Tag Archives: disease

14 ICD-10 Codes That Defy Belief

For every medical diagnosis, disease, injury, symptom, complaint and procedure, healthcare professionals use a specific code to maintain consistent outcomes, data assessment and billing. These codes, formerly called the ICD-9, are a set of characters and numbers that have experienced a series of revisions since they were first put into place. As of Oct. 1, 2015, the ICD-10 (International Classification of Diseases, Revision 10) is in effect.

With such a wide range of known diseases, ailments, symptoms and more, ICD-10 codes can get a little wacky. The infographic below illustrates 14 of the most unusual codes that illustrate the totally bizarre ways in which people manage to injure themselves. From an ice skater’s initial collision with a stationary object to computer keyboarding injuries, the ICD-10 codes don’t miss a trick.

silly-icd-10-codes_lr

To Be or Not to Be (Vaccinated)?

For many years, Americans did not need to worry about contracting the once-widespread disease called the measles. In fact, the Centers for Disease Control and Prevention (CDC) officially declared measles eliminated in the U.S. in 2000. Unfortunately, that is no longer the case. In January 2015 alone, there were already more confirmed cases in the U.S. than are typically diagnosed in a full year. Public health officials are very concerned and have moved to aggressively contain this very contagious, but 100% preventable, disease. The current outbreak and surge in confirmed cases of measles, most notably in California, has been scientifically linked by researchers from MIT and Boston’s Children Hospital to the outbreak that began in Disneyland in December 2014. Medical researchers believe the spread of the current measles outbreak is solely because of low vaccination rates in certain communities based on a widespread but false link between childhood immunizations and autism. International health officials have called the link between the MMR (measles, mumps and rubella) vaccine and autism “the most damaging public health hoax in the past 100 years.”

Just last week on April 21, the Journal of the American Medical Association (JAMA) released the findings of a comprehensive study using the health insurance data base of 95,000 children and found no overall link between autism and the MMR vaccine. The study also found no link for children with an autistic sibling. The study did find a lower vaccination rate for the younger siblings of children with autism based on parents’ continued fears of a link. The JAMA study authors from the Lewin Group in Falls Church, Va., stated; “Consistent with studies in other populations, we observed no association between MMR vaccine and increased ASD (autism spectrum disorder) risk among privately insured children.”

Despite the overwhelming medical evidence that the MMR vaccine is both very safe and highly effective, anti-vaccination groups still dispute the facts and are warning parents not to be pressured into having their children vaccinated, which is the crux of this public health problem. On the same day that the JAMA study was released, CBS Evening News ran a segment on the current U.S. Surgeon General Vice Admiral Vivek Murthy, MD, MBA, or “America’s Doctor,” who appeared on Sesame Street to promote childhood vaccinations. CBS closed the segment with; “Vaccination critics don’t see anything cute about this video after the controversy over the recent measles outbreak.” Really? There is no controversy. It was all based on a documented hoax.

The original belief that vaccinations cause autism was based on a reported study in 1988 by Dr. Andrew Wakefield in the U.K., which has since been 100% completely discredited. His report unnecessarily panicked many parents around the world, causing a sharp decline in the number of children getting the MMR vaccine. The false claims and widespread panic began when a British medical journal, the Lancet, published Wakefield’s article. It was later determined that the author had multiple conflicts of interest, had manipulated evidence and had broken ethical research codes of conduct, including accepting funding by attorneys involved in lawsuits against vaccine manufacturers. The Lancet fully retracted the article, but not until 2010, when the editor-in-chief stated that the link was “totally false” and that the world-famous medical journal was “deceived.” The Canadian Medical Journal in 2010 went on to state that the original research included a “callous disregard” for the “carefully selected” study group of only 12 children and that “several elements of this research were incorrect and contrary to findings of an earlier investigation.” Dr. Wakefield subsequently lost his license to practice medicine in the U.K as a result of this fraudulent research.

