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2018 Workers’ Comp Issues to Watch

The first Out Front Ideas with Kimberly and Mark webinar of 2018 provided our thoughts on the 20 Workers’ Compensation Issues to Watch in 2017. What follows is a summary of the issues discussed:

Healthcare

The healthcare industry continues to evolve at a rapid pace, and the evolution is vast, encompassing everything from pharma to practice to technological disruptors.

Consolidation and mergers and acquisitions in the healthcare space will continue in 2018. As CVS looks to broaden with the acquisition of Aetna, do not be surprised if Amazon, Walmart and other large employers expand their reach into health, as well. Health systems have been merging for years. In some of the mergers, we are now beginning to see hospital and facility exits resulting in local disruption for patients, providers, insurers and the benefit and risk programs of those affected. For many years, health plans have been in the business of delivering patient care. Probably the best example is Kaiser Permanente, operating as both a health plan and healthcare provider. Similar to UHG’s announcement of its DaVita acquisition, we will likely see more payer/practice mix in 2018. Drug companies are purchasing other drug companies, and, given their R&D cycles, generic and biosimilar opportunities, we do not anticipate this to decrease.

Under Dr. Scott Gottlieb’s oversight at the FDA, expect to see approval and safety pathways accelerated in 2018, which will enable speed to market for new generic drugs, digital health software and medical devices.

A few additional hot topics will include:

  • Scope-of-practice advancements for physician assistants and nurse practitioners given their underutilization.
  • Competition for convenient, quicker, more-accessible options for care with growing emphasis on community care, home care, retail clinic care and telemedicine.
  • For most medical providers, revenues are flat while expenses continue to rise, prompting significant focus on efficiency. Offices and systems need to improve speed of delivery and agility at all levels.
  • Value-based care models and value-based reimbursements. Examples in workers’ compensation include physician/health system pay for outcomes and bundled payments arrangements. Health plans look at population health outcomes and continue to advance accountable care organization (ACO) models.
  • Pharma continues to aggressively address the need to create value for outcomes related to drug pricing. The debate there continues. How much is a drug worth if it literally saves the life of a patient?

Legislative Watch

Thirty-four of the 50 state governors are currently Republicans. This, combined with the fact that insurance rates are down in most of the U.S., means we have not seen a significant push for workers’ compensation reforms the last few years. However, there are still some states where significant activity is expected in 2018.

  • Florida will again attempt to fix the plaintiff attorney fee caps that were found unconstitutional by the state supreme court two years ago.
  • Pennsylvania had the part of its workers’ compensation statutes dealing with the evaluation of impairment found unconstitutional in 2017. Efforts are underway to correct this legislatively.
  • Expect the workers’ compensation reform battles between Illinois Gov. Rauner and the Democrat-controlled legislature to continue. This is an election year for the Illinois governor.
  • In California, it is Gov. Brown’s last year. Expect yet another push by the legislature to undermine prior workers’ compensation reforms. Universal healthcare will likely be an issue in the 2018 governor’s race, and the outcome of this election could have a significant impact on workers’ compensation in 2019.

Treatment Guidelines and Drug Formularies

We have seen a positive trend in states adopting treatment guidelines and drug formularies, which can help injured workers get proper, timely care and help to reduce unnecessary treatment.

In 2018, California, New York and Arkansas will all be implementing new treatment guidelines or drug formularies. Montana is also implementing a drug formulary, but the timeline for this is not set yet.

Georgia, Pennsylvania, North Carolina and Louisiana all considered either treatment guidelines or drug formularies in 2017, and we expect them to revisit this again in 2018.

See also: The State of Workers’ Compensation  

Judicial Watch

Every year around the country, judges modify the practice of workers’ compensation in their state based on their interpretation of the statutes. These interpretations can significantly expand or restrict workers’ compensation benefits in the state. It is as important to monitor the court decisions in your state as it is to monitor legislative activity.

Along those lines, challenging the constitutionality of workers’ compensation statutes is a trend that is expected to continue in 2018. Last year, Pennsylvania joined the list of states to have a portion of their workers’ compensation statutes found unconstitutional by the state supreme court. There is a case on appeal in Kansas right now challenging the constitutionality of a portion of their statute, as well. The basis for these constitutional challenges exists in many other states.

Finally, last year, a judge in Alabama declared the state’s entire workers’ compensation statutes unconstitutional. This was appealed, and the case settled on appeal, so that decision ultimately was rendered moot. However, the issues raised in that court case regarding benefit adequacy are something we could see again anywhere.

Workplace Violence

Companies are working to raise awareness of workplace violence. Whether they are engaging consultants to assist with planning or conducting revised employee training, risk managers and human resources are working together to ensure they have a solid program in place. There is an uptick in patient attacks on healthcare workers. This is happening all too often, ranging from emergency room to mental health facilities and nursing home care settings.

Given that 2017 marks an unprecedented awareness of sexual harassment in the workplace, we are adding workplace harassment as an issue to watch. Employers small and large are looking at their sexual harassment policies, training and complaint-investigation processes.

State Variations

Workers’ compensation is a state-based system, and the variation between the states is something that has been attracting consistent attention. Two people performing the same job for the same company in different states can receive significantly different workers’ compensation benefits. The very definition of an employee varies by state. From the administrative side, a lack of consistency with regard to state forms, data templates and even the definition of disability is very challenging to payers.

