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Impact of PTSD on Workers’ Comp Costs

Mental health disorders have emerged as a potentially significant factor in workers’ compensation. This article focuses on potential impacts that post-traumatic stress disorder (PTSD), a mental health condition that some people develop after they experience a shocking, scary, or dangerous event, may have on WC system costs.

In recent years, there has been an increase in legislative activity across the country to broaden or establish eligibility for WC benefits for PTSD. The momentum of such measures has grown, and could be accelerated somewhat, given the spotlight the COVID-19 pandemic has cast on the potential for workers to contract PTSD from their employment—particularly in the healthcare field. In this paper, we review examples of WC benefit eligibility criteria for PTSD, available data and the potential impact of PTSD on overall WC costs, including possible effects stemming from the pandemic and other stressors.

How Do WC Benefit Eligibility Criteria for PTSD Vary by State?

There is much variation in WC benefit eligibility requirements for PTSD between states. The first question we reviewed is whether PTSD—without a corresponding physical injury—is explicitly addressed as being a compensable injury or occupational disease under WC statutes.

  • Statutes may generally address WC for a mental injury or illness in a variety of ways, explicitly exclude mental injuries not accompanied by physical injuries (a mental injury or disability that arises without a physical injury is also known as a “mental-mental” injury) or limit mental-mental injuries to certain situations such as crimes of violence.
  • If PTSD is compensable as a covered injury or occupational disease under a state’s WC statutes, it may be compensable for all occupations or only for some subset of occupations such as “first responders” (e.g., law enforcement officers, firefighters and emergency medical technicians).
  • In the case of first responders, statutes typically reference the PTSD subset of mental injuries.

If a state provides WC benefits for PTSD without a physical injury, what conditions need to be satisfied for it to be a compensable claim?

  • Must the condition result from a specific incident, or can it arise over time as a result of cumulative exposure to several events? (When the condition is brought about by repeated traumatic events, it may also be referred to as continuous traumatic stress disorder, or CTSD.)
  • Must the nature of the traumatic event preceding the PTSD be extraordinary in relation to the average worker’s job experiences, or in relation to other employees in the same occupation?
  • What is the burden of proof required to establish eligibility for WC benefits? For example, must PTSD be proven with clear and convincing evidence or with a preponderance of evidence? Is PTSD associated with a presumption that it arose out of and in the course and scope of employment?
  • What type of healthcare professional may make the diagnosis, and what standards can they use?

Some states have legislative proposals that consider establishing or expanding eligibility for WC benefits resulting from PTSD to first responders or a broader group of occupations. Some others have considered increasing coverage to all occupations under certain conditions. Several states where mental injuries may already be eligible for WC benefits have introduced legislation to provide a presumption that PTSD in first responders occurred in the course of employment.

In jurisdictions where NCCI provides ratemaking services, first responder classes only account for approximately 1.6% of privately insured costs, with most states ranging from 0.5% to 3.0%. Therefore, legislation focusing on first responders may have a relatively small impact on overall privately insured WC costs. But it may have a significant impact for the affected classifications. On the other hand, legislation affecting all classes could have a significant statewide impact.

What WC Data Is Available on PTSD?

WC data on PTSD is limited due to both the relative scarcity of PTSD claim data, in general, and limited data reporting for first responder employer groups. If legislation is enacted making PTSD more readily compensable under WC, the subsequently reported additional data could be used in future PTSD cost impact analyses. Until a significant volume of credible WC PTSD data becomes available, non-WC data may be leveraged.

What Are the Incidence Rates of PTSD?

We can get a general idea of PTSD frequency in the workplace by analyzing incidence rates from published PTSD studies and meta-studies of the general population, first responders, veterans and those in other occupations.

For the general population, a 2016 epidemiological study indicated that 6.1% of American adults experienced PTSD in their lifetime, while 4.7% had it as a condition during the most recent year. The presence of PTSD in the “most recent” year does not indicate when the event or events occurred that led to the condition. So, care must be taken if these prevalence rates are extrapolated to estimate annual WC claim frequency, which is the likelihood that a worker will file a PTSD claim in a particular year and that the claim is accepted.

