Tag Archives: return-to-work

Value of Onsite Physical Therapy

Physical therapy can be one of the biggest cost drivers of a workers’ comp claim. In addition to the treatment itself are the expenses for travel and the employee’s time away from work. Onsite clinics can reduce the expenditures. They are cost-prohibitive for all but the largest companies, but many organizations are starting to turn to an alternative that combines the need for easily accessible PT at a cost comparable to or lower than clinic-based therapy.

Called therapy on demand, onsite PT involves a physical therapist going to the injured worker’s worksite — or home, in some cases — setting up equipment he brings and spending an hour focused solely on a single injured employee. Contrary to what some industry practitioners fear, the logistics are fairly simple.

“All we really needed to provide was a room that looks like a big closet; a room big enough to fit a massage table,” said Sandra Palacio, a claims adjuster at Royal Caribbean International. “We had several meetings before we put this in place. We tested it out for the first week or two, got great feedback and have continued to use it. It’s been a great experience.”

See also: Therapy Charges Are Being Inflated  

Royal Caribbean teamed up with OnSite Physio, a mobile physical medicine company, to treat injuries sustained by the cruise line’s newly hired dancers and actors who train at a Miami-based facility. With the need to keep the entertainers away from work as little as possible, onsite PT has been a natural fit.

“The dance studio is a unique system where they are only here for four to six weeks, so we need to have medical appointments on a fast basis,” Palacio said. “OSP has been great in that they come to us, get the person treated with PT, and injured workers are back doing their normal daily activities within an hour.”

The fact that the workers can stay at their workplace for treatment eliminates the costs for travel and lost work time. Some companies have reported savings of as much as 30% by using onsite PT services. One, Marriott International, will discuss the results it has seen during a session at the National Workers’ Compensation and Disability Conference & Expo, Dec. 2, in New Orleans. (For a reduced registration rate, visit www.onsite-physio.com.)

Focused PT

Among the cost savings reported are fewer PT appointments needed. The one-on-one attention given to each injured worker — often by the same therapist for the duration of the treatment — and being at his workplace allows the therapist to target each patient’s unique problems and job tasks, which can result in quicker recoveries.

“In a clinic, I might work with Mrs. Smith for 10 minutes, then Mr. so-and-so, then Mr. Brown. It’s this constant juggling act while you are in the clinic because, unfortunately, that’s just the model of outpatient PT,” said Daniel Sanchez, a physical medicine expert and a founder and VP of operations for OSP. Working onsite, “there is an ‘aha’ moment, when you realize you can do so much more with this injured worker than you ever could in a clinic. You have that one-on- one time with the patient so we get to really see and put into practice our treatment alongside what it is they do. We can perform therapy that is more meaningful, treatment that is work-related and more transferable to the real world. In a clinic, you have to simulate those things.”

RTW

A key difference between clinic-based PT and onsite is the focus on returning the employee to work. Sanchez makes the analogy of treating an athlete. “If the quarterback for the Jets gets a sprained ankle…what do they have onsite for the injured worker?” he asked. “They have people who specialize and treat them to get them back to their job. They are worried about whether the quarterback can get onto the field and do specific things. All of his treatment is around that.”

That same type of thinking is at play with onsite PT companies such as OSP. One of its clients, for example, is a solid waste disposal company. While the workers in that industry no longer do as much manual labor as they did years ago, workers nevertheless sustain injuries. Repetitive motion injuries to the hand or elbow are typical, as are twisted knees and sprained ankles from getting off a truck improperly.

See also: Employers Solving Healthcare Crisis One Onsite Clinic at a Time  

“If I say, ‘this is a garbage worker,’ and I am in a clinic, I used to think I knew what that meant. Not until I did a ride along and looked at how they are pushing, pulling, spending time sitting in the heat, did I understand what the job entails,” Sanchez said. “In a clinic, I might have that worker going up and down steps. Onsite, I can train him right on that step. It’s the actual piece of equipment he uses, so his treatment is 100% functional. We’re taking the time to really understand what they do and tailor the therapy to it.”

While onsite PT is not necessarily the best option for every injured worker, advocates say it offers many advantages over clinic-based therapy. “I definitely see this as a great benefit to companies that have a lot of workers’ comp claims because they can have the worker at the office, have OSP come and within an hour that worker can be back to work instead of the worker having to leave the job early just because he has to travel early and probably is not able to return that day,” Palacio said.