The U.S. Department of Labor started looking into these issues in late 2016, but those efforts stopped after the election of President Trump. However, those issues are still very real and need to be addressed. Now is probably the best time to establish standards between state workers’ compensation systems – now, when the federal government is not pushing for it. If no action is taken, it is likely that the federal government will push for this in the future.

Pain Management

Everyone is keenly aware of the opioid crisis and the importance of tapering narcotics, narcotics avoidance, formularies and deaths related to opioids. 2018 provides the opportunity to advance our understanding of these issues and willingness to change treatment protocols for patients in pre-pain, acute pain and chronic pain states. With pain, one size does not fit all. Personalization of care and working in partnership with the patient, the family or support system and providers to collectively create a treatment pathway for the patient is important to ensure success.

Natural Disasters

2017 was an unprecedented year for natural disasters in the U.S., with multiple major hurricanes and widespread wildfires. Natural disasters can have a big impact on workers’ compensation and healthcare systems, including the risks faced by first responders, the disruption to your workforce, challenges to the benefit delivery system and supply chain disruption.

Cyber

Every company has cyber risks and preparedness, and recovery is a daily priority for the CIO. Cyber risk reaches beyond hacking and selling personal identifiable information on the deep dark web. It can be a life and death concern. Health systems locally and worldwide were hit with ransomware in 2017, shutting down hospital and practice computer systems while money was demanded in exchange for digital keys to unlock the systems. Patient data hacks have resulted in medical device malfunctions and treatment delays. A recent cyber attack on Merck hurt its ability to produce medicines. Workers’ compensation payers, service providers and stakeholders are equally at risk. History shows that companies without a solid cyber insurance program put their business at risk. Companies and customers will place even greater emphasis on cyber risks in 2018

Rate Adequacy

For the last few years, workers’ compensation rates around the country have been flat to down in most states. This is in spite of the fact that NCCI data shows that, over the last 20 years, the average medical and indemnity costs per lost time claim have increased at rates greater than inflation.

In 2017, two of the top 10 writers of workers’ compensation posted multimillion-dollar reserve increases to cover their developing losses. This attracted the attention of rating agencies such as A.M. Best, which, in a September report, raised concern about the threat of inflation on workers’ compensation tail costs and the impact this could have on industry reserves.

Multiple brokers have indicated that the workers’ compensation rate outlook for 2018 is relatively flat. But with workers’ compensation being such a long-tail business, premiums collected today must cover losses 30 years into the future. As losses continue to climb, it is inevitable that insurance rates will need to increase in the future to offset those losses.

Job Accommodation

Silos within companies result in multiple return-to-work policies, both formal and informal. Return to work is not a workers’ compensation issue, alone. The issue is inconsistent with job accommodations across organizations. Whether an employee is injured on the job, requests an accommodation as part of a disability or leave of absence or has the need for an accommodation in general does not alter the way in which an accommodation is handled. In 2018, we encourage you to break down the RTW silos and get comfortable outside your typical area of responsibility. We should not only meet ADA requirements but also provide employees the accommodations they deserve.

Impaired Workforce

2018 means that recreational marijuana is now legal in more states than ever before, with California becoming the largest state to allow use.

However, the reality of recreational marijuana is that this likely means that a percentage of your workforce is impaired on the job. Many employers stopped pre-employment drug testing for marijuana because too many potential workers failed the drug test and because the presence of marijuana in your system does not mean you are currently impaired. That’s the problem. Right now, there is no reliable method for employers to determine if their employees are impaired on the job. There is no “marijuana breathalyzer” that can quickly and accurately show whether a person is impaired. The bottom line is that the science of marijuana has not caught up with the social realities of marijuana.

What can employers do? Courts have consistently ruled that employers with drug-free workplace policies can terminate an employee who tests positive for marijuana, even if the employee is using medical marijuana. There is one notable exception. Last year, a Maryland court allowed an employee to pursue a wrongful termination claim under these circumstances. Will other states follow the Maryland precedent or the cases in California, Colorado, Michigan and other states where the termination was allowed?

In addition, what happens now that the Department of Justice has rescinded the Obama administration policy memo that indicated the federal government would defer to the states to enforce marijuana laws? Does this mean the federal government will start to arrest marijuana users and producers? No one knows for certain. Perhaps this will force Congress to take action on marijuana.

Digital Health

Digital health is a broad term related to the use of technology and health. Examples include mobile health apps, telemedicine products, tools to track consumer/patient data, education and patient reminder programs and treatment adherence. For those working in the digital health space, connectivity is the issue. There are plenty of technology solutions; the issue is how to connect all the stakeholders: patients, doctors and service providers, pharmacists and payers. Without connectivity, silos remain, and the system is too clunky to be effective.

Probably the most common digital health discussion in workers’ comp is telehealth. We have been slow to adopt comprehensive programs, whereas the benefits space has been at it for more than five years. Group health has moved past triage of physical symptoms to treating mental health and, in 2018, moving into chronic disease management. Look for more hospitals to offer telehealth services as they diversify care offerings and seek to enhance their offerings. Technology has improved, and consumer awareness and interest is growing, so now is the time for workers’ comp to jump on board.

OSHA

Under the Obama administration, OSHA had a publicly stated policy of “shaming” employers in compliance. That meant frequent press releases highlighting violations, even if those violations were later rescinded. In 2016, there were more than 200 OSHA press releases on enforcement actions.

OSHA under President Trump has been much more focused on education than penalties. As of late October, the administration had issued less than 20 press releases on enforcement actions. Scott Mungo, who worked for FedEx Ground, was nominated by President Trump to head OSHA in October. In December, his nomination was approved by the Senate committee, and it is expected he will be confirmed by the full Senate soon.