See also: Workers Comp Trends for Technology in 2021

There have been numerous PTSD studies on first responders. One worldwide meta-analysis estimates a 10% average PTSD rate for first responders overall, where the average rates vary by occupation.

Care is needed when comparing the results of studies that were conducted in varying locations and time periods, and that use differing methods to identify and analyze the incidence of PTSD. Further, it is possible that reported mental illness from traumatic events in the workplace may be increasing relative to levels reflected in past studies.

What About the COVID-19 Pandemic?

While some employees have been working from home, many employees classified as “essential workers” have continued to work at their usual place of employment. This latter group may have faced a higher risk of contracting COVID-19 and possibly experienced more fears and anxiety about becoming infected themselves or infecting their loved ones. In particular, early data suggests that first responders and healthcare workers may have been disproportionately affected by COVID-19—accounting for almost 75% of all COVID-19 claims reported to NCCI as of year-end 2020. Some of these workers have provided direct care to people with the virus, often in overburdened areas. As a result, they may experience significant physical and psychological strain. For example, a sample of 571 frontline workers in the Rocky Mountain region surveyed between April and May 2020 showed 15% to 30% reported traumatic stress.

The myriad of issues faced by first responders and those on the front lines of the pandemic have been well-documented. For example, one writer opines: “Over the last year, there has been the psychological trauma of overworked intensive care doctors forced to ration care, the crushing sense of guilt for nurses who unknowingly infected patients or family members and the struggles of medical personnel who survived COVID-19 but are still hobbled by the fatigue and brain fog that hamper their ability to work.” Extended periods of stressful conditions resulting from the COVID-19 pandemic could mean that these workers may suffer trauma not necessarily from a specific extraordinary event, but perhaps from continuous stress.

Mental health was reported as a significant concern for healthcare workers before the COVID-19 pandemic, and COVID-19 appears to have increased the stress, with 37% reporting “mental health issues” in 2019 versus 41% in 2020. And 58% of healthcare workers say mental health issues have affected their work more since the COVID-19 pandemic began. If any resulting emotional impact persists, it could increase the prevalence of PTSD and CTSD among healthcare workers after the pandemic.

Some other workers, such as nursing home staff, have also disproportionately suffered from COVID-19-related stress. One survey taken between May and June 2020 revealed some of the same adverse conditions for these workers as noted above for healthcare workers.

At this writing, it remains to be seen how COVID-19 will affect the propensity to file PTSD claims in those states that have chosen or will choose to make PTSD or other mental-mental claims eligible for WC benefits.

What About Other Stressors?

The COVID-19 pandemic is an example of a potential large-scale stressor on the WC system because it may contribute to an influx of claims involving not only physical injuries but also mental trauma. However, this is not the only potential source of escalation in mental trauma claims. Other types of events could have similar impacts at a state or local level, such as shootings, natural disasters and domestic terrorism.

Events involving mass injuries or casualties could lead to spikes in reported PTSD cases, which would present a challenge when projecting future PTSD incidence rates.

Understanding How PTSD May Affect WC System Costs

In all situations, one must account for how state law treats physical-mental, mental-physical and mental-mental events when assessing their potential impact on WC system costs.

When analyzing how proposed PTSD legislation may affect a state’s WC system, one must first consider issues related to estimating the number of compensable claims, including:

  • Nuances in current and proposed WC statutes—What are the eligibility requirements, and how are they changing?
  • Studies of PTSD prevalence rates—Are the prevalence rates for the lifetime or a recent period? What were the exact occupations of the participants in these studies? What DSM (American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders) standard was used? Did the study use clinical reporting or self-reporting? If the latter, what cutoff point of scores was used to determine the presence of PTSD? Were the participants selected at random or by convenience? What was the sample size? When was the study conducted? What country did the participants live in?
  • Other factors that might cause actual claim frequency to be different than otherwise expected—Will frequency be lower due to any potential perceived stigma associated with reporting a mental injury claim? Conversely, will frequency be higher if there are financial incentives for being diagnosed with PTSD?

