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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.

 

How Crucial Is Trust in Workers’ Comp?

Your employee was just injured at work. He is in pain, cannot perform regular job duties and is unsure how quickly he can return to work. His mortgage, medical care and kid’s tuition payments are due next month. It is a vulnerable time for him, with substantial uncertainty.

When a football player goes down on the field and is carried off, the crowd applauds in support of the player, and the player often returns a smile. When a worker is injured on the job, what happens at the workplace before and after the injury can affect the costs incurred by the employer and the outcome achieved by the injured worker.

Twelve new state studies from the Workers Compensation Research Institute (WCRI) aim to help CFOs and other stakeholders identify ways they can improve the treatment and communication an injured worker receives after an injury, leading to better outcomes at lower costs.

The studies interviewed 4,800 injured workers from across 12 states who suffered a workplace injury in 2010 and 2011 and received workers’ compensation income benefits. The 12 states surveyed were Arkansas, Connecticut, Indiana, Iowa, Massachusetts, Michigan, Minnesota, North Carolina, Pennsylvania, Tennessee, Virginia and Wisconsin. The surveys were conducted during February through June in 2013 and 2014—on average, about three years after these workers sustained their injuries.

The research found that a worker’s fear of being fired after an injury had a large and pervasive effect on costs and worker outcomes, like return to work. The fear of being fired may arise out of the relationship between the worker and the supervisor. If the relationship is low trust, the worker is more likely to fear firing when injured.

To describe the level of trust or mistrust in the work relationship, workers were asked to agree with the statement, “I was concerned that I would be fired or laid off.” Workers were given four possible answers—strongly agree, somewhat agree, somewhat disagree and strongly disagree. Depending on the state, 18% to 33% of workers strongly agreed that they feared being fired when injured.

Overall, workers who were strongly concerned about being fired after the injury experienced poorer return-to-work outcomes than workers without such concerns. Across all 12 states, 23% of those concerned about being fired reported that they were not working at the time of the interview—double the rate observed for workers without such concerns. The following are other findings from workers who were strongly concerned about being fired:

  • Concerns about being fired were associated with a four-week increase in the average duration of disability.
  • Workers who were strongly concerned about being fired had higher rates of dissatisfaction with care (21% were very dissatisfied with care) when compared with workers who were not concerned about being fired after the injury (9%).
  • Workers who were concerned about being fired were much more likely to report problems with access to care. Among workers who were concerned about being fired, 23% reported big problems getting the services they or their provider wanted. The rate was double the 10% among workers who were not concerned about being fired.
  • 16% of workers who were strongly concerned about being fired reported large earnings losses at the time of the interview predominantly because of injury, compared with 3% of workers who were not concerned about being fired.

What do these findings really signify? The following are some alternative possibilities:

  • Workers reporting a strong fear of being fired might know they have a difficult relationship with their supervisor. That difficulty might translate into fewer opportunities to return to work, or more active management of the nature of medical care and the selection of medical care providers.
  • The worker may be exaggerating the possibility of termination, being a pessimist by nature, and that tendency to overreact might characterize the workers’ general performance on the job—perhaps resulting in fewer return-to-work opportunities and more active management of the care by the payers.
  • The worker may be more likely to retrospectively report a fear of being fired if the worker has had a poor outcome. Poor outcomes color the worker’s view of most events in the course of the claim. Conversely, workers who have experienced excellent outcomes tend to see events in the course of handling the claim in a much more positive fashion.

This is not the first time we looked at trust as it relates to workers’ compensation. A study we did several years ago on attorney involvement, which was covered by CFO magazine, looked at why injured workers hired attorneys. The character of the employment relationship, for example, was a factor for the 23% who strongly agreed that they hired attorneys because they feared being fired or laid off. 15% also strongly agreed that they needed attorneys because their employer could perceive their claims as illegitimate.

Employers Can Make a Difference

WCRI contacted Lisa Healy, who is a manager of claims at AGL Resources, a natural gas-only distribution company in the U.S. She told us that AGL has been very successful in managing and reducing its workers’ compensation costs. In part, she ties this success to practices where employees in the organization feel engaged and trust the company. The following are five things she told us the company is doing to facilitate trust:

  1. Establishing a set of values and a code of conduct with the ability to report those who violate it without fear of retaliation. This gives an organization depth in terms of morals and standards, which appeal to workers of all ages.
  2. Holding claim adjusters accountable for treating injured employees in an honest fashion with dignity and respect.
  3. Encouraging employees to identify possible safety hazards as well as recommend opportunities to improve safety. When workers are encouraged to point out safety issues or offer suggestions on how to improve things and these comments are taken seriously and addressed, trust is formed.
  4. Providing a 24/7 nurse triage program to speed treatment for injured employees so they get the care they need as soon as possible. The employee can contact the nurse triage line immediately after feeling a twinge of pain or sustaining an injury that doesn’t require emergency treatment. This service not only ensures the employee gets the right care immediately, it also cuts down on unnecessary visits to the physician when the employee can use self-care treatments such as ice, rest, elevation or an aspirin.
  5. Promoting early return to work with transitional duty positions whenever possible. Research has shown that the longer a worker is out, the harder it is to for the worker to return―not to mention that the costs go up the longer that person is out, so getting him or her back quickly shows the worker you care and is good for the worker and the employer.

The WCRI research is an important first step in realizing how important trust is between employee and employer to ensuring good outcomes when the employee is injured on the job. Additional studies by WCRI and others will provide further information on which policymakers can base appropriate measures. But employers can act now, as AGL Resources has demonstrated, to improve trust while lowering their workers’ compensation costs — through early intervention, putting safety first, effective return-to-work programs and access to medical care.

