The best article I have read on this topic, “Accident Costs: Rethinking ratios of indirect to direct costs,” was written by Fred A. Manuele and published in the January, 2011 edition of ASSE’s, Professional Safety Magazine. As Manuele states, “The literature on direct and indirect costs does not present a uniformly accepted computation method. Differences in the various systems are substantial. More importantly, no published ratios are currently valid because the increase in direct costs (indemnity and medical costs resulting from an injury or illness) has exceeded the increase in indirect costs substantially in the past 15 years.”
In addition, Manuele makes a strong case to support his position on the OSHA $afety Pays program: “Data on indirect costs produced using this program is misleading.
We want employers to understand and consider indirect costs. However, if employers suspects the formula to calculate indirect costs lacks credibility, they will likely question and remain skeptical on other more credible assertions and issues.
Indirect costs are real. Reducing them is a critical component of effective risk management and cost control. However, the issue is complex and deserves a conversation that is not reduced to a simple multiplier. Let’s embrace the complexity and lead employers through a conversation that will enlighten and inspire.
Frank Pennachio is co-founder of The WorkComp Advisory Group, a sales training and consulting organization that works with agencies to leverage technical knowledge and sales strategy into successful new business development.

Managing Chronic Pain, Revisited:

Tuesday, June 21st, 2011

We posted earlier this week on draft guidelines for pain management issued by the Massachusetts Department of Industrial Accidents. While we found much to like in the draft, our colleague Peter Rousmaniere, proprietor of his own blog on immigration issues, finds that the guidelines leave much to be desired. He views them as somewhat of a mincing mini-step in an area where rather big strides are needed.
Here are his thoughts on ways to make pain guidelines more effective:

Workers Comp Insider alerted us on Monday to the publication of draft chronic pain guidelines by Massachusetts DIA.
Medical treatment guidelines are helpful where clinicians, payers and courts desire an authoritative third party to say if and when a treatment is appropriate. But the value of guidelines really strikes home not only in the details but in how they pick their topics. Only so much can be covered proficiently. Guidelines need to focus on pressing matters of protecting lives and husbanding scarce resources. Then even the non-clinician in workers comp can say, “I may not understand all the medical details, but I know that these guidelines speak to my top concerns, and I will respect them and promote them accordingly.”
Perhaps because workers comp chronic pain treatment guidelines tend to avoid some of the most pressing issues for claims payers, they are not as useful as they could be. Perhaps also because claims payers feel free to ignore them, which they regularly do, we don’t see a visible, sustained effort within the claims payer community to improve the management of chronic pain cases.
Something for the Pain
One thing the guidelines have done laudably is to alert their readers to the very important patient safety issue when opioids are prescribed. This is very important: claims payers usually don’t require periodic drug tests for injured workers who have been prescribed opiates and they rarely are trained to respond when a test shows that the patient’s urine has no trace of the prescribed drug.
On balance, the Massachusetts guidelines, like other chronic pain guidelines used in the workers compensation community, are rather narrowly focused to the point where their usefulness is compromised. These various guidelines focus on non-surgical treatment of patients after they reach the stage at which they can be called chronic pain cases, and before they become extended, multi-year dependents on pain medication.The proposed guidelines devote just a few summary paragraphs to a challenge of the highest importance to claims payers: knowing the specific steps physicians can take to help their extended treatment patients improve their pain experience and function.
Predicting Pain
None of the current guidelines invest any time in describing the quite rich and fertile topic of chronic pain prevention among newly injured workers. Prediction and prevention are areas in which only a few occupational medicine doctors and nurses have achieved proficiency. Claims payers should focus on the need to identify chronic pain risk and encourage doctors to intervene as early as possible, when chronic pain risk, having been identified, can be addressed before the downward cycle begins. Unfortunately, you won’t learn about these best practices in these or in other state-promulgated guidelines. (I have proposed that chronic pain predictive models, matured through the wisdom of many, be placed in the public domain and inserted in treatment guidelines.)
Why these gaps? I wonder if the claims community has taken the time to communicate its concerns about chronic pain, so that guideline editors might address them? I imagine that they were back at the office, unaware of guidelines being drafted, and deeply involved in the deep stack of files that welcome them every working day.
Let’s Talk!
An inconvenient truth for workers comp claims payers is the universal endorsement of counseling intervention. Virtually all the chronic pain guidelines share a high regard for the psychological dimension of non-cancer chronic pain, which surfaces in pain perceptions and beliefs, catastrophizing, poor locus of control, and other traits that can be both measured and altered. The guidelines recommend time-limited cognitive behavioral therapy, the kind used to help you, say, overcome your anxiety about elevators, re-injury, or perpetual pain. The Massachusetts guidelines contain within their relatively thin girth a full-throated endorsement of psychological intervention – and that’s a good thing.
Unfortunately, most claims adjusters refuse to recognize the importance of cognitive therapy. They will have none of it and will deny treatment if the word “psychology” is attached to a request for treatment. The adjusters argue that once they allow psychological treatment, the workers comp courts will require them to pay for a lifetime of counseling intervention. I’ve heard this argument a lot. I wonder if the claims community and treatment guideline editors have ever had an extended discussion about psychological services and how to frame the issue to be most useful in a workers comp setting.
While the proposed pain guidelines leave a lot to be desired, I believe that an effective strategy for controlling chronic pain risk is within reach. Pain management is an essential element of any cost reduction strategy. If states can begin to draft chronic pain treatment guidelines that are more prescriptive, more specific and more focused on prediction and prevention, we would take a giant step toward bringing the costs of many large comp claims under control.
Submitted by Peter Rousmaniere

