Tag Archives: barry thompson

Did the Work Comp Nurse Make It Worse?

Case management nurses can unwittingly hinder the control of workers’ comp claims. Consider the perfect storm of “assumptions” leading to disaster: An adjuster receives a claim requiring extended treatment, makes the standard screen-clicks to assign a nurse and logs the claim in the diary. The employer assumes the case is being scrutinized and treatment is being managed. The adjuster assumes it is okay to ignore the case for a while. The nurse takes the initial claim information at something approaching face value.

In these situations, many nurses act but don’t interact. They assist with referrals and expedite the collection of medical information. Unfortunately, they may not use their clinical acumen on critical issues like compensability, diagnosis, causal relationship, return to work (RTW) and treatment plans. We should note that nurses must balance caseloads and respect their company’s requirements for speed. As such, they might feel justified in expediting what appears to be a common assignment.

When it comes to referrals, a well-intentioned nurse can cause disaster. I have experienced all of the following: a claimant alleging breathing issues referred to a “sick building expert”; a claimant with negligible head trauma to a “closed head injury specialist”; a claimant alleging jaw pain to a “TMJ dentist”; and the ever popular referral of a claimant with mysterious pains to a “chronic pain specialist.”

These real examples all involved highly questionable claimants. Needless to say, medical expert “hammers” saw perfect “nails” in each claimant and fully validated the conditions and the causal relationship each alleged. By the time of the next adjuster diary, it was all over but for the increase in reserves.

The claimant can steal control of a case and contrive subjective medical issues if a nurse simply collects doctor reports and fails to interact. Countless WC case files exist where medical notes are simply pasted in by the nurse. (As far as I am concerned, this indicates adjuster/employer failure and not necessarily a poor nurse.)

I have witnessed nurse case managers decline to intervene in RTW efforts, and the corporate nurse care management entity can, conveniently, relieve itself of RTW responsibilities without affecting its fixed fee. I would argue that some level of RTW support from a nurse can and should exist on any given case in any jurisdiction.

Quick Tip: You and Your Adjuster Must Engage and Direct Nurse Assignments

A nurse should be vital in selecting providers for specialist evaluation or independent medical exams (IMEs). However, the nurse needs the insight and outlook that can only be gained by communication and planning. Engage the nurse and explain all the case issues and concerns. Compare providers and agree on who might be most appropriate. Agree on the specific background, insight and questions to be given to this provider. An early conference call should be mandatory.

The nurse should be an active member of the claim team, including adjuster, employer, defense counsel, Medicare medical savings account (MSA) vendor and, in certain cases, the special investigative unit (SIU). Nurse contributions should be vital to team decisions and strategy.

Make certain the nurse case management fee-structure allows extended work, as a claim might require. Reconfigure if necessary to ensure nurses can spend adequate time where needed.

A nurse should be asked to evaluate, comment and make suggestions based on all medical info collected. This insight can be used by the team to make tactical and strategic decisions.

A nurse is most useful for assessing the claimant on a personal level. The nurse should be sought for oral comment on impressions and gut feelings based on interaction with the claimant. Written assessments, which are subject to discovery in legal proceedings, need to be subtle and are not as meaningful. Therefore, conference calls on an interim basis are critical for gaining powerful nurse insight.

Nurses should absolutely support RTW efforts, either at most by collecting potential jobs from the employer and sharing these directly with the employee and doctor or at minimum by reminding the doctor that the employer has a RTW program and expects participation. Somewhere along this range of support should fit any jurisdiction.

Nurses are great tactical tools against unwieldy claimants. They can relay important details and extraneous issues to a physician that can affect causation determinations and reliability assessment of subjective symptoms. Nurses give doctors an “option B” of facts and background when doctors otherwise would only consider “option A,” as relayed by a claimant. Without an “option B,” doctors are more likely to give a claimant benefit of the doubt.

Most important: The power of case management nurses is wasted if you do not provide specific insight, direction and expectation for each claim assigned.

Claims Industry Has Lots to Answer for

The 2014 WC Benchmarking Study by Rising Medical Solutions depicts a claims industry with nowhere to hide and a lot to answer for. This very detailed and intelligent survey deserves some serious attention.

The survey is particularly revealing because it boldly juxtaposes four critical topics rather than focus on a single issue. The covered topics are:

  1. Core competencies
  2. Talent development and retention
  3. Impact of technology and data
  4. Medical performance and management

Surveying these four topics together prevents industry excuses. By contrast, any single-topic survey leaves the industry with room to equivocate and retort with presumptuous hope about the holistic system. For example, a survey on talent management might conclude that there is a woeful lack of investment in recruiting and training new adjusters, yet the editorial response might assert that efforts in work-flow technology can take up future slack. Further, a single-topic study showing a higher cost for WC medicine vs. non-occupational care might evoke an editorial response touting the latest strides in “managed care” that surely hold hope for future corrections to this problem.

Well, when a side-by-side evaluation of the four survey topics show consistent deficits in all areas among more than 400 responders I don’t think there is enough fresh coffee in any PR department to conjure up a reassuring response.