These are the facts that parents need to know about the measles. Symptoms typically begin with a high fever, runny nose, sore throat and cough, which can easily be misdiagnosed as a simple cold or the flu. The incubation period is between seven and 18 days of exposure to the virus. It is very dangerous because people are contagious up to four days before the red rash appears and likely do not know they are infected. In addition, a room can still be contaminated as long as two hours after an infected person leaves. A single infected person can spread the disease to between 11 and 18 people. An unvaccinated person has a 90% chance of infection if exposed to the virus. The risk of serious complications and death is even greater for adults and infants than for children and teenagers. Rubella, known as the German measles, is also caused by the virus and is usually a mild form of the disease but is a very serious infection that causes miscarriages, still births or birth defects in unborn children when pregnant women get the disease.

Most people born prior to 1957 had the measles. The disease was once so prevalent that in New York City, in the first 10 weeks of 1933 alone, there were 10,000 cases and 434 deaths. The first vaccines developed began in 1958 and became widely available in 1963. Prior to 1963, there were three to four million cases of measles reported each year in the U.S., with 400 to 500 reported deaths annually.

Although many parents in the anti-vaccination movement believe the measles is not dangerous and the MMR vaccine is, the medical facts state otherwise. In fact, from 2001 to 2013, 28% of children in the U.S. with the measles had to be hospitalized. Public health officials fear that many more cases will develop from this outbreak of a very preventable disease, unless aggressive public health measures are undertaken. What is required is an extensive education campaign including widespread vaccination of the unvaccinated U.S. population, starting with infants at 12 months and a booster shot at age four to six, prior to pre-school or kindergarten. Unvaccinated adults also need to be vaccinated.

There are a number of myths associated with the measles vaccination that keep some parents from protecting their children. The controversy surrounding the anti-vaccination movement is based largely on parents’ philosophical beliefs against the vaccination. Dr. James Cherry, a pediatric infectious disease expert at UCLA, believes that the recent outbreak in California is “100% connected to the anti-immunization campaign.” He went on the say that there are “some pretty dumb people out there.”

Medical researchers from MIT and Boston Children’s Hospital documented that the rapid spread of measles from the Disneyland outbreak, beginning in mid-December 2014, indicated a significant percentage of the population exposed had low vaccination rates. These researchers determined that the exposed population rate might have been as low as 50% and likely no higher than 86%. These rates are well below the 96%-99% level known as “herd immunity,” which is required to prevent future outbreaks.

The anti-vaccination movement includes those parents who believe that there is no medical risk from not vaccinating their child, that the disease is extinct, that doctors and drug companies push vaccinations for their own profit, and that you can get the measles from the vaccination. Still others believe the false and discredited link to autism. For the parents who are against vaccination, they not only put their own children at risk, they dramatically increase the risk for the general population who are unable to get the vaccination, such as infants under the age of one, and children and adults with weak immune systems, including people with cancer and other diseases.

Measles is still widespread throughout the world. Travelers from overseas continue to bring the disease into the U.S on a daily basis. The anti-vaccination conspiracy movement belief that doctors and insurance companies promote the vaccination to increase profit is absurd and is negated by the fact that health insurance companies pay for the vaccinations at no cost to the patient. Similar to the flu shot that is a dead virus from which someone cannot get the flu, it is almost impossible to get the measles from the MMR vaccine.

The CDC states there is a 1 in 3,000 chance of a mild allergic reaction to the MMR vaccine but a 90% chance of infection if an unvaccinated child is exposed to the virus. Parents should do the math. In addition, a blood product containing an immune globulin is available for people who are medically unable to immunize with the MMR vaccine for any reason.

What parents need to know is that the scientific community has found no evidence whatsoever of a link between MMR vaccine and autism or any other childhood development disorder. In addition to the just-released JAMA study, large epidemiological studies conducted by the CDC, the American Academy of Pediatrics, the Institute of Medicine at the U.S. National Academy of Sciences and the U.K. National Health Services all found no link between MMR and autism. This original false research has done significant damage to the field of public health and has done serious harm to children of parents who were misled by this report, which resulted in unnecessary deaths, severe impairment and permanent injury in unvaccinated children. Because of wide dissemination of this discredited link, there were many lawsuits by parents with children with autism, but a special court convened by the National Vaccination Injury Compensation program denied all compensation claims in U.S. federal court against manufacturers of the vaccine in 2009.

