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Claims Advocacy’s Biggest Opportunity

We know the single greatest roadblock to timely work injury recovery and controlling claim costs. And it’s not overpriced care, or doubtful medical provider quality or even litigation. It is the negative impact of personal expectations, behaviors and predicaments that can come with the injured worker or can grow out of work injury.

This suite of roadblocks is classified as “psychosocial” issues – issues that claims leaders now rank as the No. 1 barrier to successful claim outcomes, according to Rising Medical Solutions’ 2016 Workers’ Compensation Benchmarking Study survey.

Psychosocial roadblocks drive up claim costs far more than catastrophic claims, mostly due to delayed recovery, and claims executives told us they occur regardless of the nature of injury. In other words, one cannot predict from medical data the presence of a psychosocial issue; one has to listen to the injured worker with a fresh mind.

See also: Power of ‘Claims Advocacy’  

It’s likely no coincidence that, while the industry has progressively paid more attention to psychosocial issues this past decade, there’s also been a shift toward advocacy-based claims models over adversarial, compliance- and task-based processing styles. Simply put, advocacy models – which treat the worker as a whole person – are better equipped to control or eliminate psychosocial factors during recovery. According to the 2016 Benchmarking Study survey, claims advocacy and greater training in communication and soft skills, like empathy, are associated with higher-performing claims organizations.

Psychosocial – What It Is, What It Is Not

The Hartford’s medical director, Dr. Marcos Iglesias, says that the “psych” part does not mean psychiatric issues, such as schizophrenia, personality disorders or major depressive disorders. Instead, he points out, “We are talking about behavioral issues, the way we think, feel and act. An example is fear of physical movement, as it may worsen one’s impairment or cause pain, or fear of judgment by coworkers.”

The Hartford’s text mining has found the presence of “fear” in claim notes was predictive of poor outcomes. Similar findings were recently cited by both Lockton (“Leading with Empathy: How Data Analytics Uncovered Claimants’ Fears”) and the Workers’ Compensation Research Institute (“Predictors of Worker Outcomes”).

Emotional distress, such as catastrophic reaction to pain and activity avoidance, is predictive of poor outcomes. Other conditions, behaviors and predicaments include obesity, hard feelings about coworkers, troubled home life, the lack of temporary modified work assignments, limited English proficiency and – most commonly noted – poor coping skills. Additionally, being out of work can lead to increased rates of smoking, alcohol abuse, illicit drug use, risky sexual behavior and suicide.

When peeling back the psychosocial onion, one can see how adversarial, compliance- and task-driven claim styles are 1) ill-suited for addressing fears, beliefs, perceptions and poor coping skills and 2) less likely to effectively address these roadblocks due to the disruption they pose to workflows and task timelines.

Screening and the One Big Question

Albertsons, with more than 285,000 employees in retail food and related businesses, screens injured workers for psychosocial comorbidities. To ensure workers are comfortable and honest, the company enlists a third-party telephonic triage firm to perform screenings. “It’s voluntary and confidential in details, with only a summary score shared with claims adjusters and case managers,” says Denise Algire, the company’s director of risk initiatives and national medical director.

At The Hartford, Iglesias says claims adjusters ask one very important question of the injured worker, “Jim, when do you expect to return to work?” Any answer of less than 10 days indicates that the worker has good coping skills and that the risk of delayed recovery is low. That kind of answer is a positive flag for timely recovery. If the worker answers with a longer duration, the adjuster explores why the worker believes recovery will be more difficult. For example, the injured worker may identify a barrier of which the adjuster is unaware: His car may have been totaled in an accident. This lack of transportation, and not the injury, may be the return-to-work barrier.

It Takes a Village

Trecia Sigle, Nationwide Insurance’s new associate vice president of workers’ compensation claims, is building a specialized team to address psychosocial roadblocks. Nationwide’s intake process will consist of a combination of manual scoring and predictive modeling, and then adjusters will refer certain workers to specialists with the “right skill set.”

Albertsons invites screened injured workers to receive specialist intervention, usually performed by a network of psychologists who provide health coaching consistent with cognitive behavioral therapy (CBT) principles. This intervention method is short in duration and focuses on active problem-solving with the patient. The Hartford also transfers cases with important psychosocial issues to a specialist team, selected for their listening, empathy, communication skills and past claims experience.

Emotional Intelligence – Can It Be Learned?

Industry professionals are of mixed minds about how and if frontline claims adjusters can improve their interpersonal skills – sometimes called “emotional intelligence” – through training. These soft skills include customer service, communication, critical thinking, active listening and empathy. Experts interviewed agree that some claims adjusters have innately better soft skills. But they also concur that training and coaching can only enhance these skills among claims staff.