Return to Work Remains a Problem

According to one published report, (WorkCompCentral, March 4, 2016, “$100 Million in Workers Benefits Sits Unused”), only 3,955 checks have been issued to injured workers from the Return to Work (RTW) Fund established in Senate Bill 863. The checks total slightly less than $20 million, leaving an additional $100 million untapped by injured workers. According to regulations of the Department of Industrial Relations (DIR) that administers the fund, workers receive a $5,000 allowance if they have been issued a Supplemental Job Displacement Benefit (SJDB – commonly referred to as a “voucher”). The voucher is issued if the employer at injury fails to make a qualifying offer of employment to the worker.

While the provenance of the RTW Fund has been criticized – largely by those not in the room to witness its birth – there are more fundamental issues with the fund and its administration. First, the RTW Fund really has nothing to do with return to work.

It can be fairly assumed that the use of that particular section of the Labor Code – Section 139.48 – was a legal accommodation because there was existing statutory reference to the RTW Fund in Labor Code Section 62.5 – specifically Sec. 62.5(a)(1)(B). Section 62.5 is the Workers’ Compensation Administration Revolving Fund statute. That reference, in turn, was to the RTW Program that was originally created more than 15 years ago in Assembly Bill 749 as a mechanism to partially subsidize certain employers who brought injured workers back to work. The employer subsidy as originally enacted was for wages and worksite modifications. Later, Senate Bill 899 further revised the RTW Program to limit the reimbursement to worksite modifications and to expend funds on an “as available” basis. The RTW Program sunset on January 1, 2010, but while Labor Code Sec. 139.48 was taken out of the code, the reference to the RTW Fund in Sec. 62.5 remained.

See Also: A Physician’s View of ‘Return to Work’

Once one gets past the title of “Return-to-Work Program,” however, there is no evidence to suggest that Sec. 139.48 has anything to do with returning a worker to employment with the employer at injury – or anyone else for that matter:

“139.48. (a) There is in the department a return-to- work program administered by the director, funded by one hundred twenty million dollars ($120,000,000) annually derived from non-General Funds of the Workers’ Compensation Administration Revolving Fund, for the purpose of making supplemental payments to workers whose permanent disability benefits are disproportionately low in comparison to their earnings loss. Moneys shall remain available for use by the return-to-work program without respect to the fiscal year.

“(b) Eligibility for payments and the amount of payments shall be determined by regulations adopted by the director, based on findings from studies conducted by the director in consultation with the Commission on Health and Safety and Workers’ Compensation. Determinations of the director shall be subject to review at the trial level of the appeals board upon the same grounds as prescribed for petitions for reconsideration.

“(c) This section shall apply only to injuries sustained on or after January 1, 2013.”

The history of Labor Code Sec. 139.48 is also influenced by the Commission on Health & Safety & Workers’ Compensation (CHSWC) publication, “Report on the Return-To-Work Program Established in Labor Code Section 139.48” (2009). The most telling aspect of that report was the “alternative” recommendation to the Legislature: “California may wish to consider eliminating the program. California may wish to consider a program that more directly assists injured workers who are unable to return to their previous jobs.” (p.7) Given that the program sunsetted roughly eight months later, the commission’s recommendation is almost prophetic.

Three years later, as required by SB 863, the DIR conducted an independent study to determine how best to structure the RTW Fund in the new and improved Labor Code Sec. 139.48. That responsibility fell upon the ubiquitous RAND Corporation, whose 2014 report, “Identifying Permanently Disabled Workers with Disproportionate Earnings Losses for Supplemental Payments” is the foundation for the current RTW program. Among its recommendations were to make eligibility for the program dependent on receiving a voucher. According to RAND, approximately 20% of injured workers receiving permanent disability benefits receive a voucher. (p. 12) Under RAND’s scenarios, and anticipating utilization of the RTW fund at the same approximate levels as the vocational rehabilitation program repealed in 2004 by Assembly Bill 227 rather than their observed voucher utilization figures, RAND estimated roughly 24,000 injured workers would access the RTW Fund, thus resulting in about $5,000 per recipient to exhaust the $120 million annual assessment.

So while that explains where we are today, it also raises questions about whether the current RTW program suffers from the same lack of awareness that caused its statutory predecessors to go quietly away. But that also raises the bigger issue: What has happened to re- employment as an objective of the system over the past 20 years?

