Tag Archives: msds

‘High-Performance’ Health Innovators

A particularly pernicious American healthcare myth holds that costs are out of anyone’s control. Health plans and benefits consultants often convince organizational purchasers that costs simply are what they are — and that no better alternatives exist.

Nothing could be further from the truth. In fact, there’s reason to believe that a new crop of “high performance” healthcare innovators could make healthcare more rational. The question is whether employers and unions will embrace the high performers, independent of their health plans. Are they sufficiently frustrated that they’ll step outside the poorer performance conventions placed on them by health organizations invested in the status quo?

The marketplace is exploding with high performance healthcare companies in various high-value niches, founded by evidence-driven leaders with deep subject matter expertise. Each has rethought some clinical, financial or administrative problem and developed a different, better solution — with improved health outcomes or lower cost — than the conventional approach.

See also: High-Performance Healthcare Solutions  

Take musculoskeletal disorders (MSDs), which typically represent 20% of group health spending and 60% of occupational health spending. One company has developed treatment pathways that let it intervene in 80% of cases, and rigorous quality management allows continuous improvement. After more than 100,000 patient encounters with commercial populations, the data show that, compared with conventional orthopedic care, its clinicians obtain dramatically better pain reduction, enhanced range of motion and improved activities of daily living. Recovery time and costs are cut in half. Three-quarters of surgeries are eliminated, imaging drops by half, and injections are reduced by more than one-third. The organization is so confident in its capabilities that it will financially guarantee a 25% reduction in MSD costs. This usually translates to at least a 4% to 5% savings in total healthcare spending. True savings are generally higher.

Similar results are available within a variety of high cost sectors. Managing drugs can drop total spending by 7%. Managing imaging reduces costs another 6%. Similar savings, with enhanced health outcomes, are available by properly managing cardiometabolic care, oncology, dialysis, allergies, surgeries, etc. Managing financial processes, like moving to reference-based reimbursement and closely reviewing medical claims, are additional ways to streamline healthcare costs.

Why, you ask, doesn’t your health plan make these services available? It’s not currently in their interest, because, at the end of the day, most health plans make more if healthcare costs more. And they’re usually not interested in antagonizing their network providers, even if they’re not high performers.

Resistance to change

Worse, while a growing group of benefits advisers and managers are seeking new value through the innovators, the bonds between mainstream health plans, benefits advisers and employer benefits managers are usually rock solid and resistant to change. If an alternative solution is firmly in the interests of the health plan and the adviser, the benefits manager may be loath to disrupt that relationship, especially if the new solution is going to need care and feeding beyond what’s currently required. So even if the high-performance offering delivers better health and significant savings, getting it on the plan may be a hard sell.

Even so, the budgets and patience of many businesses and unions are exhausted. Think school districts: They’re often willing to think differently if it’ll relieve their financial pressure, especially if they’ll get better health outcomes in the bargain. They’re receptive to considering programs that can deliver better results.

That’s the way these programs — think of them as modules — are entering the marketplace now. An employer says, “Sure, let me amend my summary plan document and I’ll try the musculoskeletal disorder management and the claims review modules. If those work, let’s think about imaging.” When the savings materialize, they’ll gush to their benefits manager pals. So, one program at a time, healthcare will begin to change.

Now imagine what might happen if you put several of these modules under a single health plan structure. You could pass along the cumulative savings of each in the form of lower health plan costs. Consider what might happen if you could, say, guarantee a benefits manager a 25% reduction over current healthcare spending, with better outcomes. That would be an offer that she couldn’t refuse, especially if her CFO heard about it.

See also: Healthcare Debate Misses Key Point  

The high-performance modules I’ve described are in the market now and are available to innovative purchasers. The trick is identifying and vetting them so purchasers are comfortable that they actually deliver. The larger idea of high-performance health plans is under development now, as well, and we should start to see some in early form in the next year or so.

The results consistently available in these high-performance healthcare organizations’ offerings clearly reflect the tremendous, corrosive slop in the U.S. healthcare system and represent a better way forward. If these high-performance modules can get a foothold in the marketplace, their spectacular value propositions might overcome the health industry’s relentless focus on driving high-priced excess.