The recent measles outbreak in California is what has spiked the “controversy” over vaccinations, which has made the national news in 2015 including; CNN, the New York Times and Time Magazine. There have been 178 documented new cases of the measles by late March by the CDC, including five unvaccinated Disneyland workers in Orange County, and the outbreak is now spreading across the U.S.

Although traditional public health issues are typically rooted in poor or rural areas of the country, this current measles outbreak is concentrated in wealthy neighborhoods in California and surrounding states. Although it is reported that only 3.1% of parents in California refuse to vaccinate their children, for health or religious reasons, this number is misleading. In fact, many areas within California have double-digit exemption rates from vaccinations, with some areas as high as 50%.

The MMR vaccination is the best way to prevent disease both for the individual and the general population. It works by making the body produce anti-bodies against the virus. The measles vaccination is recommended for all people 12 months of age or older, and especially people traveling overseas. MMR vaccinations are supported by the American Academy of Family Physicians, American Academy of Pediatrics, the Centers for Disease Control and Prevention and the Mayo Clinic, to name just a few.

An extensive education campaign is required to overcome false and unfounded fears among parents of unvaccinated children. Legislation is needed to strengthen immunization laws requiring all school-age children to receive the measles vaccination, except for those with a medical exemption certified by a licensed physician. Public health officials should also track and verify both statewide and local immunization rates and should mandate that schools maintain an up-to-date list of pupils with exemptions so they can be excluded quickly if an outbreak occurs, temporarily exclude unvaccinated students and teachers from attending school and offer measles vaccinations for unvaccinated students and teachers.

The MMR vaccine is 99% effective and provides immunity for a lifetime. It was once considered one of the major public health campaign success stories. Now, health officials fear the potential for a public health crisis based on blatantly false research and unfounded fears. The CDC points out that people who refuse to vaccinate usually live in the same community. “When measles find its way into these communities, outbreaks are more likely to occur.” Consumers and parents should confirm with their doctor that they or their children do not have any allergic reactions to other medications. They should also verify that they do not have an immune deficiency condition, which may cause side effects and decrease the vaccine’s usefulness.

The myth that childhood vaccinations lead to autism was based largely on a completely discredited medical research hoax. This myth is still being widely perpetuated today not only by the anti-vaccination conspiracy movement led by Hollywood celebrities but also by the mainstream media.

My heart breaks for the parents of children with autism, including a close family friend. But it breaks my heart even more knowing that thousands of children are unnecessarily exposed to unimaginable consequences of birth defects and death from something so preventable. Parents need to listen to the Surgeon General, the CDC, the Mayo Clinic and the American Academy of Pediatrics and not Hollywood celebrities with zero background in public health.

I would like to thank my research assistant and co-author Ms. Chandler Berke who is a public health/science undergraduate student at the College of Charleston in South Carolina.

Obesity as Disease: A Profound Change

The obesity rate in the U.S. has doubled in the past 15 years. More than 50% of the population is overweight, with a BMI (body mass index) between 25 and 30, and 30% have a BMI greater than 30 and are considered obese. Less than 20% of the population is at a healthy weight, with a BMI less than 25.

On June 16, 2013, the American Medical Association voted to declare obesity a disease rather than a comorbidity factor, a decision that will affect 78 million adults. The U.S. Department of Health and Human Services said the costs to U.S. businesses related to obesity exceed $13 billion each year. With the pending implementation of ICD (International Classification of Diseases) 10 codes, the reclassification of obesity is is fast becoming a reality and will dramatically affect workers’ compensation and cases related to the American Disability Act and amendments.

Before the AMA’s obesity reclassification, ICD-9 code 278 related to obesity-related medical complications rather than to obesity. The new ICD-10 coding system now identifies obesity as a disease, which needs to be addressed medically. Obesity can now become a secondary claim, and injured workers will be considered obese if they gain weight because of medications, cannot maintain a level of fitness because of a work-related injury or if their BMI exceeds 30. The conditions are all now considered work-related and must be treated as such.