The history of vocational rehabilitation in California’s workers’ compensation is a long one – culminating in the repeal of the mandatory vocational rehabilitation program in AB 227 and the repeal of vocational rehabilitation as a compensable benefit with the amendment to Labor Code Sec. 3207 in SB 899. Legislative efforts trying to suggest that return to work is still important in the workers’ compensation system have largely been limited to the voucher, an at-best-meager program that is intended to try to put the injured worker on the path toward gaining skills to find new employment. In no way, however, is it as robust as the former vocational rehabilitation program. It is, regrettably, a $6,000 check, with some restrictions, that is intended to finalize the severing of the tie between an injured worker and the employer at injury.

See also: Return to Work Decisions on a Worker’s Comp Claim  

To paraphrase Will Turner in Pirates of the Caribbean, “That’s not good enough!”

As we move forward and discuss a whole host of issues in the workers’ compensation system, such as utilization review, the use and abuse of opioids, prescription drug formularies, independent medical review and permanent disability ratings, perhaps someone, somewhere, likely in either Oakland or Sacramento, should talk about re-employment of disabled workers.

Not some resurrection of vocational rehabilitation and what became its abuses but, rather, simply how to help workers unemployed due to a disabling injury at work to have the same access to re-employment assistance as disabled or otherwise unemployed workers whose access to re-employment assistance is defined by multiple state and federal programs and not by extracting some form of payment from the employer at injury.

There is no shortage of programs that could provide such assistance. And perceived unintended consequences that expanding the scope of re- employment assistance beyond the employer at injury would increase the number of workers unemployed after a workplace injury are unlikely given the protections of the Fair Employment and Housing Act (FEHA), the Americans with Disability Act (ADA) and Labor Code Sec. 132a.

According to the Workers Compensation Insurance Rating Bureau (WCIRB), in calendar year 2014 roughly $29 million was spent on vouchers. Labor Code Sec. 139.48 assesses $120 million annually. One should ask whether that money would be better spent providing access and coordination to the host of re-employment programs offered by the Department of Rehabilitation, the Employment Development Department (CalJOBS), non-profit private companies, such as Goodwill Industries, that offer re-employment assistance, and a host of federal programs, including those offered from the U.S. Department of Labor, Office of Disability Employment Policy and the Social Security Administration’s Plan To Achieve Self-Support (PASS).

In today’s complex world we simply cannot expect the employer at injury – especially the small to medium-sized employer – to provide all the resources necessary to facilitate meaningful re-employment for injured workers who are permanently disabled. Expanding the concept of re-employment and coordinating programs designed to create jobs for the disabled is a logical step forward to address this problem. No amount of vouchers or RTW fund disbursements will ever be a viable substitute for a job.

The sooner we realize this and look to Sacramento and Washington to break down the barriers created by the workers’ compensation system to full access to re- employment resources for disabled workers, the better.

 

Why Mental Health Matters in Work Comp

At the 2015 Paradigm Innovation Symposium, Renée-Louise Franche, PhD, RPsych, clinical psychologist and consultant in work disability prevention and occupational health, presented a session discussing why mental health issues are so important in workers’ compensation.

Mental health issues in injured workers can no longer be ignored. These conditions are increasingly being recognized as potential risk factors for prolonged work absences, and even for no return to work within the context of workers’ compensation.

Why mental health matters in work disability prevention?

  • One-year prevalence of mental disorders in North America ranges from 12% to 26%. For depression, this is 4% to 7%.
  • Worldwide, mental health conditions are the leading cause of disability in high-income countries, accounting for one-third of new disability claims in Western countries.
  • Mental health-related disability is more frequent in young adults.
  • Workers with mental health conditions have earlier retirements than those without.
  • Studies show that mental health issues have a significant impact on claim duration.
  • Another study showed that, within the first 12 months post-injury, more than 50% of workers experienced clinically relative depressive symptoms at some point during their claim. This is highest during the first month following the accident.
  • There is a significant spillover effect to the families of injured workers. Family members of injured workers are three times more likely to be hospitalized three months after the injury than three months before the injury. It is speculated that the distraction of the injured family member leads to unsafe behaviors.

What works in return-to-work interventions?

  • It is important to focus on ability and function rather than disability. The symptoms and diagnosis need to be deemphasized.
  • Worker expectations of recovery are the single most-determining factor in the ability to return to work. Attitude and state of mind are important.
  • Suitable and safe modified work and return-to-work coordination must be available.
  • A workplace culture of respect and support helps to promote return to work.
  • Claims-related stress/perceived injustices have a very negative impact on return to work.
  • Purely clinical approaches lead to purely clinical outcomes. There needs to be an integrated approach between the physician and the workplace.
  • There must be considerate early contact with the injured worker and continued contact to maintain job attachment.
  • There should be a return-to-work coordinator to facilitate labor/employer cooperation and ensure the healthcare provider understands the return-to-work goals.