See also: The 2 Types of Claims Managers  

Pamela Highsmith-Johnson, national director of case management at CNA, says the insurer introduced a “trusted adviser” training program for all employees who come into contact with injured workers. Small groups use role-playing and share ideas. An online training component is also included.

Advocacy – The Missing Link to Recovery

Could it be that advocacy – treating the injured worker as a whole person and customer at the center of a claim – is the “missing link” for many existing claim practices to work, or work better? Whether for psychosocial issues or other barriers, organizations like The Hartford, Nationwide, CNA and Albertsons are paving the road to a more effective approach for overcoming pervasive barriers to recovery. Participants in the 2016 Workers’ Compensation Benchmarking Study confirm that higher-performing claims organizations are taking this road.

The coming 2017 study will continue to survey claims leaders on advocacy topics. A copy of that report may be pre-ordered here.

A Biopsychosocial Approach to Recovery

Watching people try to recover from injury can be baffling. Some recover function quickly; others do not. Why is there so much variability with severity and duration of disability, given similar injuries or illnesses? Why do some individuals get stuck in delayed recovery?

Our medical system has tended to focus on the physical: If there is back pain, there must be something going on in the disc, vertebrae or nerve roots. That approach isn’t bad. Medicine has made a lot of progress with that tactic. But sometimes a physical cause isn’t apparent.

If we examine what else may be happening in people’s lives, what they’re thinking and what they’re feeling, we start to uncover circumstances and behaviors that may be delaying their recovery.

The Hartford is focusing on a different and promising approach that looks beyond the physical aspects (such as symptoms, physical findings, test results) and looks at the whole person as a biopsychosocial being who may have non-physical barriers that are delaying recovery. The Hartford has developed a program that offers help to assist people in getting unstuck.

Internal data analytics indicate the presence of psychosocial risk factors can account for a two- to four-fold increase in disability duration of work-related injuries.

Background

The biomedical model has served as the traditional foundation of our understanding of the body and has formed the bedrock of modern Western medicine. In essence, this model reduces illness and injury to their most basic units; the body is seen as a machine that operates on the basis of physical and chemical processes. In other words, find out what’s wrong with the body and fix it.

The biopsychosocial model seeks to amplify the biomedical model by addressing an individual holistically as a physical, psychological and social being.

The 1970s saw pioneering work in the treatment of chronic pain by using psychological — or behavioral – principles. For instance, W.E. Fordyce at the University of Washington found that helping patients with pain behave normally (that is, getting them to stop displaying pain behaviors) led to improvements in function.

In the 1980s, cognitive behavioral therapy (CBT) began to be used in treating chronic pain patients. CBT tries to change patterns of thinking or behavior that are behind a person’s difficulties all to change how they feel.

In the past 20 years, some have shown the usefulness of interventions based on specific psychosocial risk factors for pain and disability. Much of this work has been carried out in Canada, Europe, Australia and New Zealand.

See also: Better Outcomes for Chronic Pain

The medical and research literature points to social and behavioral factors — like fear, expectation of recovery, catastrophic thinking and perceived injustice — as powerful forces that can delay recovery after an injury or illness. As one example, a 2015 WCRI study showed that fear of getting fired could affect a worker’s return to work after an injury.

The Hartford Approach

Armed with an understanding of these drivers of disability, The Hartford is using its advanced data analytics and developing innovative solutions to help workers at risk regain the function they had before an injury or illness.

A patented text mining technique allows us to look for psychosocial, comorbid and other risk factors to identify, early on, individuals who demonstrate a likelihood to have a prolonged disability. By combining this early identification tool with a growing toolkit of interventions, we are finding new ways to help individuals restore their lives after an injury or illness.

One such tool is a proprietary, telephonic coaching intervention. Having identified claimants who show an elevated risk for prolonged disability, we invite them to participate in a program that matches them with a specially trained coach who helps them overcome psychosocial barriers. By equipping individuals with skills and techniques to change the way they think, feel and act, we help them develop confidence to take control of their recovery. This confidence allows them to increase function in all areas of life, including return to work.

The voluntary program, called iRECOVER(SM) uses phone calls with the coach, along with a workbook and homework assignments. It can last several weeks.

Although still in its early days, iRECOVER shows promising results: earlier return to function and return to work.

Participant feedback has been very positive. For instance, we have received emails and letters from injured workers that say:

  • “There’s light at the end of the tunnel.”
  • “I feel confident going back to work. A good part of this is due to my participation in iRECOVER.”
  • “I think what you do is probably as important as medical treatment.”
  • “iRECOVER helped me be courageous and strong.”

See also: Data Science: Methods Matter (Part 1)

Conclusion

By considering the whole patient, applying potent data analytics and developing innovative solutions, we are getting to the root of delayed recovery for many individuals. The results will benefit all concerned, especially the injured worker, who just wants life to get back to normal.