Dr. Michael Lacroix, Medical Director, The Hartford
In our previous article, we reviewed The Hartford’s Mental / Behavioral Health (BH) Group Benefits (GB) Short-Term Disability (STD) claims from 2015-2018 and compared them with BH claims from The Hartford’s California WC business for the same time period. To recap: (1) in both cases, primary BH claims are more prevalent among younger workers and women; (2) the diagnostic basis for these claims is different (more depression for GB, more anxiety / stress for WC); and (3) our oranges-to-tangerines comparison of duration-linked data indicated that BH claims were no more severe than musculo-skeletal (MSK) claims for the GB book of business, but notably more severe when they present in the WC book of business.
The impact of BH conditions extends well beyond BH claims themselves, however, to their interactions with other medical conditions. The impact of co-morbidities has been well documented1, including smoking, diabetes, and hypertension, among others. There is also much research on the impact of BH co-morbidities on medical diagnoses2, but there is very little of an objective nature on the impact of BH co-morbidities specifically on GB or WC claims. In this article we examine the impact of a secondary, or co-morbid, BH condition on claims based on primary physical diagnoses. Because MSK claims constitute the largest proportions of both GB and WC claims, we will focus on the impact of BH conditions on MSK claims. We will then examine more specifically the economic impact of BH conditions and provide some recommendations.
To set a baseline, it is useful to first look at the impact of a secondary physical diagnosis on a primary physical diagnosis, and this is shown in Table 1 for GB claims based on a primary MSK diagnosis. On average, adding either a secondary MSK condition or any other physical (not BH) diagnosis to the primary diagnosis increases disability durations across the age groupings by about 40% overall. Not a surprise here: recovering from a knee injury would be expected to take longer if one also has to factor in an exercise-limiting back condition, for example.
Table 1: Impact of a second physical diagnosis to a primary MSK on GB STD durations (days)
|Secondary Dx / Age||<35||35-44||45-54||55-64|
|MSK Secondary Dx % increase||43.2%||37.6%||41.6%||37.1%|
|Any non-BH Sec. Dx % increase||41.5%||39.2%||40.2%||38.9%|
To evaluate the impact of a secondary BH condition, we looked across our entire GB book of business. For every single major GB diagnostic grouping, adding a secondary BH diagnosis to a primary condition extends disability durations, in many cases very significantly. Table 2 shows the impact of a secondary BH diagnosis to primary MSK claims across the age groups for the years 2015-18.
Table 2: Impact of a secondary BH diagnosis to a primary MSK claim on GB STD durations (days)
|Secondary BH Dx / Age||<35||35-44||45-54||55-64|
As with MSK and other physical diagnoses, having a secondary BH condition increases claim durations for primary MSK claims. The increase in durations is about 30% on average, with the impact decreasing slightly as a function of age. While we can speculate that the impact of a secondary physical condition to a primary physical condition would typically involve some mechanical intervening variable, a mechanism linking BH and physical conditions would normally require different types of explanations (e.g., depression leading to reduced energy and motivation impacting engagement in treatment).
The next two tables essentially repeat the analyses of the GB data with our California WC data. Table 3 again level-sets by examining the impact of a secondary MSK diagnosis, as well as any non-BH secondary diagnosis on a primary MSK diagnosis, for the years 2015-18. A reminder that, with respect to WC durations, we are looking here at treatment days, NOT days on disability – and treatment (including medications) would normally extend well beyond a return to work.
Table 3: Impact of a secondary physical diagnosis to a primary WC MSK claim on treatment days
|Secondary physical Dx / Age||<35||35-44||45-54||55-64|
|MSK secondary Dx % increase||68.9%||84.4%||96.8%||81.8%|
|Any non-BH Sec. Dx % increase||71.7%||88.0%||100.7%||84.5%|
As with the GB data, adding a secondary or co-morbid physical condition to an MSK primary diagnosis increases treatment durations significantly, to about the same extent if the secondary condition is another MSK or, more broadly, another physical condition. A superficial comparison of the GB and WC data might suggest that the increases in duration are of greater magnitude for WC than for GB – but remember that the duration measures are not directly comparable. Therefore, what is appropriate to conclude is that for both GB and WC MSK claims, adding a secondary physical diagnosis increases durations across the age spectrum — which again should not be a surprise.