A How-To on Nurse Case Management

Nurse case management (NCM) has a powerful impact on workers’ compensation claim cost and outcome. Positive results of nurse involvement have long been anecdotally accepted, but widespread evidence of nurse impact has not emerged, and objective proof of value is still missing. Several factors account for this.

Inconsistent Referrals

For one thing, NCMs are usually considered an adjunct to the claims process, called upon in sticky situations. Too often, referrals to nurses is a last resort rather than an integral and standardized part of claim management. When claims adjusters have the sole responsibility to refer to NCMs, it can be subjective, uneven and therefore unmeasurable.

Besides receiving referrals for sundry issues at different points in the course of the claim, nurses have not clearly articulated their case management interventions. Claims adjusters sometimes misunderstand the nurses’ approach. However, consistent referrals and standardized procedures can bring about major change.

Consistent referrals

Referrals to NCM should be made based on specific medical conditions in claims such as comorbidity like diabetes or problematic injuries like low back strains that tend to morph into complexity and high cost. Specific risky situations found in claims data should automatically trigger NCM notification.

A recent article published in Business Insurance, “Nurses a linchpin in reducing workers’ comp costs,” points out how Liberty Mutual has developed a tool that notifies claims adjusters of cases that would most benefit from a nurse’s involvement. Decision burdens for claims adjusters are eliminated. Referrals to NCM are automatic based on specific high-risk situations found in the claim. Inconsistency disappears, and several benefits evolve from this approach.

Process standardization

An operational process can be dissected and categorized, thereby gaining better understanding of its components and relative importance. Review the data to determine which medical conditions in claims result in longer disability, lower rates of return to work and, of course, higher costs. Select the conditions in claims that should activate an NCM referral.

An example is a mental health diagnosis appearing in the data well into the claim process. A mental health diagnosis appearing during the claim for a physical injury such as a low back strain is a strong indicator of trouble. The injured worker is not progressing toward recovery. However, the only way to know this diagnosis has occurred in a claim is to electronically monitor claims on a continuous basis.

Data monitoring

To identify problematic medical situations in claims and intervene early enough to affect outcome, the data should be monitored continually. Clearly, this is an electronic, not a human function. When the data in a claim matches a select indicator, an automatic notice is sent to the appropriate person.

Standardized procedures

Catching high-risk conditions in claims is just the first step. NCM procedures must be established to guide responses to each situation triggered. Standardized procedures should describe what the NCM should evaluate and advise possible interventions. Such processes not only explain the NCM contribution, they assist in documentation and are the basis for defining value.

Measuring value

NCM has been under-appreciated in the industry because measuring apples-to-apples cost benefit has been impractical. When claims adjusters decide about referring to NCMs and individual nurses create their own methodology, variables are endless and little is measurable.

In contrast to the subjective approach, specific conditions in claims found through continuous data monitoring can automatically trigger a referral to the NCM. In response, the nurse is guided by the standard procedures of the organization. When referrals are based on specific conditions in claims and response procedures are delineated, outcomes can be analyzed and objectively scored.

7 Ways to a Better Work Comp Plan

Although some improvements in workers’ compensation claim results require large investments, resources and complex implementation phases, others require more commitment than dollar investment and are simple in execution yet sublime in positive impact. The seven suggestions that follow are field-tested and proven effective. These seven will not only improve the results of your work comp program but will enhance workers’ respect for their jobs and increase cooperative attitudes. Best of all, these seven can be initiated quickly and with moderate to low effort:

Quick-Tip: Seven Suggestions + Negligible Resources = Zero Excuses

1) Before and after each shift, supervisors can ask if anyone is hurt. This is easy to implement where crews already have before and after meetings. By asking the question, supervisors remind employees that proper work comp reporting is a job requirement. The question also discourages workers who arrive with an existing problem from making it worse on the job or blaming it on the job. This can also reduce late reports. If any injury or illness is identified, then it can be managed immediately.

2) Provide injured employees with a “rights and responsibilities” manual that is branded with the company logo. Many state WC offices provide adequate templates for this purpose. The manual serves as a reminder to employees that the WC process is connected to their employer and their job.

3) Devise a simple monthly WC/safety summary report that goes to executive management. Place a copy on public bulletin boards so staff is aware that executives monitor the related programs. This promotes the seriousness of WC and safety.

4) Work with your third-party administrator (TPA) or insurer to institute a “no fill” list of dangerous narcotic prescriptions that will automatically trigger a refusal and review by appropriate medical resources. Most claim organizations have such lists already. It is a matter of demanding this level of service from your claims or managed care vendor.

5) Require supervisors to make weekly calls to employees out on temporary total disability (TTD) and have weekly chats with employees on modified duty. This would be a simple general talk to ask how they are doing and if they need anything. This is a powerful motivator and reminder of the employee’s value and the fact that a return to their regular job is anticipated. It can also identify problems in the claim that need to be addressed.

6) Write a simple standard “Return to Work (RTW) Expectation” letter that will immediately be given to every claimant’s treating doctor. This will cause doctors to recognize your transitional duty program, understand their expected role and enhance cooperation. The letter will reduce the likelihood of a claimant’s refusal to participate in early RTW and reduce the reliance of doctors on a claimant’s version of RTW opportunities.

7) Make employees aware of WC costs in personal terms. “Dollars” are not as meaningful as referring to units produced or operating time. For example, if employees are aware they work the first 45 minutes of every shift or produce a certain number of pieces per shift, week or month just to cover WC costs they will relate to the problem. Track costs creatively to have impact.

Give these a try. Commit to changing the WC perspective in your organization. My experience says it will pay off.