That could begin to change everything for the better.

Better Management of Soft-Tissue Injuries: A Case Study

The Gatesway Foundation, a nonprofit organization in Tulsa, OK, had seen an increase in its work-related musculoskeletal (MSD) cases, which the U.S. Department of Labor and Occupational Safety and Health Administration (OSHA) define as injuries of the muscles, nerves, tendons, ligaments, joints, cartilage and spinal discs. These types of disorders, commonly referred to as soft tissue injuries as well as sprains and strains, most often present as injury or pain of the back, neck, shoulder or knee and are a major source of disability. According to the 2010 report by the Bureau of Labor Statistics, the disorders account for 29% of total cases.

The Gatesway Foundation was experiencing both an increased frequency of claims and a rise in the cost of treatments, so, in 2012, the foundation began employing the EFA’s soft-tissue management program to compare pre- and post-loss data to accurately distinguish if there is acute pathology after a work-related injury. The program determines if pathology arises out of the course and scope of employment. A baseline test is conducted at the time of hire and compared with post-incident tests. State workers’ compensation laws may have many differences but have one thing in common: The employer is only responsible for returning the individual to pre-injury status. 

In the past, determination of pre-injury status, especially for soft tissue injuries, was often guess work.  Having objective findings can prevent costly misdiagnosis, unnecessary or inappropriate surgery, prolonged treatment periods and fraudulent claims. Employees also receive better treatment for compensable conditions.

The Gatesway Foundation began its program in April 2013 and had no MSD claims or OSHA recordables until Sept. 17, when a 52-year-old health care provider reported that a patient had fallen on her.  Initially, her complaints included her arm and shoulder. By the time she saw a doctor, her pain included her back.  The physician ordered a post-loss test for comparison with the baseline test.  The comparison showed a minimal increase in lumbar muscle spasms that decreased with stretching.  Two sessions of physical therapy were prescribed, and the employee has returned to work.

In the adjuster’s words, “This could have involved a great deal more expense and possible lost time without this information” from the baseline test. The program enabled the physician to have objective information and allowed the injured worker to receive appropriate care.

The program has drastically reduced the Gatesway Foundation’s soft-tissue-related workers' compensation claims.  The year prior to initiating the program, the foundation’s developed losses were $1 million. In the first six months of the policy year, before starting the program, the developed losses were $500,000. With the implementation of the program, the developed losses in the last six months of the policy year were $30,000.

A detailed analysis of the data revealed a dramatic decrease in the cost per claim when a baseline test was conducted.

Average Cost of Sprain Strain Claim Since Sept 2011
Without Baseline $18,794
With Baseline $2,241
% Reduction With Baseline 88%

This resulted in a dramatic return on investment (ROI)

Reduction in Claims Cost $316,544
Total Program Cost $9,200
ROI (Impact to Claims) 3,441%

The utilization of this book-end strategy allows for unprecedented access to information and allows for better treatment.

Myths About Obamacare and Workers’ Comp

The Obama administration has said that the Patient Protection and Affordable Care Act, enacted into law in 2010 and scheduled to take effect on Jan. 1, will reduce workers’ comp claims because so many additional people will be covered under personal insurance policies. But there is reason to think otherwise.

The first issue is that so many companies are reducing the insurance they offer employees or are cutting employees’ hours so much that they fall below the law’s threshold, so employees don’t have to be covered at all. Employees who aren’t covered under corporate policies or who are underinsured are more likely to make workers’ comp claims.

Here are just a few examples from National Review Online:

SeaWorld used to let part-time employees work as many as 32 hours per week, but the company is dropping the limit to 28 hours to keep them under the 30-hour threshold at which it would be required to provide health insurance under Obamacare. More than 80 percent of the company’s thousands of employees are part-time or seasonal.