A Question of Language?

Monday, July 19th, 2010

The following guest post was submitted by Gary Anderberg, Phd, the Practice Leader For Outcomes and Analytics at Broadspire.
I was participating in a recent meeting of health, wellness, workers’ compensation and disability professionals. One of the issues on the table was information that the regs defining “Cadillac” plans may loop the cost of wellness programs, disease management and other health related productivity benefits into the total cost of the employer’s health plan for purposes of assessing penalties. If this intelligence is correct and if such provisions become effective, most large employer plans, so defined, will be subject to potentially expensive penalties, thus strongly incenting employers to relegate employee health care to the soon to be created exchanges.
This question stirred up a wide ranging discussion of how to frame the value of health and productivity programs for employers. For the last several years, most of the players in this space have been using the “investment” and “ROI” model, telling employers that they will reap rewards for astute investments in employee health and productivity. As a practical matter, returns on investment have been problematic to quantify. There is broad, intuitive agreement that a healthier workforce is a good thing, but what does it drive to the bottom line?
I suggested a different model — risk management. If trained, knowledgeable, productive employees are indeed a corporate asset — like trucks, buildings, airplanes, equipment, and so forth — then the health and well being of those employees presents a major risk exposure for the corporation in very immediate terms. We know that as the overall well being of a workforce declines, not only do absences of all types go up, but so do opportunity costs and the costs of poor performance and decision making. As absence rates and disability claims climb, more positions are filled by new employees with less experience and training than the absent workers. Mistakes get made, customers do not get the service they expect, and product quality suffers.
I suggested that, properly viewed, health plans, chronic disease programs and all types of effective wellness programs are really risk management tools in much the same way that fleet maintenance is a risk management tool. We assume that companies will maintain their eighteen wheelers and provide safety courses for their drivers, but the health and well being of the person behind the wheel is equally critical to the company’s risk exposure when a truck is on the road.
Every time a company hires a new employee, it takes on a new risk. For every employee on the payroll, from the CEO on down, there is a definite risk cost of employment which is based in large part on that person’s health and well being. So, are health, wellness and productivity programs investments with uncertain returns or are they critical risk management tools which allow the employer an important measure of control over the performance of a key asset — employees? It seems to me that these tools are vital to controlling employment costs and critical parameters of product and service delivery, especially in a world of very lean staffing and just in time management.
To my mind this is not just a question of which metaphor to use. Managing risk is real and the consequences of poor risk management are often dramatic and even tragic. I wonder how many companies would consider handing over the maintenance of their critical manufacturing and distribution equipment to a government program just to save a few bucks. But how many employers may be tempted to do the same thing if the soon to be created healthcare exchanges offer a short term dollar saving?
The words we use to frame decisions can carry massive consequences. If you think about the health and well being of your employees as a risk exposure to be effectively managed to minimize replacement costs and the expense of suboptimal performance and errors, what might you do differently? Think about it.