The problem of obesity for employers is not confined to workers’ compensation. The Americans with Disability Act Amendment of 2008 allows for a broader scope of protection for disabilities. The classification of obesity as a disease now places an injured worker in a protected class pursuant to the ADA amendment. In fact, litigation in this area has already started. A federal district court ruled in April 2014 that obesity itself may be a disability and will be allowed to move forward under the ADA (Joseph Whittaker v. America’s Car-Mart, Eastern District of Missouri).

Obesity as an impairment

Severe obesity is a physical impairment. A sales manager of a used car dealership was terminated for requesting accommodation and won $128,000. He was considered disabled, and the essential function of the job was walking, so he was terminated without reasonable accommodation.

The judge ruled that obesity is an accepted disability and allowed him to pursue his claim against his employer. This could have substantial impact for employers as injured workers could more easily argue that their obesity is a permanent condition that impedes their ability to return to work, as opposed to a temporary life choice that can be reversed.

The Equal Employment Opportunities Commission (EEOC) has recently chimed in on obesity. According to the EEOC, severe [or morbid] obesity body weight, of more than 100% over the norm, qualifies as impairment under the ADA without proof of an underlying physiological disorder. In the last year, we have seen an increasing number of EEOC-driven obesity-related lawsuits. Federal district courts support the EEOC’s position that an employee does not have to prove an underlying condition, especially in cases where there is evidence that the employer perceived the employee’s obesity as a disability or otherwise expressed prejudice against the employee for being obese.

Workers’ compensation claims are automatically reported to CMS Medicare with a diagnosis. When the new ICD-10 codes take effect, an obesity diagnosis will be included in the claim and will require co-digital payments, future medical care or continued treatment by Medicare.

There is good news on the horizon. Reporting of a claim only happens if there is a change in condition not primarily for obesity. It is recommended that baseline testing for musculoskeletal conditions be conducted at the time of hiring and on the existing workforce. In the event of a work-related injury, if a second test is conducted that reveals no change in condition, it results in no reportable claim and no obesity issue. In the event of ADA issues, the baseline can serve to determine pre-injury condition or the need for accommodations.

What does this mean to employers?

Obesity is now considered a physical impairment that may affect an employees’ ability to perform their jobs and receive special accommodations pursuant to the ADA.

An increasingly unhealthy workforce will pose many challenges for employers in the next few years. Those that can effectively improve the health and well-being of their employee population will have a significant advantage in reducing work comp claim costs, health and welfare benefits and retaining skilled workers.

Recent studies

In a four-year study conducted by Johns Hopkins with an N value of 7,690, 85% of the injured workers studied were classified as obese. In a Duke University study involving 11,728 participants, researchers revealed that employees with a BMI greater than 40 had 11.65 claims per 100 workers, and the average claim costs were $51,010. Employees with a BMI less than 25 had 5.8 claims per 100 workers, with average claim costs of $7,503. This study found that disability costs associated with obesity are seven times higher than for those with a BMI less than 30.

A National Institute of Health study with 42,000 participants found that work-related injuries for employees with a BMI between 25 and 30 had a 15% increase in injuries, and those with a BMI higher than 30 had an increase in work-related injuries of 48%.

The connection between obesity and on the job injuries is clear and extremely costly for employers. Many employers have struggled with justifying the cost of instituting wellness programs just on the basic ROI calculations. They were limiting the potential return on investment solely to the reduction in health insurance costs rather than including the costs on the workers’ comp side of the equation and the potential for lost business opportunities because of injury rates that do not meet customer performance expectations. Another key point is that many wellness programs do not include a focus on treating chronic disease that may cause workers to be more likely to be injured and prolong the recovery period.

Customer-driven safety expectations

There are many potential customers (governments, military, energy, construction) who require that their service providers, contractors and business partners meet specific safety performance requirements as measured by OSHA statistics (recordable incident rates) and National Council on Compensation Insurance (NCCI) rating (experience modifiers) and, in some cases, a full review by 3rd party organizations such as ISNet World.