What should we expect from OSHA under President Trump? If the first year of his term is any indication, we will see fewer new regulations and perhaps even a rollback of some existing regulations. The approach has been more consultative with employers, rather than combative.

Workforce Wellbeing

Human resources, risk managers and executive leaders recognize that workforce wellbeing affects both top and bottom line performance of an organization. Benefits are a talent attraction and retention tool in 2018, and human resource officers are deploying programs to address physical, emotional and financial wellness – the three pillars of health. Wellbeing programs place emphasis on an individual’s personal needs and considerations for both health and productivity. Workplace wellbeing programs in 2018 expand far beyond weight loss and smoking cessation. They may also include financial planning tools, resilience and mental health awareness training. To promote use of benefits, human resources departments need to break down the benefit silos. The whole health model at Sedgwick health is a great example, because it integrates group health, leave of absence, workers’ compensation, short-term disability and job accommodations. Benefit integration and ease of use drives engagement, which, in turn, improves business performance.

Fraud

When you hear about workers’ compensation fraud, the first thing that comes to mind is videos showing allegedly disabled workers engaged in a variety of physical activities they claim to be unable to do. While these videos are sensational, the reality is that true fraud from injured workers is rare.

The most common source of workers’ compensation fraud comes from employers in the form of premium fraud. Underreporting payroll, misclassifying workers and incorrectly classifying workers as independent contractors is something that happens all too often. Employers that commit workers’ compensation fraud drive higher premiums for honest employers and create an unfair competitive business environment. The construction and staffing industries have been dealing with this issue for many years. Many states have been aggressively cracking down on this type of fraud, but it continues to be a significant problem.

See also: 25 Axioms Of Medical Care In The Workers Compensation System  

Medical provider fraud is another area of workers’ compensation fraud getting more attention lately. In the last two years, we have seen several high-profile prosecutions of medical providers in California. The fraudulent treatment alleged in these cases amounts to billions of dollars. We have not seen medical fraud like this in other states, in part because California’s system has a high percentage of post-injury CT claims, which allows unauthorized treatment and the filing of a lien by the medical provider. These elements create an environment that is ripe for fraud and abuse. We hope that we will not see this fraudulent behavior spread to other states and that California will continue its diligent prosecution of these cases.

Consumer Experience and Engagement

We are living in a consumer’s world today. The pace with which we want our services delivered and the high standard of excellence expected has led all sectors in business, including health and workers’ compensation, to consider their definition of consumer. Failure to engage a consumer leads to complaints and negative PR and possibly lack of treatment adherence, whereas high levels of consumer experience lead to positive outcomes. You will hear more about use of net promoter score (NPS) to understand consumer experience and link to engagement in 2018, and we believe use of NPS has potential in workers’ compensation. Now is the time to engage consumers in the conversation around our products, services and certainly program design. The injured worker’s voice is often missing in the workers’ compensation system.

People, Places and Things

The aging workforce, the evolving workforce and technology are all having a significant impact on the workers’ compensation industry. In the coming years, we will see a significant exodus of talent from our industry due to retirement. How do we attract the next generation and compete against other industries for people? What will the office of the future look like? How will changes in technology affect the way we do our jobs, including how we communicate with injured workers?

Insurtech

If you have not checked out the latest conversations in insurtech, 2018 is the time. The market has grown considerably in the last three years with a worldwide platform. What’s insurtech? Insurtech is use of technology to bring efficiencies to the insurance industry. Those engaged with insurtech believe new tech players will disrupt the current insurance market by bringing coverage to a digitally savvy customer base. Customer expectations of seamless, instant transactions are increasingly the norm, and insurtech use of blockchain and AI are promising – although yet to be proven in most scenarios. Much of the focus of insurtech is on personal lines, but it is starting to move into commercial segments. McKinsey reported last year that 46% of insurtech companies are focused on property and casualty, 33% on health and the remainder on life. They target primarily pure risk insurance, where they have developed access points to the value chain on innovations.

Immigration Reform

Finally, immigration reform is something that has been talked about politically for years, but Congress has not been able to advance any meaningful discussions in this area. Will that change in 2018? Our country and Congress appear deeply divided on this very important issue. The outcomes of these discussions could have a significant impact on the millions of undocumented immigrants currently working in this country without the benefit of workers’ compensation coverage or other workplace rules and regulations.

To listen to the complete webinar, click on this link.

The State of Workers’ Compensation

Workers’ compensation is constantly evolving with new case law and legislation around the nation every year. Because of this, managing a workers’ compensation program is a huge challenge for risk managers. At the CWC and Risk conference Mark Walls lead a panel discussion around the state of workers’ compensation.

The panel included:

  • Janine Kral, Vice President of Risk Management, Nordstrom, Inc.
  • Jennifer Saddy, Director of Workers’ Comp/Corporate Insurance & Risk Management, American Airlines, Inc.
  • Miriam Levario, Director of Workers’ Compensation, Warner Bros. Entertainment Inc.
  • Duane Hercules, President, Safety National
  • Rick Taketa, President and Chief Executive Officer, York Risk Services Group, Inc.
  • Tom Ryan, Managing Director, Workers’ Compensation Market Research Leader, Marsh LLC
  • Mark Walls, Vice President Communications & Strategic Analysis, Safety National (Moderator)

Talent attraction and retention for the future: what can we do?

Social mission is a key message to attracting new talent. Employees care about getting those workers back to work as soon as possible. Employees want to have meaning and value added to their job.

