To compete in today’s tightly controlled and heavily regulated workers’ compensation environment, payors and employers must manage limited resources wisely to positively impact injuries. Injuries happen despite measures taken to prevent or mitigate them. Simply knowing an injury occurred and its severity does not help organizations effectively manage treatment, employee time, and financial resources. Therefore, employers and workers’ compensation payors need to rely on available information to help successfully manage claims. For instance, an injured worker’s health status, specifically five conditions of interest, can drastically change the expected outcome of an injury.
According to a recent Official Disability Guideline (ODG) study, “[the] morbidity of workplace injuries increases where there are other health conditions, such as obesity and mental health problems. Health outcomes are also shown to be worse where comorbidity exists.” (1) In some cases, these conditions are potentially preventable and treatable before an injury occurs. However, even if steps are not taken to eliminate the conditions prior to injury, knowing that the condition is present can assist in efforts to reserve capital, coordinate treatment, and engage the right resources to holistically manage the claim.
Workers’ compensation payors can no longer afford to dismiss comorbid conditions such as diabetes, depression, hypertension, obesity, and tobacco use as group health-related concerns (2). Historically these conditions and related behaviors were left to injured workers and their employers to address. However, the impact of their decisions greatly affects injured worker claim outcomes. To explore the effect, Coventry Workers’ Comp Services (CWCS) conducted a study to better understand the impact health status can have on workers’ compensation claims. The underlying data source for this study was the CWCS Workers’ Comp Data Warehouse. Data stored in this warehouse includes transactional medical billing data, provider demographics, and numerous reference data sets.
Using unique claim numbers along with dates of injury and dates of service, a reasonable window of treatment (12 months post injury) was created. The study period was defined as dates of injury between January 1, 2007 and December 31, 2008, capturing 1.9 million unique claims.
In order to effectively compare claims, efforts were made to group or classify claims according to a consistent rule. While many possibilities exist, for this study CWCS employed a method of classifying based on the claim’s most expensive ICD-9-CM diagnosis. All diagnoses on the bills within the study period were scanned for the presence of any complicating conditions. A condition list and corresponding diagnosis code list was created and reviewed by medical directors within CWCS. For each condition found, an individual claim-level indicator was created for use in comparing/contrasting.
When a comorbid condition was found on a workers’ compensation claim, CWCS’ study confirmed what other research has indicated: the medical experience was significantly more costly. Exhibit A demonstrates the difference in median 12 month medical allowed amounts for several high volume diagnosis categories.
Exhibit A: Median 12-month Medical Allowed Amount by Complicating Condition & Injury Classification
CWCS’ Research Showed the Following:
- The median medical allowed for a claim with a complicating condition was always higher than those without, regardless of injury type
- The utilization for claims with complicating conditions was at least 100% higher than those without (as measured by bill volume within the claim)
- Complications of obesity and depression were often associated with higher medical costs regardless of injury type
- Obesity and depression were the two conditions with the lowest identification rates within the study even though the estimated population prevalence of the condition was above 30% and 9% respectively
- Claims with a comorbidity of depression had 33% more bills per claim than obesity
- While hypertension and smoking were the two most prevalent complicating conditions identified, they were also associated with smaller median claim costs than many of the other conditions. $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000 $18,000 $20,000
As expected, there were multiple complicating conditions present on many of the claims. Several of the more common combinations are as follows:
Exhibit B:Prevalence and Median 12-month Medical Allowed Amount for Claims with Multiple Complicating Conditions
Points for Further Discussion
It is important to note that information related to a comorbid condition may not be present for all cases within the data set analyzed. According to the National Diabetes Information Clearinghouse, 5.9% of the U.S. population had diagnosed diabetes in 2007 (3) . In a perfect world where workers’ compensation parties had access to an injured worker’s entire medical history, one could expect to see roughly 6% of the claims with the presence of diabetes. However, the study was only able to identify 1.2% of the claims with the presence of diabetes. Possible reasons for the disparity include the injured worker not sharing this information with the provider, the provider not asking for or diagnosing conditions not specificallyrelated to the injury, or the provider failing to report information not specific to the injury or treatment being rendered.
Additionally, the relationships found within the data naturally lead to conclusions about causal relationships. While these relationships exist, assuming that these relationships are causal could lead to erroneous conclusions and ill-advised efforts to control costs. For example, with depression, one cannot determine from the data at hand whether the injured worker was clinically depressed prior to the injury or as a result of the injury. If we look at “burn” injuries, the group identified with a depression complicating condition is associated with higher costs. It may be that the severe burn claims lead to a high rate of depression, and the complicating condition is a result of the injury.
Further study is needed to explore the impact of such conditions on total claim costs, lost time, litigation rates and total claim duration. There have been studies completed that evaluate individual conditions as they relate to specific procedures; however, a closer examination is needed. Additionally, it would be worthwhile to study whether the presence of these conditions actually increases the likelihood for a work place injury.
Future attempts at merging a given client’s group health experience with their workers’ compensation claims might offer the opportunity to gain even further insight into the affect of these conditions and others. The National Council on Compensation Insurance (NCCI) has referenced multiple experts and thought leaders on the importance of managing comorbidities and challenges organizations to work towards integrative health management and return-on-investment that includes group health, workers’ compensation, and workforce productivity (4) .
According to many researchers and governmental data sources, trends of diabetes, hypertension, obesity, and depression are continuing to rise. Smoking, the second most prevalent complicating condition, while trending downwards for many years appears to have stabilized around 21% of the adult population (5). As the prevalence of many of these conditions continues to rise, it provides a challenge to workers’ compensation payors who continue to face pressure to reduce rising medical costs.
An early intervention nurse triage service is a solution many payors have chosen to help mitigate the impact that comorbidity-related factors can have on a claim. These services provide 24/7/365 access to nurses who are tasked with assessing injuries when they occur and assisting the injured employee and supervisor in making appropriate treatment decisions. Therefore, at the onset of a claim, early predictors of complex or high dollar claims, such as comorbidities, may be discovered by the nurse during the standard triage process and the catalyst for working with the claims adjuster or employer to coordinate other services such as focused case management programs designed to appropriately manage such complex claims.
Additionally, many organizations have turned to predictive modeling software to help with the early identification of potential high dollar claims. Once high risk claims are identified, payors set protocols to ensure an appropriate level of intervention to help reduce exposure. With the inclusion of factors related to comorbid conditions, predictive capabilities have the potential for greater accuracy. While these models have proven to be an effective technique for some payors, they require large amounts of data resources and advanced statistical expertise to develop and maintain.
For questions regarding this article, please contact:Barb Robinette, Vice President, Marketing Coventry Workers’ Comp Services Direct: 858-547-2528 [email protected]
(1) Davies, Raewin & Gould, Alex. “Managing Medical Costs: Scheme Perspectives.” Prepared for the Institute of Actuaries of Australia’s (Institute) 12th Accident
Compensation Seminar. Copyright PricewaterhouseCoopers Australia. November 2009. Web: April 8th, 2010.
(2) As always, Coventry advocates and encourages compliance with State and Federal laws, rules and regulations, including, but not limited to, all laws
enforced by the U.S. Equal Employment Opportunity Commission.
(5) U.S. Centers for Disease Control and Prevention. www.cdc.gov
Copyright © 2010 Coventry Health Care Workers Compensation, Inc. All rights reserved.