Working for the best customers often requires that your company’s safety record be in the top 25th percentile to even qualify to bid. To be a world-class company with a world-class safety record requires an integrated approach to accident and injury prevention.

Challenges of an aging workforce

The Bureau of Labor Statistics projects that the labor force will increase by 12.8 million by 2020. The number of workers between ages 16 and 24 will decline 14%, and the number of workers ages 25 to 54 will increase by only 1.9%. The overall share of the labor force for 25- to 54-year-olds will decline from 68% to 65%. The number of workers 55 and older is projected to grow by 28%, or 5.5 times the rate of growth in the overall labor force.

Employers must recognize the challenge that an aging workforce will bring and begin to prepare their workforce for longer careers. A healthy and physically fit 55-year-old worker is more capable and less likely to be injured than a 35-year-old worker who is considered obese.

Treating chronic disease

Employers who want a healthy work force must recognize and treat chronic disease. Many companies have biometric testing programs (health risk assessments) and track healthcare expenditures through their various providers (brokers and insurance carriers).

The results are quite disappointing. On average, only 39% of employees participate in biometric screenings even when they are provided free of charge. For those employees who do participate and who are identified with high biometric risk (blood pressure, glucose, BMI, cholesterol), fewer than 20% treat or even manage these diseases.

This makes these employees much more susceptible to injury and significantly lengthens the disability period. The resulting financial impact on employers can be devastating.

Conclusion

Best-in-class safety results will require a combined approach to reduce injuries and to accommodate new classes of disability such as obesity. It is important that employers focus on improving the health and well-being of their workforce while creating well-developed job descriptions, identifying the essential functions, assessing physical assessments and designing job demands to fall within the declining capabilities of the American workers. It is important for an employer to only accept claims that arise out of the course and scope of employment. This is especially true with the reclassification of obesity as a disease. Baseline testing will play an essential role in separating work-related injuries from pre-existing conditions in this changing environment.

Ebola and Beyond: Protecting Self-Insured Work Comp Plans

Epidemic diseases such as Ebola present a significant threat to the safety of both victims of the disease and the individuals who come into contact with those who are infected. Even with advanced medical facilities and protocols, healthcare workers are particularly vulnerable to outbreaks of infectious diseases because they work in close proximity to the victims for extended periods. Further, the facilities themselves tend to be densely populated with workers who run the risk of secondary exposure from medical equipment and other workers who may have been exposed to the disease. Self-insured workers’ compensation plans are very popular among the large health facilities that are likely to deal with these outbreaks. It is therefore important for risk managers and hospital executives at these facilities to not only prevent these infectious diseases from spreading to their employees, but to protect the hospital financially if such an outbreak does occur.

An excess workers’ compensation policy provides reimbursement to self-insured employers for any workers’ compensation claim that exceeds the policy’s self-insured retention (SIR). Under most policies, a claim is defined as an occurrence or event that causes a loss. This provision allows the self-insured employer to combine the losses from multiple individuals injured in the same event under a single SIR rather than individually for each employee. Most policies however, require a separate SIR per employee for claims of occupational disease and illness. Therefore, if 10 employees contract the same disease in the course of their employment, the self-insured employer would be required to retain the SIR 10 times (once for each employee) under most basic policy forms. Clearly, this is an area of potential concern for self-insurers especially because most excess workers’ compensation carriers require minimum SIRs of $500,000 (or more).

To help self-insured employers manage the expense of occupational disease claims, many excess workers’ compensation carriers offer a communicable disease coverage either as part of their policy form or as an endorsement to the underlying policy. A communicable disease coverage combines the losses of multiple employees suffering from the same disease or illness under a single claim and, therefore, a single SIR. Unfortunately for self-insurers, not all communicable disease coverage is created equally. Unlike traditional workers’ compensation policies, where carriers use the same policy form, each excess workers’ compensation policy is unique.

My current excess policy has a communicable disease endorsement, so I don’t need to worry… right?

Just because an excess workers’ compensation policy contains a communicable disease provision doesn’t mean the policyholder is fully protected from this exposure. Communicable disease coverage is unique to the underlying policies to which it is attached and the carriers that issue them. In many instances, the only consistency between various carriers’ coverage forms for this potentially serious exposure is the name of the coverage itself.