We are here to help people, here to help, here to entertain. Bringing in employees that are like family. They are coming to work for the brand not necessarily the company. That is how to retain employees.

Employees are looking for a mission or bigger picture to be part of a bigger and greater good. Continue to tell the greater good of how we help injured workers. Work with universities and internships to create and build those relationships.

People want a job with a purpose.

How important is total cost of risk?

Total cost of risk includes all costs of an insurance program. Imagine a pie cut into slivers and each of those pieces are costs of variable and fixed costs involved in a workers’ compensation program. As small as 10% could be fixed and 90% could be variable including surveillance, lost wages, medical costs, etc.

Look at benchmarking compared to peers to see where your company stands compared to others.

Create specific goals to measure and chose key data elements and watch those costs.

Do not want the claims of today to turn into the claims of tomorrow.

Open communication between workers’ compensation and company.

See also: 25 Axioms Of Medical Care In The Workers Compensation System  

Thoughts around drug treatment guidelines and drug formularies?

Should create similar procedures and protocols for similar injuries, positives far outway the negatives.

Create better true treatments for injured workers now not using 17 year old data and treatments that are outdated.

Create clinical treatments early on and create benchmarking to create results, be proactive and not reactive.

Predictive analytics is an industry buzzword now. How are you using analytics?

First thing to look at is prevention. Look at how we can use that data and create prevention in that area. Post loss – look at opportunities to mitigate those losses.

Prevention. Once you have an open claim, you have an open claim. Meet with safety and other departments that are having multiple similar injures.

The word predictive is important. This requires action after you receive that data. Look into those claims and see which one will benefit from this predictive analytics the most.

Pattern recognition from huge groves of data. Its not just about identifying what has happened in the past but how can that be used for the future. Use that data and create a workflow path for similar injuries.

Need to check and recheck data to make sure its accurate. Make sure the reports are credible.

Machine learning and artificial intelligence. What are some other technology areas for potential impact of workers’ compensation?

Assisting and changing the way we communicate with injured workers. Large area for improvement for communicating with injured workers.

Claimants should be able to get any information regarding their claim whenever they would like such as a portal they could log in and see where their claim is standing.

Understand and know your audience. Some technology will work for younger claimants but some older claimants appreciate the personal phone call and not the text message.

Collision avoidance programs to decrease injuries.

Wearable technology and wearable devices can provide real time data to proactive to reduce injuries.

How does California compare with other states?

Its a nation to itself. Just the size is huge. Geographic and demographic complexity. Over the past few years there has been a lot of positive change. The state is also highly regulatory complex. Clear litigation issue in California that needs to be addressed.

Highly more expensive.

Changes over the past years have been favorable but there are still issues with litigation.

Issues around marijuana

More research needs to be done, it is an evolving trend for sure.

Safety is a big issue and some companies want to remain a drug free workplace.

Minimal regulations on medicinal marijuana. Needs to be a more safe environment and regulated.

Challenge for some companies is around drug testing and remaining a drug free environment but these injured workers are taking heavy doses of opioids.

Dealing with issues in states where marijuana is legal but the company is a drug free workplace. This gets confusing for employees.

See also: How Should Workers’ Compensation Evolve?  

How do you think workers compensation needs to evolve?

Crucial for claims examiner and their role with the claimants. They can make a huge impact with the way the claim plays out.

Effective use data and technology to increase workplace safety. This leads to better outcomes. Evolve to meet on demands needs such as Uber, Lyft and even delivery services. Attract the best and brightest new talent.

Nothing is better than getting injured workers back to health and back to work.

Look at a more holistic approach to health management and better alignment with health and wellness.

Perspectives From Injured Workers

Many stakeholders in the workers’ compensation industry have been engaged in conversations regarding opportunities to improve the workers’ compensation system. The perspective of injured workers has been lacking in these conversations. This perspective has been difficult to obtain because there really are no respected “injured worker” advocacy groups such as there are in the group health setting. Attorneys and unions are not the true voice of the injured worker – they have their own sets of priorities. The voice of the injured worker is an important one. It will help us gain a deeper understanding of the challenges in the workers’ compensation setting as well as give us greater empathy for what they are facing.

At the 2016 Comp Laude Gala, the Alliance of Women in Workers’ Compensation sponsored a session featuring injured workers talking about their struggles. It was an extremely powerful and moving experience that left few dry eyes in the packed room. In this article, we attempted to capture the essence of this session. Our goal is for this information to be used to help us better understand the obstacles faced by injured workers so that we can be better advocates for them and, ultimately, achieve better outcomes on claims.

The Participants

The participants included an injured worker in recovery from his dependency on opioids, regaining his life 14 years after his injury. Another, with two prosthetic legs, continues working and leaves a legacy for the workers’ comp community. A third participant was a woman with incomplete quadriplegia, who started a business helping others with chronic pain.

We’ve heard these stories before. The question is, however, what makes these cases different? How have these injured workers been able to get back to function and work despite debilitating conditions that leave others homebound and drug dependent forever?

All three of these injured workers have unique personalities that may have contributed to their successes. But the one thing they have in common that was a deciding factor for all was support, positivity and encouragement from people around them – especially those in the workers’ comp industry. The stories they shared should serve as lessons for the workers’ comp community to illustrate that what we say and do makes a difference. It sends a message that by taking responsibility for our actions, words and decisions, we can truly make a difference for injured workers and our companies.