Carnegie Museum in Pennsylvania scaled back the hours of 48 of its 600 part-time employees to less than 30 hours a week to sidestep the mandate to provide health-care coverage

Virginia Gov. Bob McDonnell decided to limit the state’s part-time employees to 29 hours per week.

Brevard County, Florida told a local television station that the county’s 300-plus part-time employees will be “capped at something less than 30” hours to save the county about $10,000 per employee in health insurance.

Fatburger  announced that franchises had begun making efforts to keep employees under the 30-hour threshold, including some franchises’ engaging in “job sharing.”

As more companies shift to shorter work weeks, you can expect claims under workers’ comp to keep climbing.

Proponents of Obamare still say it will decrease workers’ compensation costs in several ways, including through the elimination of lifetime caps on medical insurance coverage. The argument is that these caps on employees’ private policies pushed them to file workers’ compensation claims. Really? Many of the leading cost drivers for work-related injuries are Musculoskeletal Disorders (MSD), better known as soft tissue injuries.  According to the Bureau of Labor Statistics (BLS), soft tissue injuries (sprains and strains) accounted for 40% of all work-related injuries that resulted in lost days of work. I do not believe that these types of injuries would affect the lifetime maximum for health insurance, which is typically $1 million.

Proponents also note that a healthcare insurer can no longer refuse to provide coverage because of preexisting conditions, conditions they claim were often not covered by private healthcare and thus encouraged employees to seek coverage under workers’ compensation. While this is a good point, the National Review’s examples show that many people are losing healthcare coverage or will see it reduced, meaning that there will be a greater likelihood of workers’ compensation claims. Yes, there are penalties for not securing healthcare coverage, but they are modest, especially in the early years of Obamacare, and there is no real mechanism for enforcement. The IRS has the responsibility for collecting penalties but has no true powers to do so.

How are people supposed to afford care if their hours have been cut?  You guessed it: workers’ compensation.

What Do New Workers' Compensation Reforms Sweeping the Country Have in Common?

AOECOE – Not Just Another Acronym

California Senate Bill 863 was passed in the fall of 2012 and went into effect on January 1, 2013. Senate Bill 1062 was just signed into law by Governor Mary Fallin of Oklahoma and will take effect January 1, 2014. On April 30, 2013, Tennessee Governor, Bill Haslam, signed into effect Senate Bill 200. House Bill 154 is expected to go into effect in Georgia in July, 2013. What are these bills? The first of many sweeping Workers' Compensation reforms. A common theme in these bills and other pending reforms is to level the playing field for employers and accept only those claims that arise out of the course and scope of employment, AOECOE.

A well-known term of art in the Workers' Compensation arena, AOECOE is not just an acronym. It is transitioning from a term of art to a statement with teeth, as reforms are actually including such wording into bills. The purpose of doing this is to establish whether an employee's alleged injury is work-related and happened in the course and scope of employment, or whether the injury is non-industrial or affected by third parties.

Workers' Compensation is a no fault system and thus benefits the injured worker, as, in order to receive benefits, he or she does not need to prove that the employer was negligent. However, it is the injured party's burden to show that the injury did, in fact, occur while at work, while employed as an employee and while undertaking some activity for the benefit of the employer. The injury itself must have been caused by the accident or employment conditions, and not from some other non-industrial related factors or degenerative factors.

The determination of AOECOE has long been an OSHA policy. OSHA's Injury and Illness Recordkeeping Regulation Section 1904.5: Determination of work-relatedness contained under section (a) basic requirement states in order for an injury or illness to be work-related an event or exposure in the work environment is either caused or contributed to the resulting condition or significantly aggravated a pre-existing injury or illness. Work-relatedness is presumed for injuries and illnesses resulting from events or exposures occurring in the work environment.

California's SB 863 was signed into law by Governor Brown on September 18, 2012, for a January 1, 2013, effective date. While certainly not the first bill to consider AOECOE issues, it is one of the most significant Workers' Compensation reform bills to specify AOECOE language. SB 863 calls for an Independent Medical Review (IMR). While this process may be problematic for an employer, since an IMR can be requested only by an injured worker following a denial, modification, or delay of a treatment request through the utilization review (UR) process, the bill specifically states that this does not apply if the injury is in question for AOECOE reasons.