Healthcare Reform and Workers Compensation

Monday, June 14th, 2010

In the the following guest post, Gary Anderberg, Phd, the Practice Leader For Outcomes and Analytics at Broadspire offers his thoughts on the potential impact of healthcare reform on workers comp in the coming years.
At the moment, health care reform appears to have a number of positive and negative potential impacts on workers compensation over the next few years. The net results cannot be estimated this early in the game. We can, however, identify a few elements and their possible consequences:

  • Insuring the now uninsured: Positive — employees who have health insurance tend to file fewer workers compensation claims. They have less incentive to cost shift. Another result will be that chronic medical conditions will be, over time, better controlled and less likely to increase the severity of work related claims.
  • Availability of care: Negative — with a large number of people having new health coverage, doctors and facilities may be swamped in some areas. The problem will lead to (a) delays in appointments for workers compensation-related medical treatments and (b) less willingness by providers to participate in occupational medical networks and offer discounts off fee schedules.
  • Removing the pre-existing exclusion: Unknown — in 2014 the pre-existing exclusion will disappear in group health. This cuts several ways at once. There will be less incentive for employees to claim long standing “wear and tear” conditions as work related – a positive change. There may also be much greater demand on employers for workplace and job accommodations leading to new exposures and safety issues.
  • Medicare reform: Negative — the passage of HR 3590 was predicated on massive adjustments in Medicare reimbursement levels, which are marginal for medical providers now. This will pressure providers, especially hospitals and some specialists, to cost shift where possible and workers compensation is a soft target in most states. We could see significant increases in medical costs per claim as the Medicare changes begin to bite in a couple of years. (The recession-driven cutbacks in state Medicaid reimbursements will only amplify this effect in the near term.)
  • Libby care: Unknown — the “Libby care” clause of HR 3590 (sec 1881A) is not intended to lead to the federalization of industrial diseases absent some very specific catastrophic circumstances comparable to those of the WR Grace disaster in Libby, MT. But we all know that ERISA was intended to address a very narrow set of union pension abuses when it was passed, but the Department of Labor, abetted by the Florida Administrators decision of the Supreme Court in 1977, expanded it greatly. The Libby care provision will bear watching.

Workers compensation was not at the table when Congress hammered out its health care reform solutions. Other than a few glancing mentions, such as the Libby care clause noted above, occupational medicine was overlooked and, by default, left to the states. This is probably a good thing, on balance. Yet, as health care reform changes begin to penetrate the enormous US health care enterprise, they will impact workers compensation in many overt and subtle ways over the next several years. Carriers, third party administrators, and managed care vendors will need to be alert to capture possible advantages and avoid potential nasty surprises.

Chronic pain management in workers’ comp

Friday, February 26th, 2010

Recently, I attended the 2010 Health and Productivity Forum jointly sponsored by the Integrated Benefits Institute (IBI) and the National Business Coalition on Health (NBCH) in San Antonio. I had been invited to participate in a panel discussion by Gary Anderberg, of Broadspire, who, as I have written previously, is one of the smartest people I’m fortunate to know.
With me on the panel were Dan Shaughnessy, Director of Disability Programs, Textron, Inc., and Mike Machanich, Chief Executive Officer, Workers’ Comp Solutions. Gary’s charge to us was to discuss the effect of national health care reform on workers’ compensation. Thanks a bunch, Gary. But we had a stimulating discussion as we opened that colossal can of worms. I’ll write more about this in another post. One of the issues our panel tossed around was chronic pain. We’ve written about chronic pain many times over the last few years. Here are links to a couple of the relevant posts:Workers Comp Drugs: Paying too much…For the Wrong Medicines!; The Pain Conundrum.
Our concern is that the treatment of chronic pain often involves what is to us a highly problematic overutilization of narcotics. So, I was a bit surprised to learn of Broadspire’s well thought out and relatively holistic approach to treating this debilitating and often times life-changing medical condition. With that in mind, I invited Broadspire’s medical team to submit a guest blog post for the Insider. Our one requirement was that it be informative to our readers, but not a self-serving advertisement for Broadspire. The company accepted our invitation, and what follows is Broadspire’s approach to the treatment of chronic pain. I’d be remiss if I didn’t add that Broadspire is not a client of Lynch Ryan’s and our publication of this guest blog post does not constitute an endorsement of the company’s products or services.
Chronic Pain Management Matters
Candy Raphan RN, BSN, ARNP, MAOM and Dr Jacob Lazarovic, MD, FAAFP, Broadspire
In 2006, The Center for Disease Control and Prevention (CDC) released its 30th annual report on the health status of America, “Health, United States, 2006” which found that the overall health of the nation seemed to be improving or holding steady, but highlighted one particular condition as needing further attention: pain.
Pain is a common and troubling condition around the world. In a 2005 European study, it was estimated that 20% of the world’s population deals with some form of chronic pain. In Europe, chronic pain accounts for over 30 billion euros in lost productivity. In 2002, an American study found common pain conditions caused 13% of workers to experience a loss of productivity over a two-week period. The estimated cost to corporate America was $61.2 billion dollars that year. In fact, pain has been such a prominent health care issue that the 106th U.S. Congress passed Title VI, Sec. 1603, of H.R. 3244, declaring the period between January 1, 2001 and December 31, 2010 the “Decade of Pain Control and Research.”
Solutions
Conventional treatment of chronic pain is time-consuming and often very expensive, particularly for those claims that continue without resolution over the course of several years. For this reason, it is important that employers and payers understand the dynamics and drivers of the costs associated with chronic pain. By employing a focused, multi-disciplinary clinical approach very costly segments can be targeted. It is then possible to effectively manage chronic pain from the overall costs associated with medical care and treatment as well as loss of a productive workforce.
Using evidence-based medicine to create a plan of action for those individuals with inadequately managed chronic pain promotes optimum results. Medical management programs can provide information and resources to the claimant’s current treating doctors, clinics and hospitals. These types of consultations with providers help achieve the following objectives:

  • Safe, rational and effective management of the chronic pain population
  • Maximized functionality and return to work
  • Management of medical costs
  • Focused and designated processes/people to reduce internal duplication of effort
  • Documented and measurable results and ROI metrics

How It Works
Broadspire’s Chronic Pain Program, for example, uses a defined and rigorous process. After an initial eligibility assessment, a team of specialty physicians and nurses reviews the medical and psychosocial aspects of each case. The team establishes a list set of customized strategies in the form of recommendations to ultimately achieve the goals and objectives for each case. The team then monitors the impact of interventions during subsequent meetings and follows the case through to timely resolution.
The key to the program is the expertise clinical and claim professionals bring to each claim. A highly experienced staff performs the data analysis, oversight and management of the process. An expert panel of specialized pain physicians (anesthesiologists, physiatrists, orthopedists, and psychologists or psychiatrists) provides guidance. Other contracted resources such as selected, accredited pain management facilities and urine drug monitoring labs help ensure that patients are compliant with prescribed regimens.
A Chronic Pain Program has the power to make a sizable difference. With proven methods, resources, and expertise it can provide the support and control to help employees beat pain back and return to productivity.

Making Safety a Universal Language

Tuesday, July 21st, 2009

The following article is a guest post by Joey Lucia, a loss prevention supervisor at Austin-based Texas Mutual Insurance Co., the largest provider of workers’ compensation insurance in Texas.
Non-English-speaking Hispanic workers present unique safety challenges.
Picture this: It’s your first day on the job with a construction crew. Your boss asks you to help lay a foundation for an office building. High above, another worker is walking along a scaffold. He accidentally kicks a hammer off the scaffold, and you’re directly below it.
Fortunately, your company embraces a “total safety” culture. In a “total safety” culture, employees look out for one other. Everyone is accountable for not only their own safety but also their co-workers’ safety.
With that in mind, someone yells, “¡Cuidado, el martillo se puede cáer sobre ti!” Your co-worker warned you to get out of the way. If you didn’t understand Spanish, you might have been involved in a serious accident.
In 2006, Hispanic workers died at a rate that was 25 percent higher than all other workers in the United States, according to a study published last year in Morbidity & Mortality Weekly Report. As of 2006, nearly 20 million workers in this country were Hispanic, making them one of the fastest-growing segments of the U.S. workforce.
Here are some tips for keeping non-English-speaking Hispanic workers safe. Follow the ones that fit your business, and you can help make your workplace safer and more productive.
Challenge: language
Language can be a barrier to communication, even among people who speak the same language. Imagine how hard it is for Hispanic workers who speak little or no English.
Solutions

  • Use more pictures and fewer words to point out hazards and teach safety procedures.
  • Most communication is nonverbal. Watch workers’ eyes, body language and expressions to see whether they understand instructions.
  • Train supervisors in basic, conversational Spanish. Send non-English-speaking Hispanic workers to a conversational English class. Focus on commonly used words in your industry.
  • Hire Spanish-speaking supervisors who have experience in your industry.
  • Ask bilingual employees to translate safety messages.
  • If you have training requirements, the Occupational Safety and Health Administration mandates that you provide them in a language that workers can understand. Hire a translation company to put safety training material into Spanish. Make sure the translator is fluent in the Spanish dialects spoken by your employees.

Challenge: literacy
Many Hispanic workers do not have the luxury of pursuing their education because they have to help support their families. About 40 percent of Hispanics age 25 and up do not have a high school diploma, according to the U.S. Census Bureau. By comparison, about 14 percent of the total U.S. population does not have a high school diploma.
Solutions:

  • Keep training basic.
  • Provide simple, hands-on safety demonstrations.
  • Do not let employees start work until they show that they understand the training.
  • Provide follow-up training, and be sure to address new workplace hazards.