The Stories

Kenny: “I had never hurt my back in my life, but I twisted it lifting something.” That was in 2000, before his 40th birthday. By 2014, Kenny had undergone two surgeries, multiple implants, epidurals, a myelography – which he described as “the worst thing in my life” – and was prescribed a cocktail of various opioids, including a fentanyl patch and oxycontin. He had been told by a medical professional in a Florida hospital that he would likely be dead in two years from all the medications he was taking.

“Your mind just goes,” he said. “You’re useless. Suicide – it’s right there.” Two case managers and several years later, things were no better. Though he wanted to work again, the back fusions on L4 and L5 left him unable to walk and the meds left him in a zombie-like condition.

“We were young. It was scary,” said Kenny’s wife, Karen. “I lost my husband, my boys lost their dad.”

See also: 3 Reasons to Talk With Injured Workers

Kenny and Karen’s story might have continued that way forever, if not for the arrival of their third caseworker 12 years after the initial injury. “It was like she flew in on angel wings,” Karen said. “She took the time to get to know him. Nobody else did.”

At the end of their very first conversation, the new caseworker promised she would get Kenny fishing again – one of his favorite pastimes, and said she would go with him. “That’s a really big deal,” Karen said.

But the road ahead was not to be an easy one. The caseworker’s plan to send Kenny to a Florida hospital for treatment didn’t sit well; at least, not with Kenny. It wasn’t until the following weekend during a family anniversary party that his sisters, wife and sons convinced him to go along with the treatment plan.

At the hospital, he received rehab, biofeedback and the care he truly needed to be able to function again. Six weeks later he was no longer taking the hydromorphine, or the fentanyl, or the oxycontin, or the percocets, or the duragesic patches.

Three years later he is still off the medications, including aspirin. He goes to the gym daily to walk, do light stretching and exercise.

“I’d tell anyone, ‘Get off the drugs; that’s 50 percent of your pain,’” he said. “Your body will help heal you.”

For Kenny, a single individual was able to change his life. A physician had previously told him he ‘was as good as he was going to get.’ The first case worker was “distasteful,” and the second never showed up. But the third caseworker had a different approach.

“It just really matters what you say — as a doctor, nurse or case manager. And that was the big difference for us,” Karen said. “She never said anything negative. She always said, ‘we’re going to do that,’ ‘we’re going to get you to that,’ ‘we’re going to go here, it’s going to be great,’ And we believed it.”

Becky: It’s been more than a decade since Becky was lying in a hospital bed with a broken neck, two collapsed lungs, all of her ribs on one side broken, and a broken clavicle. A work-related auto accident rendered her ‘an incomplete quadriplegic.’

“My spinal cord was not quite severed; damaged, but not severed,” she explained. “My left side has partial paralysis. My right side looks normal, but I can’t feel hot or cold, sharp or dull [sensations].”

Because her body no longer functioned the way it had before the accident, she had to learn how to walk again and to function with one hand — since the other does not work. Then, two years later, she developed burning nerve pain from the neck down.

“That was the darkest time for me,” she said. “They tried all kinds of medications. I was depressed, I wasn’t sleeping at night, I stopped exercising, I stopped having any kind of positivity. It was a really, really dark time.”

Becky was subsequently diagnosed with a syrinx — a fluid-filled cyst in her spinal cord. In her case, it is essentially inoperable. Becky reluctantly agreed to go to a functional restoration program in California, although she wondered how that could alleviate her pain.

“I discovered that pain is an experience, not a sensation. And I get to decide what it means,” she said. “And when the fear goes away, and the negativity goes away, the pain comes down. And when my activity goes up, eventually I’m less sore and I’m better. And life could still be good.”

Becky has an active life these days. She and her husband, Barry, have started a company to help people with long-term chronic pain. It is something in which she is intimately familiar.

“I still have the syrinx, I still have burning nerve pain from my neck down, it just doesn’t have me,” she said. “I don’t take any meds. I live a very good, a very functional life.”

Dwight: Despite losing both legs from two separate work-related incidents, Dwight became a force within the workers’ comp community. He was tired of people looking at his prosthetic legs and decided to give them something special to see. He started creating outlandishly colored hand-painted sneakers – first for himself, then for others. These gained notice in the workers’ compensation community when they were worn by the late David DePaolo, founder of WorkCompCentral, at numerous industry events.

Tragically, Dwight passed away in March of this year from heart-related issues, but his positivity and energy are not forgotten.

Dwight’s story began seven years ago, when he picked up a staph infection while working in Hong Kong. By the time he returned to Los Angeles, his left leg was dead and had to be amputated.

He returned to work with the one prosthetic leg, inspecting some of the world’s tallest buildings. “I loved what I was doing,” he related.

Three and a half years later, Dwight suffered another industrial accident, leading to the loss of his other leg. Before his passing, Dwight said his recovery was going, “Pretty good. I started playing golf again.”

Having grown up in the Del Mar, California area beach community, he was an avid surfer. “I surfed every day,” he said. “So I got water [prosthetic] legs to surf.” He also had special legs made for running and was doing stained glass artwork for restaurants in the San Diego area.

In addition to his hobbies, the father of seven opened Soule Innovations, a business that creates brightly-colored sneakers for people. He and his wife Debbie also donated the shoes to other amputees and war veterans.

The Lessons

The stories are different. But the messages from these and other injured workers are the same: positivity, peer support, and advocacy are imperative to recovery.

Attitude: “After an injury the person dealing with us has to be positive,” Dwight explained. “We’re trying our best, but on the other hand, on the other end of the line, tell me everything’s going to work; tell me you care. It’s so important.”