When it comes to the impact of a secondary BH condition in WC more generally, the analysis becomes more problematic because most states set very high bars for recognizing BH conditions in WC, and as a result many clinicians (and patients) do not see BH as relevant, and simply do not report or code these for WC claims where the primary diagnosis is a physical condition. In view of the fact that psychological diagnoses are often not coded in WC, one could argue that those claimants whose treaters took the trouble to identify a secondary psychological diagnosis (less than one half of one percent of our 2015-2018 MSK census) must have had very significant BH conditions affecting their recovery. Consequently, we looked not only at BH in terms of those cases with a formal secondary BH diagnosis, we also analyzed the data using a less stringent definition (labelled “Inclusive” in the table) of what constitutes a BH co-morbid condition. For the purpose of the present analyses, where information in the claim suggested that the client (a) may have had psychological issues, or (b) was prescribed psychoactive medication, or (c) where the claim referenced words related to BH (e.g., “fear,” “stress,” “anxiety,” “depression”), the claim was flagged as having a BH “co-morbid”. These BH “inclusive” claims constituted 16.2% of the California MSK claims – a much more credible proportion. The two sets of analyses tell a similar story, except that cases with a formal secondary BH diagnosis turned out to be more expensive in terms of both medical and indemnity costs (which we will discuss shortly).
Table 4 examines the impact of a secondary BH co-morbidity on WC MSK treatment durations.
Table 4: Impact of a BH co-morbidity to a primary MSK WC claim on mean number of treatment days
|BH Diagnosed Secondary Dx definition % increase||268%||275%||346%||256%|
|BH co-morbid, BH “inclusive” definition % increase||230%||243%||237%||230%|
As with adding a secondary physical diagnosis, adding secondary BH co-morbidities increases treatment durations. Moreover, a comparison of Tables 3 and 4 suggests that, for WC MSK claims, adding BH co-morbidities increases treatment durations considerably more than adding a secondary physical diagnosis. The increases in treatment duration are further exacerbated if the secondary BH condition is officially diagnosed, as opposed to simply being inferred from other information in the file.
We now turn to the economic implications of all these findings and provide some recommendations.
Clearly, BH conditions, whether as primary diagnoses or as co-morbidities, carry a significant human impact, but what is their economic impact? As noted above, durations for primary BH claims in GB are on par with MSK claims. Treatment durations in WC for primary BH claims are significantly longer, but there are very few of those claims, even in California, which is generally considered more open to BH claims. The major financial impact of BH conditions will therefore typically be “hidden” as co-morbidities, sometimes coded as part of the claim, but many times (particularly in the WC space) ignored altogether either by the claimants themselves and/or their treating clinicians.
For GB, the additional direct benefit cost associated with increases in claim durations from BH co-morbidities can be easily calculated. Adding an average of 20 days (roughly) to an MSK claim from the presence of a secondary BH condition adds $2431 in direct benefit payments to the average claimant ($1013.27 average weekly wage per BLS statistics * 4 weeks * 60%) plus additional indirect claim management and other costs. Of course, for some employers the costs can be quite a bit more. For the 2020 RIMS conference (cancelled due to Covid-19), our joint presentation with a large (Fortune 50) employer included a calculated additional average cost of $4116 per STD claim that included a secondary BH condition. These costs increase further for those STD claims that then transition to LTD (which were not evaluated in the present analysis).
For WC, things are quite a bit more complicated because there are both treatment costs and indemnity costs (there are no treatment costs in GB) – and, of course, 50 states with 50 different legislations and regulations. Table 5 looks at the impact (average increase in claim costs) associated with BH co-morbidities when superimposed on primary MSK claims in our California WC data, using our “Inclusive” definition, i.e., where there was information in the claim suggestive of the presence of significant BH factors but not necessarily a formal BH diagnosis. Overall, the total amounts associated with both medical and indemnity costs rise enormously in the presence of BH concerns, and even more so in the older age groups.