WC benefits available to workers with PTSD may vary significantly by state and by occupation. Considerations when estimating the average WC cost of a PTSD claim include:

  • Types of medical treatment provided—Beyond the cost of counseling sessions and primary care office visits, what medicines may be prescribed to sufferers of PTSD? What health issues may arise directly related to PTSD or related to the treatment provided, such as side effects of prescription drugs? Might there be cases of self-harm?
  • Temporary versus permanent disability—How might healthcare professionals determine when a worker has reached maximum medical improvement? How likely is it that a worker will be found to have a permanent total disability due to PTSD? How will benefits be determined in cases where the worker has a permanent partial disability? How will statutory time limitations affect expected costs?

See also: Addressing PTSD in the Workplace

Conclusion

Mental health conditions in the workplace are receiving greater attention, whether they arise from a single event or continual exposure to an unusually traumatic work environment. Many state legislatures have been considering establishing or expanding the eligibility for WC benefits to those suffering from work-related PTSD. And COVID-19 could intensify this trend.

To gauge the impact of PTSD claims by occupational group and on overall costs, one needs to estimate the number and average cost of such claims. Recognizing the scarcity of WC-specific PTSD claims data, a projection of the potential impact that PTSD claims may have on WC costs may result from analyzing available literature and incorporating key considerations. These considerations include the extrapolation of prevalence rates to estimate annual WC claim frequency and the applicability of historical studies to the current situation, given the locations, time periods and methodologies underlying such studies.

State of Mental Health in the Workplace

Discussions around the impact of mental health and well-being in the workplace are frequent Out Front Ideas with Kimberly and Mark topics. May is Mental Health Awareness Month, so we are offering our thoughts on the current state of mental health in the workplace.

Even before the pandemic, benefits managers were adapting employee benefits to better equip employees and plan members with mental health resources. However, as the work from home assignments continued and social isolation set in, employers became even more aware of the impact of mental health and well-being on productivity, absence and performance. With a greater emphasis on employee well-being, we hope programs initiated during the pandemic will continue to support improved access to care and will break down the stigma related to mental health.

Employers took advantage of employee resource groups (ERGs), either existing or newly implemented, to foster peer interaction, open conversation and joint problem-solving related to issues that have an impact on their personal and professional lives because of the pandemic. Group collaborations focused on important topics at that time with employees, such as home school successes, caring for an ill family member, loneliness and depression, challenges with family and positivity sharing, to name a few. Many found the sessions to be an excellent way to bring positivity and support into their life and provide a break from the hectic pace of working at home. As companies create back-to-office and hybrid workforce models, ERGs continue to be a priority to ensure all who want to can participate.

Access to care has been a long-standing challenge for those seeking mental health care. Reimbursement rates, timely appointments and limited provider options are some of the issues the industry is working to solve. Previously, while telehealth visits were growing for triage of minor medical and follow-up appointments, there was slow adoption for teletherapy and telepsychiatry. Fortunately, telemedicine was a saving grace for many aspects of healthcare during the pandemic, and mental health care saw a boon. Employers and network partners are now offering multiple options for telemedicine and improved coordination between employee assistance programs (EAPs) and online therapy platforms for mental health care. Phone calls, video conferencing and texting are becoming an integral part of the therapist-patient relationship. With less social connection, this has found success for many in the workforce — and their families. Organizations are now offering various programs, including adult, family and teen counseling.

The Center for Workplace Mental Health is an important resource for all employers. The entirety of its work focuses on helping employers create a more supportive work environment and advance health policies at their organization. They have created a mental health toolkit for Mental Health Awareness Month, which includes topics such as promoting resiliency for people and the organization; promoting self-care; and addressing isolation and loneliness. These programs (and others) can be easily integrated into your company culture to reduce stigma, promote well-being and provide an environment where employees and leaders both care and thrive.

See also: The Long Haul for Mental Health at Work

From a workers’ compensation claims perspective, mental health has always been a complication lurking in the background. The industry tended to ignore the issue because of a combination of stigma and outright resistance. Claims where the injured workers never fully recovered probably had a significant untreated mental health component. Thankfully, that is changing; it is now widely recognized that all chronic pain has a significant mental health component, and, if you fail to address this, it will increase claims cost and lead to poorer outcomes. Multidisciplinary pain management programs now spend as much time on mental health as they do physical health. 