Each communicable disease coverage has its own set of definitions, rules and limitations, so it’s important for the policyholder to understand the key provisions that determine how the coverage is triggered and how it responds to potential claims. In general, communicable disease coverage can be compared using four basic criteria: covered diseases, transmission sources, symptom manifestation and coverage limits.

 What’s in a name?

The definition of a communicable disease is extremely important. Some coverage forms define communicable disease in very broad terms while others define such illnesses very narrowly. Forms that use the terms “disease” or “illness” generically but do not specifically enumerate covered or excluded diseases are most favorable to the policyholder. Forms with non-specific definitions can provide the policyholder with coverage for virtually any type of work-related communicable disease ranging from the common cold to meningitis.

Some carriers’ communicable disease forms will specifically list the names or types of diseases that will be covered or the types of diseases that will be excluded under the policy. Much like a named-peril insurance policy, a communicable disease form that lists specific illnesses will only respond if two or more employees contracted a disease that was listed on the coverage form. If the policyholder suffers a claim that does not appear on the list of covered diseases, it’s not likely to be subject to the communicable disease coverage. Narrow definitions of covered losses can be particularly problematic when an outbreak of a previously unknown illness occurs. Again, if it isn’t listed, it’s probably not covered. Conversely, coverage forms that exclude specific diseases not only prevent the self-insurer from seeking coverage for such losses under the communicable disease provisions but may also exclude coverage under the basic occupational illness section of the underlying excess workers’ compensation policy, as well.

Consider the source

One of the few universal components among communicable disease coverage forms is that the disease must be transmittable between individuals to be covered. Diseases such as black lung and asbestosis are often considered to be occupational illnesses but are not subject to communicable disease coverage because they cannot be transmitted from person to person. These specific diseases can only be contracted by prolonged exposure to coal dust and asbestos, respectively, and not merely by being in close contact with someone suffering from those diseases.

The term “transmission” (or some similar term) appears in all communicable disease forms, but the manner in which the disease is transmitted is far more important. Generally speaking, some policies require a disease to be transmitted directly from one person to another to qualify for communicable disease coverage while others allow for both direct and indirect transmissions. Indirect transmissions are commonly referred to as source-to-source exposures. Forms that require a disease to be transmitted directly from person to person are far more restrictive than those that permit diseases to be transmitted from source-to-source. For example, if a group of hospital workers contracts swine flu after being exposed to an infected patient or even another co-worker who was previously exposed, the incident would likely be covered under both the person-to-person and source-to-source rules. If, however, a janitor and a nurse contracted swine flu after handling a soiled pillowcase, communicable disease coverage would only be triggered under a policy with a source-to-source provision because the individuals contracted the disease from an object and not directly from another person.

Tell me the truth – how long do I have?

Communicable disease coverages typically require individuals to contract the same disease or manifest symptoms within a specified period to be eligible for the coverage. If two employees treat a patient suffering from SARS and both exhibit symptoms of the disease a couple of days later, this would likely meet the coverage triggers required under most communicable disease forms. Conversely, if one employee develops SARS within a few days of exposure and the second begins to exhibit symptoms eight weeks later, the communicable disease coverage would be unlikely to respond. The incubation period for this particular disease is normally seven days, therefore, even though both employees ultimately contracted the same disease, it is highly unlikely that they contracted it from the same exposure. Thus, their claims would not be combinable.

Illnesses with long incubation periods are sometimes more difficult to classify under communicable disease coverages because of the time constraints required under some forms. Some forms set forth very specific time frames in terms of hours or days between the time when a group of employees is first exposed to a particular disease and the time the symptoms manifest. Coverage forms that allow symptoms to be manifested at some point during the policy period are generally more favorable to the policyholder. Such forms can combine losses for a successive string of employees infected by one another over a prolonged period (weeks or even months) as long as the infections took place during the policy period and their respective illnesses can be traced back to the same original source.