Table 5: Impact of a BH “co-morbidity” to a primary WC MSK claim on mean Indemnity and Medical costs: Average additional costs associated with BH co-morbidity (BH “Inclusive” definition3)
|Indemnity and Medical Costs / Age||<35||35-44||45-54||55-64|
|Mean Increase in Indemnity Cost||$6,920||$10,167||$13,533||$14,539|
|Mean Increase in Medical Cost||$10,651||$14,344||$17,811||$17,203|
Finally, Table 6 duplicates the cost analysis done in Table 5, but now associated with actual secondary BH diagnoses when these are provided. Notice that the impact is primarily on the older workers, and relates to both medical and indemnity costs. The addition of a diagnosed BH diagnosis to a primary MSK diagnosis in WC cases further increases both the medical and the indemnity costs, and disproportionately so for older workers.
Table 6: Impact of a diagnosed BH co-morbidity to a primary MSK WC claim on mean Indemnity and Medical costs: Average additional costs associated with diagnosed BH co-morbidity
|Indemnity and Medical Costs / Age||<35||35-44||45-54||55-64|
|Mean Increase in Indemnity Cost||$6,364||$9,816||$18,203||$33,102|
|Mean Increase in Medical Cost||$10,451||$14,313||$25,172||$45,847|
These numbers are eye-popping. But in fact, and consistent with our numbers, peer-reviewed studies show that mental health co-morbidities, and depression in particular, result in significant delays in recovery from physical injuries, even for minor injuries4. In the California WC system in 2018, psychoactive medications accounted for 8.3% of all prescriptions.5 Having anti-depressants prescribed was associated with an additional $22,318 in medical cost and $50,911 in total claim cost, respectively.6 The effect on total paid costs associated with antidepressant prescription was greater in magnitude than all other drug classes; in fact, anti-depressant prescriptions were associated with a three-fold increase in the likelihood that the claim would cost more than $100K. In this context, our WC cost data would seem to be in the right ballpark.
What to do?
These findings should not be surprising, although it is nice to see some actual data as opposed to speculations. I always like to ask people, “If you were the one who had (fill in the blank: lost your leg, been diagnosed with cancer, whatever), how do you think you would react?” BH issues are just part of the picture of being a human who is dealing with serious difficulties in life. And this is something that we should keep firmly in mind as we look at these numbers: they reflect the real pain experienced by our claimants / your employees.
When I have spoken to adjusters / claims analysts from many companies over many years about BH issues in their claims the typical response has been, “I know it’s there but I just don’t know what to do about it.” The purpose of these articles is to make the point as powerfully as possible that when mental / behavioral health issues are present, they impact the claimants, and they impact claims. What to do? The first step is to acknowledge that many of our claimants will experience BH challenges (even more so now with COVID-19), and that the presence of BH challenges emphatically does NOT imply malingering. If we can get past that point, it gets easier.
- Early intervention is definitely to be recommended.7 Communications, early and often, and from people who are important to the claimant such as his/her supervisor, are critical.8 If you are an employer, you know full well that our claimants are still your employees, and in the vast majority of cases you want them back to work as soon as possible. Continue to treat them as your employees, and don’t just leave all communication to the insurer or third party administrator. A rule of thumb in our field is that the longer a person is out of work on claim, the less likely they are to ever go back.
- If at all possible, offer help early. We recently reported on a study that we carried out with UPS9 in which we provided employees requesting a leave on the basis of a BH condition with reminder information about their Employee Assistance Program and other generic information. This turned out to have a significant impact, particularly on the duration of leaves based on stress / anxiety, and on STD durations for those leaves that migrated to STD. Don’t assume that your employees know where to get help, and don’t assume that they are aware of all their benefits. While many employers offer generous benefit plans, employees are often busy such that, by the time they need the information, it may take some time and effort to find it. The required effort may be particularly challenging when they are under stress or depressed, yet that is when they need the information most urgently. A quick, friendly reminder phone call, or even an email or text about their benefits can actually go a long way.