Challenge: fear
Have you ever been afraid of asking a question in front of a large group of people? Imagine asking it in a different language. Non-English-speaking Hispanic workers may put themselves at risk because they’re too embarrassed to ask questions about safety procedures. Some may even fear for their jobs if they report unsafe working conditions.
Solutions

  • Encourage every employee to report unsafe conditions.
  • Offer safety training away from the workplace. If the trainer is someone other than a manager, employees may be less intimidated and more likely to ask questions.
  • Make sure non-English-speaking Hispanic workers have peers they feel comfortable talking to.
  • Deliver the safety message to employees in their environment. For example, distribute Spanish-language safety training material at community functions.
  • Reward safe behavior in front of co-workers.
  • Take time to learn about your Hispanic workers and their culture.

Past blog posts that relate to this topic:
Safety for Spanish-speaking workers must address cultural as well as language barriers
Keeping the multicultural workforce safe
Qualified interpreters can save lives
Hispanic Fatalities on the job: the Tip of the Iceberg
When it comes to safety, make sure you speak the same language!
Mandatory English at the workplace?

The Delicate Brain

Thursday, March 19th, 2009

Our guest blogger is colleague Peter Rousmaniere, a columnist for Risk & Insurance magazine and blogger on the immigrant workforce. Beginning with the sudden and unexpected death of actress Natasha Richardson, Peter explores the murky issue of brain injuries, where what appears to be minor may suddenly morph in to a life-threatening – indeed, life ending – catastrophe.

The actress Natasha Richardson’s death was emblematic of the frightening uncertainties surrounding brain injury. She died from what appeared at the outset to be a trivial incident on the slopes of Mont Tremblant, Quebec.
The NY Times reported: “Ms. Richardson, who was not wearing a helmet, had fallen during a beginner’s skiing lesson, a resort spokeswoman, Lyne Lortie, said Tuesday. “It was a normal fall; she didn’t hit anyone or anything,” Ms. Lortie said. “She didn’t show any signs of injury. She was talking and she seemed all right.” Within two days, she was dead. She joins 50,000 others who die in the U.S. each year from brain injury.
Here are some lessons from this tragedy.
First, brain injuries are far more frequent than we assume.
One million athletes a year sustain brain injuries, the vast majority being “mild” traumatic brain injuries, or MTBI in medical jargon. Rand Corporation estimates that 19% of American troops in Iraq and Afghanistan sustain a brain injury, once again mostly MTBIs.
Second, prevention is improving. Sports helmets are less onerous to wear (though Richardson, a novice on the slopes, declined to wear one). In the military, Humvees are better designed to deflect IED blasts. One important step in secondary prevention and in avoiding re-injury is to remove from activity for about a week anyone who sustains a concussion, until subtle imbalance problems from the initial incident resolve. (We are beginning to see a much more cautious approach to managing athletes with concussions.)
Third, is it increasingly evident that the quality of medical and rehab care greatly matters in TBI outcomes. We in workers comp are focused, appropriately, on vocational outcomes, where the variance in return-to work outcomes for TBI survivors is much wider than it is for burn and spinal cord injury survivors.
I recently interviewed TBI experts working for Paradigm Corporation, including its chief medical officer, Nathan Cope, MD. This firm’s specialty is taking over the management and financial responsibility for medical care of catastrophic work injuries. The firm’s thoughts on TBI treatment is useful because a Milliman study showed that Paradigm’s TBI patients return to work 40% of the time versus a workers comp industry average of only 8%. I asked Paradigm to explain this wide variance of outcomes in light of the Richardson tragedy.
According to the company, the immediate initial care can be deemed adequate as long as the TBI is diagnosed upon initial intake. Treatment has to begin very quickly after injury. In Richardson’s situation, the symptoms began to occur a couple of hours after the incident, when the actress experienced a headache.
Problems are usually indicated by a combination of two factors: physical complications (such as headaches) and behavioral (such as depression). Supervisors and managers need to look for these symptoms in any worker suffering a head injury.
For the brain injured who survive the immediate aftermath of trauma, there is another layer of risk, involving low expectations for recovery: there is a cultural (and perhaps even medical) tendency to assume that once the brain is damaged, recovery automatically becomes a remote possibility. This is not necessarily the case.
Unfortunately, in workers comp few managed care people really understand TBIs. For them, brain injured workers disappear into a black box, with virtually no prospect for returning to productive employment. Such pessimism is often misplaced and usually results in substantial costs to both the injured worker and the employer.
Peter Rousmaniere