On May 8, 2013, Oklahoma Governor Fallin signed into law historic Workers' Compensation reform, Senate Bill 1062. The bill defines compensable injury as arising out of the course and scope of employment and does not include: any strain, degeneration damage or harm to disease or condition of the eye or musculoskeletal structure or other body part resulting from the natural result of aging, osteoarthritis, degenerative process or pre-existing, except if a treating physician clearly confirms an identifiable and significant aggravation arising out of AOECOE.

On April 29, 2013, Tennessee Governor Haslam signed a Workers' Compensation reform bill into law, SB 200. It specifies that injuries arise out of and in the course and scope of employment only if proven by a preponderance of evidence that employment contributed more than 50% to causing the injury, AOECOE.

In my experience, the majority of injuries are real, but they are not AOECOE. Injured parties may exaggerate the severity and extent of their injuries or may attempt to hide pre-existing conditions. So how do any employers determine if injuries are AOECOE? The answer is simple. They need to ascertain what the employees' statuses are pre-injury. This is effectively done with baseline testing.

Baseline testing is a bookend solution. To be effective, it should be objective, meet the criteria for evidenced-based medicine, be job related and consistent with medical necessity. It needs to be specific to the metrics being evaluated. A good example of a specific baseline test that is recognized in some jurisdictions by statute is audiometric testing. Hearing tests are routinely done in environments with high noise exposure to determine a baseline that is referenced once a claim is filed. This is commonly referred to as the lock box defense.

Audiometric testing is beneficial for documenting hearing loss but is not designed to address other conditions such as musculoskeletal disorders (MSD). MSDs are the most frequent and costly claims for an employer. In order for a baseline test to be utilized for MSD, it must not only be objective and reproducible, it must contain measurements to ascertain electromyography (EMG), range of motion (ROM) and function.

In addition, baseline testing must be legally defensible. In 1990, Congress enacted the Americans with Disabilities Act that outlines what makes a legally defensible test. To be legally defensible, the testing needs to be job-related and consistent with business necessity i.e. the employer must show that it “substantially promote[s]” the business' needs. It must be repeatable, objective and address functionality. Also, since baseline testing is considered to be a medical exam, it needs to evaluate some functions of the job.

Baseline testing is not a post-offer, pre-placement test, as it can not identify disability because the data is not read and no hiring decisions are made with baseline evaluations. When a work-related injury occurs, a post loss test is conducted, at which time the baseline test is read and compared to the post loss results, hence the bookends.

When compared, the results can determine if an injury exists and if it has arisen out of the course and scope of employment, thus determining an employer's true responsibility. Good baseline testing is non-discriminatory and prevents “false” claims. The sweeping Workers' Compensation reforms allow for a new definition of “false” claim: one that is not AOECOE. A false claim no longer means fraud! A proven example of an effective baseline test is the EFA-STM.

Workers' Compensation statutes are helping employers by allowing them to accept the claims that are only AOECOE. Employers need to see that they comply with legislation, and baseline testing now gives them an objective assessment to do just that.

The Healthcare Industry Is Ripe For Baseline Testing

We are very pleased to be able to include the phone interview above. We are able to provide this rich media content through a new, special media partnership with World Risk and Insurance News (WRIN.tv). World Risk and Insurance News is an online video-based insurance news network delivering late-breaking and relevant business-to-business information, analysis and forward-thinking programming for the global risk, insurance and financial services industries.

Workers in the healthcare industry face many risks, and one that consistently arises as a major cost driver is musculoskeletal disorders (MSDs), better known as soft tissue injuries. Because of the difficulty in objectively identifying and subsequently treating these conditions, employers must now consider new options when it comes to risk control.

Patient handling tasks are recognized as the primary cause of musculoskeletal disorders among the nursing workforce. A variety of patient handling tasks exist within the context of nursing care, such as lifting and transferring patients. Nursing personnel have been on the top-10 list of workers with the highest risk for musculoskeletal disorders since 1999, and although the numbers of injured health care workers has decreased, nurses, nurse’s aides, orderlies, and attendants have remained at the top of this list since then.