High-level findings include:

– Claim providers can easily cite the critical core competencies for adjusters: return to work, medical management and compensability investigations, etc. However, many do not measure performance based on these competencies, nor support active efforts to develop these talents. Only half of responders report using positive or negative reinforcement of core competencies.

– Regarding adjuster training, 48% of responders have no or “unknown” budgets. Only 36% have formal training for new hires, most of which is 40 hours or less.

– Fewer than 40% of responders use outcome-based claim measures.

– Fewer than 30% measure medical provider performance, indicating that the network discount is all important and that the care itself an afterthought.

– The IT/data areas indicate no clear focus or vision or investment in workflow, cross-system integration or predictive modeling. (Only 25% report using predictive analytics. Being a proud skeptic of this folly, that is fine with me, but hold that thought for a future article.)

There is creative cross-referencing one can do among this survey’s sections, which I believe shows responders’ disregard for outcome in favor of profit. For example, one section measures the use of cost-containment applications, while a separate section asks for ranking of cost-containment applications based on how critical they are. Nurse triage is listed as having the third most critical impact on outcome yet is in 7th place among tactics responders use. In contrast, bill review is number one in use, by 95% of responders, yet ranks as only 6th on scale of impact on outcome.

I conclude that, in spite of bill review’s low impact on outcomes, many claim-service providers deem the “percentage of savings” cash flow stream as most important. Let’s not forget there is a huge IT investment in bill scanning and processing centers. So, despite pressure on other aspects of IT, there apparently is an IT budget available when it supports cash flow.

Bottom line, claim providers do little to invest in long-term improvement, while focusing on short-term savings and cash-flow streams.

My suggestion for future studies by Rising Medical is to totally split for-profit insurers and TPAs from in-house, self-administered responders. The former chases profit; the latter chases outcomes. I predict a very telling dichotomy among this split.

To Hellness With Wellness

It seems the only people made “well” from corporate wellness programs are those who collect $6 billion in annual costs. Still, all is not lost. If we use the most basic workings of human nature as a guide we can salvage a more reasonable realm for the notion of employer-sponsored “wellness.”

Corporate wellness is seriously flawed on the grand scale it once proclaimed. Here are four reasons why, in my opinion:

First: Wellness costs too much and thereby sets a high threshold for return on investment (ROI), which begs failure by any score based on savings. Let’s say you have a 500-person workforce. After a couple of years of “wellness,” 10 smokers legitimately quit for life, and five obese employees legitimately get to normal BMI and sustain it. For these individuals, the wellness program is an amazing success with great implications for future health. Unfortunately, with the average cost per employee in corporate wellness programs at more than $500 per year, two years costs more than $500,000, and a calculation of ROI depicts an abysmal failure.

Second: The profit motive of wellness purveyors supersedes common sense. Their sweeping approach provides incentives for assessments to identify candidates at risk and assumes that simple potential indicators of unhealthy lifestyle or other conditions create a savings opportunity. This is absolutely false. One fact is missing. Of the persons targeted, only a precious few are at a personal decision point and have the will to actually attempt difficult lifestyle changes.

Targeting must take human nature into account. We can properly diminish the presumed footprint of wellness if we look back and study individuals with actual historic success. Let us understand what indicators of personal human attitude that handful of successes gives us to use as a second-step screen. How much easier is it to realize ROI when only spending $500 per head on a smaller number of likely candidates?

Third: There is an absurd, blind thirst in both the private and public sectors to find believable reductions in projected future healthcare costs. The hype of wellness is perfectly suited to quench this thirst. Unfortunately, the absurdity is legitimized by governmental acceptance of the fool’s gold of claimed lower healthcare costs to gain leverage in negotiating state-worker union contracts, rigging budgets and passing federal legislation. (Can you spell ACA?) The term “fool’s gold” has the word “fool” in it for a reason.

Fourth: The wellness industry ignores lessons that should be learned from success in its sub-area of  disease management — specifically, that human nature feels no call to action until mortality comes knocking. Disease management savings can be documented in examples like the PepsiCo program called Healthy Living, initiated in 2003 and providing real savings today. Why does disease management work? In my opinion: People with a disease feel their mortality and are inclined to follow any program that might help.

Disease management supports a population with more personal incentive and will. Conversely, the debunked lifestyle approach targets an abundance of people who are personally happy while smoking or overeating. Fewer are suffering the acute implications of their lifestyle. “Wellness” money spent on them is useless.

Quick Tip: Trade “Big Wellness” for disease management with limited lifestyle programs

Don’t throw the baby out with the bathwater. There are many people who need and will accept disease management. As far as lifestyle, there are but a few people ready to commit to change. The good news is that over time, and organically with no cost, these few might spark an interest by others in any employer population. Keep the doors open for them and keep awareness high. In the meantime, don’t waste real money or use gimmicks on them.

I suggest wellness vendors create a new approach that unlocks the psychology of raw lifestyle change, targets the few and is willing to take on smaller footprints. Accept less money but stay for the longer haul.

You owe it to the tarnished notion of “wellness” to fix what you broke.