The attitudes of those involved with an injured worker are vital in determining the outcome. Karen tells the story of seeing a medical provider who walked into the exam room, looked at his information and told Kenny “you’re as good as you’re going to get.” On the way home from the appointment, Kenny was crying in the car and asking, “This is it?” Those and other negative conversations kept Kenny in a disability mindset until his third caseworker arrived on the scene.

See also: A Better Reality for Injured Workers  

Becky related her experience when she was first in the hospital. “As soon as they took the ventilator tube out of me I asked, ‘What’s the prognosis?’ [The doctor] just looked at me and said, ‘You’ll never be normal.’ It was true. I cried after that. Couldn’t move, couldn’t scratch my nose but I didn’t like that answer,” she said. “I asked another doctor the next day. He smiled and said ‘you’re going to walk again.’”

The positive reframing of the message made a difference in Becky’s attitude and ultimately, her outcome. Much of Becky’s and Barry’s work with chronic pain patients involves reframing the message.

When someone asked what she focuses on while feeling burning nerve pain from the neck down, she responded “You focus on the neck up. There’s always something we can focus on that is ok,” she said. “If everybody’s on the same page – the provider, case manager, adjuster – even if it’s just one person that will speak some kind of positive into your experience, it makes a huge difference.”

Nevertheless, the message must be truthful in addition to being positive. “One thing that used to really get to me is if someone said, ‘we’re going to bring you back to normal,’” Dwight said. “If I’m going to be normal, we’re going to cut everybody’s legs off and then we’ll be normal. Normal for me would be impossible. It has to be positive. We all have to work on ourselves.”

Advocacy: Peer advocacy is also crucial to a positive outcome. Often the injured worker’s only support is his family, and that can be volatile.

“It’s a powerful journey to be a spouse of an injured worker,” explained Barry. Fear creeps in, he said, which can impede recovery. “One of the things that I experienced is that it is really easy to find yourself defaulting to that workers’ comp check that’s coming in the mail. It’s almost a feeling like, ‘you’ve got to stay injured, you’ve got to stay dependent.”

For injured workers and their families, showing support and caring can make the difference between an injured worker staying dependent on the system or recovering.

“It begins with positivity, looking at what you have rather than what you’ve lost. You have to celebrate what you have, not dwell on what you lost,” Barry said. “I coach family members of people going through pain and that’s what I tell them all the time. We spend a lot of time talking about grieving that loss. At the same time, grief is also acceptance of what you’ve lost and then celebrating what you have. We spend a lot of time on that.”

Becky empathizes with her clients who are going through the pain. “We specialize in working with the difficult cases,” she said. “We want to give them hope and support and all they need to be self-managers instead of passive patients.”

Hearing and believing what the injured worker says is a crucial part of advocacy. In Becky’s case, her diagnosis of ‘incomplete quadriplegia’ may have expedited the care she received. But a case like Kenny’s, with a questionable diagnosis, is more vague and complex. There can be a stigma attached that can leave the injured worker feeling alone and forgotten.

“If somebody’s on drugs for two or three years and nothing is happening, you’ve got to stop it then,” he said. “Thirteen or 14 years is terrible. You go to these doctors and say ‘yes, my back’s killing me.’ They write you a prescription and that’s it. It’s hard.”

Kenny spoke of the family-like support he received at the rehab facility as being key in his recovery. For the 12 years before that program, he had only his wife.

“If somebody is alone and disabled, I don’t even know how they cope,” Karen said. “Because he was in such a stuporish state that, if I wasn’t there or later on, when [the case worker] came into our lives, if she wasn’t there, he’d probably be dead right now.”

Dwight likewise found good support from his provider.

“My doctor gave me two options: ‘put you in a wheelchair and give you enough drugs, or get up off your ass and do something.’” He chose the latter.

How to Assess Municipal Threats

At the 2017 PRIMA Annual Conference, a session discussed development of a municipal risk assessment program. The speakers were:

  • Dan Hurley – risk manager, City of Chesapeake, VA
  • Marilyn Rivers – director of risk and safety, City of Saratoga Springs, NY

A threat assessment is designed to determine vulnerabilities of employees to physical harm. Public employees are particularly vulnerable due to a variety of exposures.

Understand Internal and External Threats

When it comes to workplace violence, most people think this is primarily internal and involves a disgruntled co-worker. However, particularly with public entity employers, the main threats are external. Someone is disgruntled about something and acts out violently against the public entity employee.

Domestic violence is also a significant source of workplace violence. The violence can spill into the workplace and affect not only the domestic partner but others around them.

Among the public entity employees at greatest risk for violence are:

  • Public works/utility workers
  • Inspectors
  • Social workers
  • Home health aids
  • Animal control
  • Anyone handling money
  • Recreational staff
  • Emergency response
  • Law enforcement
  • Risk management

Any public situation that can be confrontational or stressful has the potential to escalate into violence.

See also: IT Security: A Major Threat for Insurers  

Identify Threats

You should develop a threat committee to help assess potential threats for violence against your employees. Members of this should include:

  • Police
  • Fire
  • Social services
  • Human resources
  • Library
  • Public works
  • Public utilities
  • Recreation
  • Finance, risk and safety
  • City attorney
  • Code and licensing
  • Collective bargaining units

It can be challenging to bring all these different people together on the same committee as they have such a wide variety of experiences and interests. It is important that everyone feels they have a voice on the committee and that their views are heard.