One potential downside to the policy period provision can occur when the event straddles two different policy periods. If an infection occurs during one policy period and continues to affect employees through a second policy period, it is likely that two separate claims would be developed, thus requiring the employer to satisfy the SIR twice. In this instance, the communicable disease coverage from the first policy would respond to the employees who exhibited symptoms from the time of exposure up until the end of the policy period. Any employees who exhibit new symptoms after the effective date of the new policy period would constitute a separate claim under the new policy’s communicable disease coverage.

Take it to the limit

Coverage extensions and endorsements sometimes share the same limits as the underlying policies to which they are attached. In other cases, coverage extensions carry their own limits in addition to the underlying policy limits or sub-limits, which may erode the underlying excess policy’s shared limit. These limits can be provided on an occurrence basis, aggregated basis or both. Communicable disease forms that carry coverage limits outside of the underlying policy’s basic limits can pose a very significant (and hidden) exposure to the policyholder and therefore should be examined closely.

If communicable disease coverage shares its limits with the underlying policy, the policyholder need only determine an adequate coverage limit for the underlying policy. If, however, the communicable disease coverage carries its own limits, it’s important for the policyholder to make certain those limits will provide adequate protection in the event of a loss.

In some instances, communicable disease coverage can carry per-occurrence or aggregated limits as low as $1 million. Although the policyholder gets the benefit of combining multiple claimants under a single SIR, the collective losses can also serve to erode the occurrence limit very quickly, especially for diseases that require significant amounts of treatment and lost time. Aggregated limits are typically shared over the course of a policy period and are likewise eroded by each communicable disease claim filed during the policy period, thus leaving less coverage available for future claims. More importantly, once the limit is exhausted under communicable disease coverage, any amounts exceeding the coverage limit would be ineligible for reimbursement under the communicable disease coverage and possibly the underlying excess policy, as well. Depending on the circumstances of a given loss and the coverage provided under the applicable communicable disease form, it is possible that the communicable disease coverage could actually end up costing the employer more than a basic, unendorsed policy.

That’s great information, but what can I do with it?

Many excess insurance carriers do allow at least some flexibility in the coverage they offer. In many instances, limits are negotiable on the underlying coverage, and those limits can sometimes be increased even after the policy has been issued. There may be an additional premium required to add communicable disease coverage to an underlying excess policy or to increase the limits on existing communicable disease coverage but the cost is typically modest as compared to the excess policy and the overall self-insurance program. Self-insurers may also want to consider adding aggregate excess coverage to limit the collective unreimbursed costs resulting from multiple occupational disease or communicable disease claims occurring during a single policy period.

Lastly, it may be prudent for self-insurers to take the terms and limitations of various communicable disease coverage forms into consideration when choosing an excess workers’ compensation policy. Epidemic diseases represent potentially one of the greatest financial risks to self-insured employers with exposures to such claims, especially hospitals and other healthcare providers. It is therefore important for those self-insured employers to make the communicable disease and occupational disease coverage a priority and not simply an add-on. Again, not all communicable disease coverage forms are created equally. Choose carefully.

New AMA Classification Of Obesity: How It Affects Workers’ Compensation And Mandatory Reporting

On June 16, 2013, the American Medical Association voted to declare obesity a disease rather than a comorbidity factor. This change in classification will affect 78 million American Adults and 12 million children. The new status for obesity means that this is now considered a medical condition that requires treatment. In fact, a recent Duke University / RTI International / Centers for Disease Control and Prevention study estimates 42 percent of U.S. adults will become obese by 2030.

According to the Medical Dictionary, obesity has been defined as a weight at least 20% above the weight corresponding to the lowest death rate for individuals of a specific height, gender, and age (ideal weight). Twenty to forty percent over ideal weight is considered mildly obese; 40-100% over ideal weight is considered moderately obese; and 100% over ideal weight is considered severely, or morbidly, obese. More recent guidelines for obesity use a measurement called BMI (body mass index) which is the individual's weight divided by their height squared times 703. BMI over 30 is considered obese.