- The Americans with Disabilities Act (ADA/ADAA) provide employers with another approach to mitigating the impact of BH challenges. The ADA requires employers to engage in an “interactive process” with employees requesting workplace accommodations for a disability. Employers have a duty to accommodate a “known disability.” In recent years, about a quarter of the appeals to the EOC for accommodation requests have been based on BH issues. Oftentimes, the employee will be able to tell you exactly what she needs in order to be able to return to work. In many cases, the accommodations requested are fairly simple, e.g., more frequent breaks, modifying instructional methods, limiting the job to only essential duties, allowing a service animal, or working from home. Common, straightforward strategies can accommodate many BH challenges.
- Bear in mind that many employees’ BH challenges may not reach the level of diagnostic criteria. We all experience high levels of stress or feel down in the dumps at times. Helping them with their specific issues, and again early, can prevent these snowballs from building. For example, The Hartford’s iRecover program is a coaching program for injured workers who meet certain criteria. They are provided with a “coach” (not psychotherapy) who follows standardized modules that address the major psycho-social barriers that often prevent people from returning to work.
- For those employees who need clinical assistance, don’t assume that treatment will go on for years and years and that only board-certified psychologists and psychiatrists can provide treatment. Many mental health specialists with Masters level training are highly trained in delivering a variety of psychotherapy treatments and do so very effectively. Medication can often be very helpful, but if we’ve learned anything from the opioid epidemic, it’s that we should think beyond medication alone, to solutions that can directly address the underlying problem(s). Behaviorally-based treatment strategies such as Cognitive Behavior Therapy (CBT, of which there are many forms) have been validated again and again. There are many tools and many BH practitioners who can help you bring your employees back.
- Lastly, there is help coming from technological innovations, which COVID-19 has helped speed up. There are now many apps on the market that allow us to monitor our BH symptoms and to address them in real time, through some version of web-based CBT or mindfulness meditation. Many of these have no data behind them, but we are now beginning to see some that have been validated in peer-reviewed studies. Some of the best ones also allow for the data to be forwarded to the employee’s treating clinician, which would be a quantum leap in terms of the accuracy of the clinical information over the more typical, “So, how have you been over the last couple of weeks?”
If you had an injury, how would you want to be treated? The Golden Rule turns out to be a sure-fire recipe for success. “Do unto others as you would have them do unto you,” and you may be pleasantly surprised with the outcomes.
About Dr. Michael Lacroix
Dr. Michael Lacroix, Ph.D., is Medical Director with The Hartford. He is a licensed psychologist in Florida. He has worked in the overlapping areas of Disability and Workers’ Compensation for the last 30 years, in a variety or clinical, management, program development, and consulting roles. Prior to joining the corporate world (Concentra, then Coventry, then Aetna, and now The Hartford) Dr. Lacroix held academic appointments, he developed a large clinical practice focused on assessment, treatment, and rehabilitation of injured and disabled workers, and he also carried out grant-supported research over many years, resulting in over 100 peer-reviewed publications and papers. He is a frequent contributor at industry conferences and publications. He currently resides in Sarasota, FL.
About The Hartford
The Hartford is a leader in property and casualty insurance, group benefits and mutual funds. With more than 200 years of expertise, The Hartford is widely recognized for its service excellence, sustainability practices, trust and integrity. More information on the company and its financial performance is available at https://www.thehartford.com. Follow us on Twitter at @TheHartford_PR.
2 Pagoto, S. (Ed.), Psychological co-morbidities of physical illness. New York: Springer, 2011.
3 A reminder that, “BH-inclusive” claims refers to those where information in the claim suggested that the client (a) may have had psychological issues, or (b) was prescribed psychoactive medication, or (c) where the claim referenced words related to BH (e.g., “fear,” “stress,” “anxiety,” “depression”). The analysis is based on all California WC claims with The Hartford 2014 to 2018 inclusive.
4 Kellezi, B et al. The impact of psychological factors on recovery from injury: a multicentre cohort study. Social psychiatry and psychiatric epidemiology, 2016:52(7). doi:10.1007/s00127-016-1299-z
5 Young B & Hayes S. California WCI Research Update. https://www.cwci.org/document.php?file=4190.pdf
6 Hunt D et al. Association of opioid, anti-depressant, and benzodiazepines with workers’ compensation cost: A cohort study. J Occ Env Med, 2019: 61(5):e206–e211. doi: 10.1097/JOM.0000000000001585