Each group on your committee has their own specific risk factors. For example, libraries are in a variety of neighborhoods. They are not heavily staffed, and they are open late into the evening. If there are homeless in the area, there is a tendency for them to look to libraries as a place of refuge.

The leading cause of workplace homicide for women is domestic violence, with 32% of killings related to a domestic partner. Only 2% of men killed were due to domestic violence. This leads to the question of whether you should require your employees to notify you if they have a restraining order against another individual that would escalate the threat of violence.

Prioritize Threats

As threats are identified, the next step is to prioritize them. Start by putting the threats on a grid, with one bar being the likelihood of the exposure and the second being the potential severity of the risk. If you have threats that are high likelihood and high potential severity, those are your priorities.

Potential priorities include:

  • Active shooter training
  • Emergency evacuation plans
  • Building security plans and building design for security
  • EAP
  • Work-alone procedures for both the office and field
  • See something, say something
  • Internet resource page

These priorities assist you in developing training and prevention programs to address your biggest risks.

Active Shooter Training

The standard now for active shooter response is RUN, HIDE, FIGHT. The first priority is to try and escape the situation.

RUN

Employees should be trained to think of what their escape path would be if faced with a shooter. People should have multiple options. You need an assembly point that is safe where employees can go and you can figure out who is missing.

HIDE

Train employees on places to hide. Can it be secured? Does it have good air circulation? An office with lots of cubicles can create very limited options both in terms of run and hide.

FIGHT

When you have no other options, be prepared to fight. Think of potential weapons you could use. Should you provide mace or tasers to certain employees who work alone and could be attacked? The stampede effect works best, as a shooter cannot target multiple targets at the same time. If one person attacks, others will usually join in. Announcing a police presence can also be useful, as many times active shooters kill themselves as police are closing in.

Other Issues

Building floor plans are a very important element of your active shooter program. You should provide building plans to local police and make sure those plans are updated as modifications are made to the building.

See also: Protecting Institutions From Cyber Risk

FEMA has online active shooter training programs that are very detailed and can be downloaded.

Other Security Issues

  • Periodically do walk-around inspections of your secured locations to make sure they are properly secured. Too often, employees prop doors open, especially around loading docks, cafeteria rear doors and smoking areas. The easiest way into your secured building is usually the back.
  • Another area to check is the lighting around your building. Lights go out. Trees and bushes may grow to block lights or security cameras.
  • Keypad locks can be a problem, as you need to change the combination every time you have employee turnover. Card swipes are much better.
  • Police vehicles are a deterrent. Just parking their vehicles in a visible place aids in discouraging violence.
  • Open access counters are necessary for public access, but they sometimes lack a retreat barrier. Make sure you have cameras in the area and ample panic buttons for employees.
  • Having a security camera with a big screen facing outward can be a deterrent. People see themselves on camera, which can deescalate the situation, as they know they are being watched.
  • Safe rooms need to have the ability to withstand time. Perhaps have water available in case people have to shelter in place for an extended period.
  • Work-alone people are vulnerable not only to violence but a personal medical emergency or serious workplace injury. Have a way to track those people.

Impact on Mental Health in Work Comp

According to the World Health Organization, mental health is described as: “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stress of life, can work productively and fruitfully and is able to make a contribution to his or her community.” But the World Health Organization’s definition applies only to part of the population.

At any given time, one in five American adults suffers with a mental health condition that affects their daily lives. Stress, anxiety and depression are among the most prevalent for injured workers. Left untreated, they can render a seemingly straightforward claim nearly unmanageable, resulting in poor outcomes and exorbitant costs.

Increasingly, many in our industry are recognizing the need to do all we can to address this critical issue. We must openly discuss and gain a deep understanding of a subject that, until now, has been taboo.

Four prominent workers’ compensation experts helped us advance the conversation on mental health in the workers’ compensation system during a recent webinar. They were:

  • Bryon Bass, Senior Vice President for Disability, Absence and Compliance at Sedgwick
  • Denise Zoe Algire, Director of Managed Care and Disability for Albertsons Companies
  • Maggie Alvarez-Miller, Director of Business and Product Development at Aptus Risk Solutions
  • Brian Downs, Vice President of Quality and Provider Relations at the Workers’ Compensation Trust

Why It Matters

Mental health conditions are the most expensive health challenges in the nation, behind cancer and heart disease. They are the leading cause of disabilities in high-income countries, accounting for one third of new disability claims in Western countries. These claims are growing 10% annually.

In addition to the direct costs to employers are indirect expenses, such as lost productivity, absenteeism and presenteeism. Combined with substance abuse, mental health disorders cost employers between $80 billion and $100 billion in these indirect costs.

In the workers’ compensation system, mental health conditions have a significant impact on claim duration. As we heard from our speakers, these workers typically have poor coping skills and rely on treating physicians to help them find the pain generator, leading to overuse of treatments and medications.

See also: Top 10 Ways to Nurture Mental Health 

More than 50% of injured workers experience clinically related depressive symptoms at some point, especially during the first month after the injury. In addition to the injured worker himself, family members are three times more likely to be hospitalized three months after the person’s injury. Many speculate that the distraction of a family member leads the injured worker to engage in unsafe behaviors.

Mental health problems can affect any employee at any time, and the reasons they develop are varied. Genetics, adverse childhood experiences and environmental stimuli may be the cause.

The stress of having an occupational injury can be a trigger for anxiety or depression. These issues can develop unexpectedly and typically result in a creeping catastrophic claim.