What needs to improve for workers with mental health issues?

  • Access to care is a concern. A quarter of Americans have inadequate access to mental health services.
  • Healthcare for mental health conditions is NOT work-focused. There are limited tools and published standards around return to work.
  • Workers feel stigmatized and disrespected, and that there is suspicion about the legitimacy of their condition.

Best practices for return-to-work for workers with mental health conditions:

  • Facilitation of access to clinical treatment for those who need it. Too often, this treatment is delayed. Delays in treatment will, ultimately, delay recovery.
  • Work-focused clinical interventions.
  • Facilitation of navigation of the systems involved.
  • Improved processes, leading to improved sense of fairness.
  • Early identification and screening to identify workers who are high risk for psychosocial complications, and assigning those claims to specialized adjusters.
  • A case manager who plays an important role in humanizing communications, decreasing adversary feelings, clarifying the claim process, decreasing delays and developing more accurate expectations in the worker.
  • Judicious use of independent medical exams. Injured workers view these as a very adversarial experience, which usually leads to litigation.

Best bets for future investments:

  • Perceived justice. Perceived injustice leads to longer disability, higher pain complaints, more depression and increased narcotic use. It is important to fully explain the workers’ compensation system to injured workers, including the benefits that they will receive and the role of the injured worker in his recovery. People need to be treated with respect and receive information that is clear, accurate and timely.
  • Development of soft skills in the front line claims team. This includes communication skills, conflict-resolution skills and training related to identifying potential mental health issues.
  • Early screening for psychosocial issues so that appropriate intervention strategies can be implemented.

Wanted: Workers’ Comp ‘Warriors’

Employers need to define and fortify the position of workers’ comp manager. It is a sad reality that this job often falls short of the impact and respect it deserves. It owns no distinct professional standard as compared with the role of risk manager, HR manager, safety engineer or even production supervisor, and the role is often added to those positions as an afterthought. Worst of all, employers freely allow vendors (third-party administrator or broker) to assign this job’s process and tasks. I say we retire the current notion of the “workers’ comp manager” and unleash the “workers’ comp warrior.”

Why? Because “warrior” recognizes what should be the employers’ daily fight against a WC system that puts data-driven process and so-called efficiency above personal service and intervention. The term “warrior” does not imply a negative position that simply fights fraud and bad actors… Rather, this is a noble fight that seeks the best and fastest route to employee healing and return to productivity.

Consider that “healing and return to productivity” as an endeavor has been dumbed down by our industry. Vendor preferences in the name of best practices would have you believe the task is met by simply reporting a new loss and leaving the employee at the whim of the claims and managed-care team. In reality, healing and return to productivity is an extremely complicated and personal process that is easily thwarted by the insult and cross-purposes of a claims team seeking “fast track” method while a managed-care team seeks “savings” based on a rigged system of medical reimbursement. Our industry-wide elephant in the room — churning WC claims — evidences a dire lack of ability to “heal and return to productivity.”

A WC warrior fights to ease the gauntlet for employees. She proclaims the hub-position in a turning wheel of WC action while establishing vendors and other aspects as spokes. Other wheel-spokes include employee expectation and responsibilities, supervisory role, top management support and resources, experienced-based allocation of costs, return to work (RTW) culture, medical providers, cooperation, etc. No two employer-wheels are completely alike, but all need a workers’ comp warrior at the center. No single vendor can re-create or support such a turning wheel. Most critically: In practical application, no employee skips the ride to a quality medical healing and return to productivity; however, any ill-intended employee who jumps off early is easily spotted.

Quick Tip: Raise the Bar and Redefine an Employer-Based “Warrior” Position

Key aspects of a “workers comp warrior” include:

– Emphasis on employee advocacy above all else

– Technical knowledge and experience in all the processes and interactions of WC

– Claim-by-claim insight otherwise not available via the common process

– Solutions, options and strategies tailored to each situation

– Real-time interaction, not adhering to adjuster diaries

– Inclusive program with company-wide involvement and awareness

– Learning opportunities seen in a poor claim outcome

– Accepting inevitable frustrations without blaming adjusters, doctors, state laws or employees

– Not falling for the perfect-world bubble that a broker or other vendors might try to claim exists

The ‘CURES’ for Work Comp Claims

When an injured worker submits a claim, it initiates processes aimed at returning the injured worker to gainful and sustainable work at the earliest possible time. In this journey, checkpoints and milestones are the best means to monitor progress. Checkpoints generally relate to visits with a medical practitioner where medical conditions are checked against expectations and, if necessary, treatments are adjusted. Milestones are associated with reaching a goal.