Laws are also changing to make it easier to pursue psychological injuries under workers’ compensation. More states are allowing “mental-mental” claims, which are psychological injuries with no physical injuries. In addition, one of the leading workers’ compensation legislative initiatives for several years has been the expansion of first responder presumption laws, which are primarily focused on post-traumatic stress. In the past, the threshold for a mental health injury was a “usual and extraordinary” experience. That threshold was used to deny very real traumatic situations that first responders encounter because the situations were “usual” aspects of their job. While these traumatic situations may have been expected, there is nothing ordinary about responding to severe accident scenes, seeing your partner shot or having someone die in your arms. In certain ways, public entities created the path to these presumption laws by denying such claims rather than focusing on getting the injured worker the treatment they needed. Public entity employers are now reporting that they are seeing an increasing number of PTSD claims with no corresponding physical injuries being filed under workers’ compensation.

Managing Absences for Disability Insurance

As our research has consistently shown, value-added services are increasingly one of the top areas of interest among customers, and one area of growing interest is integrated absence management for disability insurance. (We discussed this growing trend in a webinar with the Standard, a leading insurer that has provided integrated disability and absence management to their customers for a long time. You can watch a replay of the webinar here.)

Because apps and interfaces are now designed through a customer-first approach, not a product-first approach, there is a profound shift in how disability claims can be filed and leaves of absence requested, making the process straightforward despite all the regulatory nuances.

Employers are looking to their insurance companies or third-party administrators (TPAs) who manage their disability programs to provide an intuitive, digital platform where they can easily submit a leave request, view their time remaining and upload or download any necessary documentation to have their leave or claim approved.

Insurance companies and TPAs with a digital solution that provides integrated disability and absence management are well-positioned to address this significant market need, while providing customers with a single point of contact for their benefits, avoiding duplication and simplifying the employee experience.

See also: Long-Term Disability in the Time of COVID-19

Simplifying the Increasing Complexity of the Leave Landscape

It’s hard to talk about the leave of absence landscape without using the word “complexity.” It’s increasingly difficult to stay on top of federal and state paid and unpaid leave laws, and there’s no sign of the complexity diminishing, with new regulations in the works.

The transition to remote working is adding an additional layer of complexity, with employees scattered across the country working from home, expanding the number of state regulations that must be managed.

As Lincoln Dirks, a senior compliance analyst for absence management at the Standard, put it during the webinar, “You take the already complex aspect of dealing with federal, state and municipal leaves in a given state, and then you multiply that by 50. The issue becomes that no two of these states run their programs in even close to a similar manner. Rules, regulations, processes, procedures all vary by state.”

This complex landscape, though, has created a significant market demand for absence management – making it the big trend for 2021! Employer customers need it because spreadsheets and sticky notes aren’t getting it done. And, increasingly, insurance companies are expanding their offerings to include it as an integrated value-added service, differentiating them in the market.

The Value-Added Service Opportunity for Insurers

These trends offer a significant opportunity for insurers to expand their offerings with an integrated disability insurance and absence management solution that their customers are seeking.

Watch the entire webinar and hear from the Standard on how they’ve elevated corporate programs with their integrated disability and management offering on the Majesco website.

Workers Comp Trends for Technology in 2021

One year after the start of the COVID-19 pandemic, Mitchell International conducted its annual survey of about 100 workers’ compensation professionals to determine how technology use changed in the industry during the pandemic and how those changes will continue. The survey found:

Technology use is increasing in the workers’ compensation industry  

  • Predictive analytics and telemedicine stood out, showing that the industry rapidly increased the pace of adoption – or the desire to adopt – those technologies during the pandemic.
  • More than half of organizations report implementing telemedicine since the pandemic began, and respondents ranked telemedicine (35%) and predictive analytics (35%) as the technologies that will have the largest influence on the industry in the next five to 10 years. 
  • Claims providers are facing pandemic-related challenges and are using technology to help overcome them. Almost one-quarter (22%) of respondents ranked adapting to pandemic-related challenges as the top obstacle their organization faces today, and 40% said they believe the pandemic is the leading driver of technology adoption.
  • Despite the technology changes in 2020, the workers’ compensation industry still has an opportunity to introduce automation into the claims process. Only 23% of respondents said that their organization uses straight-through processing for 50% or more of the medical bills they manage.