The World Health Organization further classifies BMIs of 30.00 or higher into one of three classes of obesity:

  • Obese class I = 30.00 to 34.99
  • Obese class II = 35.00 to 39.99
  • Obese class III = 40.00 or higher

People in obese class III are considered morbidly obese. According to a 2012 Gallup Poll, 3.6% of Americans were morbidly obese in 2012.

The decision to reclassify obesity gives doctors a greater obligation to discuss with patients their weight problem and how it's affecting their health while enabling them to get reimbursed to do so.

According to the Duke University study, obesity increases the healing times of fractures, strains and sprains, and complicates surgery. According to another Duke University study that looked at the records for work-related injuries:

  • Obese workers filed twice as many comp claims.
  • Obese workers had seven times higher medical costs.
  • Obese workers lost 13 times more days of work.
  • Body parts most prone to injury for obese individuals included lower extremities, wrists or hands, and the back. Most common injuries were slips and falls, and lifting.

The U.S. Department of Health and Human Services said the costs to U.S. businesses related to obesity exceed $13 billion each year.

Furthermore, a 2011 Gallup survey found that obese employees account for a disproportionately high number of missed workdays. Also earlier National Council on Compensation Insurance (NCCI) research of workers' compensation claims found that claimants with a comorbidity code indicating obesity experience medical costs that are a multiple of what is observed for comparable non-obese claimants. The NCCI study demonstrated that claimants with a comorbidity factor indicating obesity had five times longer indemnity duration than claimants that were not identified as obese.

Prior to June 16, 2013, the ICD code for comorbidity factors for obesity in workers' was ICD-9 code 278. This is related to obesity-related medical complications, as opposed to the condition of obesity. Now the new ICD codes will indicate a disease, or condition of obesity which needs to be medically addressed. How will this affect work-related injuries?

Instead of obesity being a comorbitity issue, it can now become a secondary claim. If injured workers gain weight due to medications they are placed on as a result of their work-related injury or if an injured worker gains weight since they cannot exercise or keep fit because of their work-related injury and their BMI exceeds 30, they are considered obese and are eligible for medical industrially related treatment. In fact, the American Disability Act Amendment of 2008 allows for a broader scope of protection and the classification of obesity as a disease means that an employer needs to be cognizant that if someone has been treated for this disease for over 6 months then they would be considered protected under the American Disability Act Amendment.

Consider yet another factor: with the advent of Mandatory Reporting (January 1, 2011) by CMS that is triggered by the diagnosis (diagnosis code), the new medical condition of obesity will further make the responsible party liable for this condition and all related conditions for work-related injuries and General Liability claims with no statute of limitations. It is vital to understand that, as of January 1, 2011, Medicare has mandated all work-related and general liability injuries be reported to CMS in an electronic format. This means that CMS has the mechanism to look back and identify work comp related medical care payments made by Medicare. This is a retroactive statute and ultimately, it will be the employer and/or insurance carrier that will be held accountable.

The carrier or employer could pay the future medical cost twice — once to the claimant at settlement and later when Medicare seeks reimbursement of the medical care they paid on behalf of the claimant. This is outside the MSA criteria. The cost of this plus the impact of the workers' compensation costs as well as ADAA issues for reclassification of obesity for an employer and carrier are incalculable.

The solution is baseline testing so that only claims that arise out of the course and scope of employment (AOECOE) are accepted. If a work-related claim is not AOECOE and can be proved by objective medical evidence such as a pre- and post-assessment and there is no change from the baseline, then not only is there no workers' compensation claim, there is no OSHA-recordable claim, and no mandatory reporting issue.

A proven example of a baseline test for musculoskeletal disorders (MSD) cases is the EFA-STM program. EFA-STM Program begins by providing baseline injury testing for existing employees and new hires. The data is only interpreted when and if there is a soft tissue claim. After a claim, the injured worker is required to undergo the post-loss testing. The subsequent comparison objectively demonstrates whether or not an acute injury exists. If there is a change from the baseline site specific treatment, recommendations are made for the AOECOE condition ensuring that the injured worker receives the best care possible.

Baseline programs such as the EFA-STM ensure that the employee and employer are protected and take the sting out of the new classification by the AMA for obesity.