At the first medical appointment, the physician is required to prepare a report for the claims administrator based on a comprehensive medical examination of the injured person, including a review of the medical history. At the same time, the physician can access CURES (Controlled Substance Utilization Review and Evaluation System) to check whether the patient has received any scheduled controlled substances in the prior 12 months. Through this access, the physician can identify an at-risk patient and accordingly establish a treatment plan that considers both medications and adjunctive treatments. Also, if a patient is identified as an addict, he can be referred for rehabilitation and social re-integration. With subsequent medical appointments, the physician can again use CURES to check for any changes to the patient’s scheduled controlled substances usage since his last visit.

The importance of a physician using CURES to check a patient’s use of scheduled controlled substances cannot be overemphasized, especially in workers’ compensation, where a patient may not be forthcoming in sharing comorbidity information because of a lack of trust. Not knowing if a patient is currently taking scheduled controlled substances, the physician could jeopardize the patient by prescribing inappropriate medications.

In addition to the medical profession, CURES is available to Department of Justice investigators and law enforcement agencies to identify persons who visit a number of physicians to obtain supplies of scheduled controlled substances for abuse and diversion (i.e. physician shopping). Pharmacists and numerous regulatory boards from the medical board to the veterinary board also have access to CURES, providing them with the opportunity to monitor the medical profession for aberrant prescribing of scheduled controlled substances.

While states like Florida implemented a PDMP (prescription drug monitoring program) as late as 2011, California has monitored Schedule II controlled substances since 1940 and with the introduction of CURES in 1996 extended its monitoring to include Schedule III and IV controlled substances. Online access to CURES has also been available to the medical profession since 2009. Consequently, California has not experienced the abuse and diversion that Florida has with its “pill mills.”

Access to CURES by claims administrators or their representatives (i.e. third party payers) will not deliver improved quality of care or reduce prescription drug fraud and abuse and will add unnecessary costs through duplication of efforts already being performed by others using CURES. Close monitoring of checkpoints, however, by the claims administrator will provide benefits. Monitoring is accomplished through what is commonly referred to as “encounter data” and includes diagnoses, services performed and medications dispensed along with amounts charged and paid. Diagnoses, medical procedures and pharmaceuticals translated into coding systems such as ICD-10 (International Classification of Disease, 10th revision), HCPCS (HeathCare Common Procedure Coding System) and NDC (National Drug Code) provide excellent opportunities to automate the monitoring of encounter data.

Have claims administrators been able to implement technology solutions to automate the monitoring of encounter data and achieve outstanding results? Over the past two decades, many claims administrators have opted to outsource the management and control of critically important functions such as utilization review, medical bill review and pharmacy monitoring. Many of the outsource organizations only focus on that part of the encounter data that directly applies to their function — for example, pharmacy benefit managers only monitor the pharmacy. But using all the encounter data can promote a vibrant synergy very capable of achieving outstanding outcomes and results for the injured worker.

Losing control of encounter data eliminates the claims administrator’s ability to establish and monitor adherence to best evidence-based practices. When physicians have not adhered to their proposed treatment plans, opportunities to trigger yellow and red flags for investigation are lost.

Claims administrators who have automated the monitoring of their encounter data can assist states in reducing abuse and diversion by monitoring the quantities of medications being dispensed in a progressive or step therapy pain management plan, for example, and encouraging unused supplies to be returned to the physician at the next appointment. This can be achieved at no additional cost to the claims administrator and reduces the quantities of unused or unneeded prescription medications in circulation, which has been the focus of the DEA’s (U.S. Drug Enforcement Agency) “take back” initiatives. To date, the DEA has collected in excess of 1,400 tons of unused medications, which could otherwise have found their way into the illicit drug market.

For as long as the U.S. remains the biggest licit and illicit drug market in the world, claims administrators will remain challenged to deliver on their workers’ compensation claims handling obligations.

With a changing workforce, claims administrators will need to move more and more toward a biopsychosocial approach to managing medical conditions. They must provide quality care at the lowest possible cost, which can only be achieved through the fine analytics of consolidated encounter data.

Capturing encounter data through the claims administrator’s processes and fine analytics will consistently yield the best claims outcomes, from earlier return-to-work to lower costs associated with medical treatment through to automated overseeing of a claim, including provider performance monitoring and evaluation. All of these are the essence of superior workers’ compensation claims management.