Telemedicine had the most substantial impact (35%) of all technologies implemented in 2020

  • As expected, most respondents reported that telemedicine had the most substantial impact (35%) of the technologies they implemented in 2020.
  • Survey respondents also indicated that they believe both telemedicine (35%) and predictive analytics (35%) are the technologies that will have the most significant influence in the workers’ compensation industry in the next five to 10 years, compared with other listed technologies. 
  • The majority of respondents said the best application of telemedicine is or will be for provider visits (54%), followed by nurse case management (26%) and triage (21%)
  • Mobile placed at a distant third (8.5%). 

These findings aren’t too surprising, as telemedicine, predictive analytics and mobile technologies have been key focus areas in workers’ compensation for years. Prior to the pandemic, 32% of people who responded to a similar survey in February 2020 said they thought telemedicine would have the biggest impact on the industry in the future and ranked artificial intelligence and predictive analytics as the next most potentially effective technologies.

See also: Covering for a Gap in Workers Comp Data

It’s clear that telemedicine has been crucial in helping to deliver care to injured employees during the pandemic. With innovation and the addition of other technologies, such as wearables, telemedicine has the potential for broader uses in the industry and could serve a more vital purpose in helping improve claim outcomes for injured employees.

The workers’ compensation industry will see increased demand for predictive analytics 

  • Respondents list claim triage as the most popular future application of predictive analytics (35%,) followed by severity or reserving (35%), intelligent decisioning and adjuster guidance (24%) and claim automation (22%)

Indeed, these applications of predictive analytics and more will be vital for efficient and effective workers’ compensation claims processing in the years to come. From triage to automation, predictive analytics can help claims organizations get the right information at the right time to make informed and intelligent claim decisions.

Changes and pressures from the COVID-19 pandemic are the primary driver of new technology adoption

  • While 40% of respondents noted the pandemic as the top driver for change, claims organizations are still looking to solve challenges that existed before the pandemic began
  • Respondents rated efficiency (22%) as the second top driver of technology adoption, followed closely by cost containment (20%)

The workers’ compensation industry still has a significant opportunity for automation

  • Despite the rapid rate of technology adoption in the past year, less than a quarter of respondents (23%) said they automate 50% or more of workers’ compensation medical bills using straight-through processing.
  • 22% of respondents said they process 25% or fewer of their bills automatically. 
  • Even fewer respondents said their organization processes workers’ compensation claims automatically, with only 16% saying they use straight-through process automation for 10% or more of their claims, and about a quarter (24%) said they only automatically process 0-5% of claims.

Typically, an efficient workflow passes 60% to 70% of medical bills through without human intervention, and it is clear the industry still has much opportunity to reach this level of automation. Straight-through processing offers many benefits, including removing repeatable tasks from adjusters’ workloads, boosting consistency and freeing employees up to have more time to focus on complex claims that need extra scrutiny and care to help achieve better outcomes. 

While we may never achieve full automation of all workers’ compensation claims—unlike other lines of insurance, some workers’ compensation claims will always require a level of human touch. There are plenty of opportunities to boost automation now and in the future using rules engines, artificial intelligence like predictive analytics and more. As technologies become more advanced in the years to come, claims organizations will need to think about how they can strike the right balance and implement the appropriate level of automation that allows them to spend their time focusing on the claims that need special attention.  

See also: Optimizing Care with AI in Workers Comp Claims

Survey demographics

Mitchell surveyed nearly 100 workers’ compensation professionals at a range of companies, including insurance carriers, third-party administrators, public entities, managed care and risk management organizations, and brokers. The majority of respondents (75%) had 10 or more years of experience in the workers’ compensation industry.

You can find the full report based on Mitchell’s 2021 survey here.

Bring Certainty to Remote Injury Claims

The working world is changing. Even before the COVID-19 pandemic, remote work was gaining popularity as employees sought greater flexibility and as advances in telecommuting removed barriers. Some employers even offered work-from-home options as an incentive to attract and retain top talent, save money and sharpen their competitive edge. 

Since the pandemic, remote work has become a fact of life, and, like it or not, it’s here to stay. Even with vaccinations on the rise and many watching the horizon for a return to “normal” — or to the office — many workers will never return to a physical worksite. Employers who acknowledge the shift are developing and implementing plans to provide continued work-from-home options.