According to OSHA, in 2010 there were 27,020 cases, which equates to an incidence rate (IR) of 249 per 10,000 workers, more than seven times the average for all industries. In 2010 the average incidence rate for musculoskeletal disorder cases with days away from work increased 4 percent, while the musculoskeletal disorder incidence rate for nursing aides, orderlies, and attendants increased 10 percent. For musculoskeletal disorder cases involving patient handling, virtually all were the result of overexertion, sprain, strain, or tear.

Additionally, according to an American Nurses Association 2012 study, 52 percent of nurses complain of chronic back pain with a lifetime prevalence up to 80% and 38% report having occupational-related back pain severe enough to require leave from work. The same study revealed that 12% of nurses leaving the profession report back pain as a main contributory factor and 20% have reported changing to a different unit, position, or employment because of back pain. In fact, nursing personnel have the highest incidence rate of workers compensation claims for back injuries of any occupation.

Nursing aides, orderlies and attendants incurred occupational injuries or illnesses in 48% of the musculoskeletal disorder cases involving health care patients. Other occupations with musculoskeletal disorder cases involving health care patients included licensed practical and licensed vocational nurses, emergency medical technicians and paramedics, personal and home care aides, health care support workers, radiologic technologists and technicians, and medical and health services managers.

A significant challenge in the healthcare industry is nursing home workers. Providing care to residents is physically demanding work. While the cost of musculoskeletal disorders to the health care industry is staggering, it has an even greater impact in nursing homes. Caregivers often suffer physical pain from their injuries and subsequently lose time from work. Nursing home facilities lose stability from caregivers’ absences, and residents suffer the loss of caregivers who understand their individual needs.

According to the CDC, the financial burden of back injuries in the healthcare industry is estimated to add up to $20 billion annually. These costs include higher employer costs due to medical expenses, disability compensation, and litigation. Nurse injuries also are costly in terms of chronic pain and functional disability, absenteeism, and turnover. Furthermore, this is an aging workforce (average age is 46.8 years), and there is an expected 20% shortage of personnel by 2015 and 30% by 2020. The indirect consequence is that back claims will likely increase as the workforce ages and new, inexperienced workers are hired to fill the shortage.

This is such a problem that as of April 2012 the following states — California, Illinois, Hawaii, Maryland, Minnesota, New Jersey, New York, Ohio, Rhode Island, Texas, and Washington — have enacted safe patient handling legislation. However, prevention may not always work for this industry. The teaching of manual lifting techniques has not been successful in affecting injury rates for nurses. This is largely due to the fact that patient characteristics and workplace environment may make it difficult to employ correct techniques. In addition, even if proper techniques are used, patient weight may exceed National Institute for Occupational Safety and Health lifting guidelines.

Why Baseline Testing Is The Solution For Employers
Employers are only responsible for work-related injuries that arise out of the course and scope of employment. The employer needs only to return the injured worker to pre-injury status, but it is virtually impossible for employers to objectively document an employee’s pre-injury status. The only way the Healthcare industry can manage their musculoskeletal disorder cases is by adopting the the EFA-STM baseline test, which is an objective, evidence-based tool designed to measure the functional status of an injured worker and to identify return-to-work opportunities.

The EFA-STM Program is specifically customized for an employer’s current workforce as well as new hires and complies with all ADAAA and EEOC regulations.

It begins by providing baseline soft-tissue injury testing for existing employees, as well as new hires. The data is maintained off-site and 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, thereby granting control of claim when this is often not the case. The subsequent comparison objectively demonstrates whether or not an acute injury exists. If so, the claim is accepted for the exact injury, or aggravation delta between the post-loss and baseline tests, thereby limiting liability to only what the employer owes and eliminating the issue of paying for existing or degenerative issues. If no acute pathology is found, then the claim is never accepted. The utilization of this book end strategy allows for unprecedented access to information and allows for better treatment.