One of our speakers relayed the story of a claim that seemed on track for an easy resolution, only to go off the rails a year after the injury. The injured worker in this case was a counselor who had lost an eye after being stabbed with a pen by a client. Despite his physical recovery, the injured worker began to struggle emotionally when he finally realized that for the rest of his life he would be blind in one eye. Because his mental health concerns were raised one year after the injury, there were some questions about whether he might be trying to game the system.

Such stories are more commonplace than many realize. They point out the importance of staying in constant contact with the injured worker to detect risk factors for mental health challenges.

Challenges

Mental health conditions — also called biopsychosocial or behavioral health — often surprise the person himself. Depression can develop over time, and the person is not clued in until he finds himself struggling. As one speaker explained, the once clear and distinct lines of coping, confidence and perspective start to become blurred.

In a workers’ compensation claim, it can become the elephant in the room that nobody wants to touch, talk about or address. Organizations willing to look at and address these issues can see quicker recoveries. But there are several obstacles to be overcome.

Stigma is one of the biggest challenges. People who realize they have a problem are often hesitant to come forward, fearing negative reactions from their co-workers and others.

Depictions of people suffering from behavioral health issues in mass media are often negative, but are believed by the general public. Many people incorrectly think mental health conditions render a person incompetent and dangerous; that all such conditions are alike and severe; and that treatment causes more harm than good.

As we learned in the webinar, treatment does work, and many people with mental health conditions do recover and lead healthy, productive lives. Avoiding the use of negative words or actions can help erase the stigma.

Cultural differences also affect the ability to identify and address mental health challenges. The perception of pain varies among cultures, for example. In the Hispanic community, the culture mandates being stoic and often avoiding medications that could help.

Perceptions of medical providers or employers as authority figures can deter recovery. Family dynamics can play a role, as some cultures rely on all family members to participate when an injured worker is recovering. Claims professionals and nurses need training to understand the cultural issues that may be at play in a claim, so they do not miss the opportunity to help the injured worker.

Another hurdle to addressing psychosocial issues in the workers’ compensation system is the focus on compliance, regulations and legal management. We are concerned about timelines and documentation, sometimes to the extent that we don’t think about potential mental health challenges, even when there is clearly a non-medical problem.

Claims professionals are taught to get each claim to resolution as quickly and easily as possible. Medical providers — especially specialists — are accustomed to working from tests and images within their own worlds, not on feelings and emotional well-being. Mental health issues, when they are present, do not jump off the page. It takes understanding and processes, which have not been the norm in the industry.

Another challenge is that the number of behavioral health specialists in the country is low, especially in the workers’ compensation system. Projections suggest that the demand will exceed the supply of such providers in the next decade. Our speakers explained that, with time and commitment, organizations can persuade these specialists to become involved.

Jurisdictions vary in terms of how or whether they allow mental health-related claims to be covered by workers’ compensation. Some states allow for physical/mental claims, where the injury is said to cause a mental health condition — such as depression.

Less common are mental/physical claims, where a mental stimulus leads to an injury. An example is workplace stress related to a heart attack.

See also: New Approach to Mental Health  

“Mental/mental claims” mean a mental stimulus causes a mental injury. Even among states that allow for these claims, there is wide variation. The decision typically hinges on whether an “unusual and extraordinary” incident occurred that resulted in a mental disability. A number of states have or are considering coverage for post-traumatic stress among first responders. The issue is controversial, as some argue that the nature of the job is, itself, unusual and extraordinary and that these workers should not be given benefits. Others say extreme situations, such as a school shooting, are unusual enough to warrant coverage.

What Can Employers Do

Despite the challenges, there are actions employers and payers are successfully taking to identify and address psychosocial conditions.

For example, Albertsons has a pilot program to identify and intervene with injured workers at risk of mental health issues that is showing promise. The workers are told about a voluntary, confidential pain screening questionnaire. Those who score high (i.e., are more at risk for delayed recoveries) are asked to participate in a cognitive behavioral health coaching program.

A team approach is used, with the claims examiner, nurse, treating physician and treating psychologist involved. The focus is on recovery and skill acquisition. A letter and packet of information is given to the treating physician by a nurse who educates the physician about the program. The physician is then asked to refer the injured worker to the program, to reduce suspicion and demonstrate the physician’s support.

Training and educating claims professionals is a tactic some organizations are taking to better address psychosocial issues among injured workers. The Connecticut-based Workers’ Compensation Trust also holds educational sessions for its staff with nationally known experts as speakers. Articles and newsletters are sent to members to solicit their help in identifying at-risk injured workers.

Continuing communication injured workers is vital. Asking how they are doing, whether they have spoken to their employer, when they see themselves returning to work reveal underlying psychosocial issues. Nurse case managers can also be a great source of information and intervention with at-risk injured workers.

Changing the workplace culture is something many employers and other organizations can do. Our environments highly influence our mental health. With the increased stress to be more productive and do more with less, it is important for employers to make their workplaces as stress free as possible.

Providing the resources to allow employees to do their jobs and feel valued within the organization helps create a sense of control, empowerment and belonging. Helping workers balance their work loads and lives also creates a more supportive environment, as does providing a safe and appealing work space. And being willing to openly discuss and provide support for those with mental health conditions can ensure workers get the treatment they need as soon as possible.

As one speaker said, “By offering support from the employer, we can reduce the duration and severity of mental health issues and enhance recovery. Realize employees with good mental health will perform better.”

To listen to the full webinar on this topic, click here.