But what does this change mean for your organization when a worker gets hurt on the job?

It may seem that working from home would provide employees with a safe environment and low risk of injury, but, in truth, employers won’t always know what specific hazards exist in every worker’s home. The reality is that injuries occur all the time in any environment, at home just as they do in a conventional workplace.  

Evaluate

Workers’ compensation claims for injuries sustained in the home can and should be evaluated the same as any other industrial claim — but they still present their own unique challenges. While every state has its own laws and interpretations, compensable claims generally have these things in common: the injury must be work-related; it must have occurred in the course and scope of employment; and the injury or accident must arise out of job-related activities. A proper investigation can provide the details needed to make an accurate determination and ensure the appropriate benefits are administered.

There is no requirement that an injury must occur at a place of employment outside the home — such as a worksite, factory, warehouse or office — for a workers’ compensation claim to be compensable. What is required is to establish whether it arose out of employment (AOE) or the course of employment (COE). The goal of a compensability investigation is to establish if the reported injury occurred, if it occurred in the course and scope of employment or if it was non-industrial.

See also: Pressure to Innovate Shifts Priorities

AOE/COE Compensability Determination

To be eligible to receive workers’ compensation benefits — including medical treatments, disability benefits, vocational rehabilitation and death benefits — an injury or illness must have arisen out of employment (AOE) and occurred during the course of employment (COE).  

As a general rule, if an employee deviates from work activities benefiting their employer to activities for a personal benefit, any injury occurring during such deviation is generally not considered within the course and scope of employment and is therefore not covered. But once the employee returns from the deviation to work-related tasks for the benefit of the business, any injury that occurs after that point is typically covered. 

However, there are nuances when considering the work-from-home environment. Take lunch, for example. When an employee leaves the office for lunch, compensability is typically more straightforward for injuries sustained while away from the workplace. But when an at-home employee trips and falls while walking to the refrigerator for lunch, the question may be somewhat less clear-cut. 

Investigative Solutions

It is crucial to conduct an investigation early on in any claim to document the facts, gather/secure any potential evidence and identify any potential third-party liability. The investigation will seek to determine if an accident or incident occurred, if an injury was sustained, whether anything unusual or unexpected occurred and whether the incident caused or aggravated a medical condition. 

While an accident at a job site or office may benefit from reliable witnesses or security footage, at-home employees are often working alone and unsupervised. This means injury incidents often occur without reliable witnesses to corroborate accounts. 

Recorded Statement

Obtaining recorded statements is a key technique for thorough remote injury investigations. At-home injuries are often unwitnessed (or potential witnesses are likely family members), so investigators will assess the credibility of the claimant and any witnesses and secure their recorded statements. Investigations must rely heavily on claimant and witness statements bolstered by medical records, scene inspections and other investigative solutions.

Here are some critical details an investigator will verify:

  • The time and date of the incident
  • Whether the incident occurred within the employee’s routine working hours
  • The activity that preceded the injury
  • Exactly what work was being done at the time of the injury
  • The mechanism and nature of the injury 
  • Medical history and claim history

Confirming when the in-home worker took breaks and other corresponding details about their daily routine are also important pieces. In addition to determining whether the employee was legitimately working for the employer at the time of the injury, investigators will inquire further to ascertain if the employee was solely engaged in work-related activities or if there were any other activity or distractions involved. If a reported injury arose from playing with the dog between calls or consuming alcohol while listening to a training, these may be valid reasons to deny the claim. 

See also: Long-Haul COVID-19 Claims and WC

Subrogation Investigation

Subrogation potential can also be complicated with a remote employee injury. What if your employee’s injury was caused by a roommate or landlord negligence? Or, imagine that a claimant reports she sustained an injury at her home workstation as a result of a broken chair. It’s then essential to obtain all needed information about the chair, any prior complaints or defects, litigation involving the manufacturer and other facts required for a potential subrogation claim.

Make a Plan

Create policies and procedures specific to your telecommuting employees. Work-from-home agreements can help ensure everyone understands expectations around creating a safe environment and guidelines for the reporting of an injury and the investigation of a claim.