Case Management

Missed Appointments, Missed Opportunities

Eliminating missed medical appointments can significantly reduce claims costs and improve outcomes for injured workers.
By: | September 7, 2017 • 4 min read

Non-compliance with medical protocols, including missed medical, therapeutic and diagnostic appointments, “are a problem and have always been a problem” for workers’ compensation carriers.

However, the mechanisms they and care managers use to keep tabs on injured workers produce a higher compliance rate — and better outcomes — than in the general medical environment.

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Stakeholders, including employers and insurers, “have a strong incentive to get workers back to work to reduce indemnity,” said Robert Hartwig, co-director, risk and uncertainty management center, Darla Moore School of Business, University of South Carolina.

Most employees are also eager to return to work, he said, other than a few instances of claim malingering, which preventive mechanisms tend to minimize.

Ten to 18 percent of injured workers never reach “substantial return to work,” according to new research by the Workers Compensation Research Institute that compares outcomes for injured workers in six states.

By contrast, only one percent of people on Social Security disability ever return to work, Hartwig said.

The goal of worker’s compensation — to restore to the maximum degree possible the employee’s health and ability to return to work — and the resources poured into that goal, accounts for the huge difference in outcomes, Hartwig said.

The workers’ compensation system is also sensitive to overutilization of appointments and procedures, he said.

Although no studies address the cost of missed workers’ compensation appointments specifically, all missed medical appointments cost the U.S. health care system more than $150 billion per year, said Joseph McCullough, senior vice president, transportation and language, One Call Care Management.

The cost of all non-adherence to medical protocols in the U.S. is approximately $290 billion, wrote Tomas Philipson, economist, University of Chicago, in “Forbes.” That equates to about 13 percent of total health care spending, or 2.3 percent of GDP.

Some Mechanisms

Carriers and care managers are harnessing all manner of mechanisms, high and low tech, to urge, prod and remind workers of their appointments. For example, One Call partners with Lyft to provide transportation for ambulatory workers to and from their appointments.

Through text messages limited to times, travel conditions and locations, One Call’s program seeks to prevent missed and delayed treatment caused by transportation snafus, McCullough wrote in an email interview, and instantly reschedules appointments when necessary.

Robert Hartwig, co-director, Center of Risk and Uncertainty Management at the Darla Moore School of Business, University of South Carolina

CorVel uses a three-point strategy that embraces highly coordinated care management, transportation and motivation techniques to make sure workers get to their appointments, understand their importance and accept accountability for their own recovery, said Karen Thomas, director, case management innovation, CorVel.

Its case managers — telephonic, field and one-off task managers — orchestrate scheduling with workers, issuing reminders about dates and what they need to bring. Most important, she said, “We educate them on why the appointment is important and how it impacts recovery. Case managers develop a relationship with the worker.”

Like One Call, CorVel arranges transportation for ambulatory and non-ambulatory workers. It schedules pick-ups, and through a proprietary system, communicates in real time with the worker, providers, adjuster and case manager, then documents and tracks the progress of the appointment.

Finally, Thomas said, there’s the worker’s accountability. “The worker doesn’t want to let the case manager down. After the appointment. I’ll ask, ‘Did you get what you needed? Are your questions answered?’ We don’t necessarily want to pressure the worker, but buy-in is important.”

“Our challenge is to figure out how to help workers get better despite themselves.” — Karen Thomas, director, case management innovation, CorVel

More encouragement may be necessary for the small number of injured workers who throw up roadblocks to their own recovery.

Case management is an advanced practice, Thomas said, and its nurses have experience with rehab medicine, trauma, chronic pain and its associated depression and self-sabotage.

“Our challenge is to figure out how to help workers get better despite themselves,” using every available motivation: return to an active lifestyle or playing catch with the kids.

Biggest Cost: Lost Time

Most physicians waive fees for missed appointments, said Dr. Teresa Bartlett, MD, senior vice president and medical director, Sedgwick Claims Management Services Inc. But every lost workday costs $400 to $900 as well as the worker’s lost productivity. It can also protract indemnity benefits unnecessarily.

For example, a missed appointment just prior to return to work could add a week or more to the claim if the physician can’t fit in a rescheduled appointment earlier.

Depending on the jurisdiction, deliberately missed appointments and other schemes to protract benefits can jeopardize workers’ compensation payments, Bartlett said. “That’s why we do friendly reminders. It’s in their own best interest.”

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Because timely care that conforms to best practices produces the best outcomes, Sedgwick, a claims and care manager, expedites appointments from the moment of the injury, said Bartlett. Sedgwick brings care to the worker almost immediately through telemedicine.

Sedgwick also trains its examiners to spot the signs of the behaviors and comorbidities that can lead to creeping catastrophic claims — the rolled ankle that spirals into wheelchair confinement, obesity, diabetes and heart disease, for example.

“If the worker says he just doesn’t have the energy to get into the car and go to the appointment, we’ll refer him for behavioral health intervention,” Bartlett said. “To get the case back on track, that worker will be queued up for telephonic nurse case management or field case management where a nurse goes with him to the appointment.”

Susannah Levine writes about health care, education and technology. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

2018 Most Dangerous Emerging Risks

Emerging Multipliers

It’s not that these risks are new; it’s that they’re coming at you at a volume and rate you never imagined before.
By: | April 9, 2018 • 3 min read

Underwriters have plenty to worry about, but there is one word that perhaps rattles them more than any other word. That word is aggregation.

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Aggregation, in the transferred or covered risk usage, represents the multiplying potential of a risk. For examples, we can look back to the asbestos claims that did so much damage to Lloyds’ of London names and syndicates in the mid-1990s.

More recently, underwriters expressed fears about the aggregation of risk from lawsuits by football players at various levels of the sport. Players, from Pee Wee on up to the NFL, claim to have suffered irreversible brain damage from hits to the head.

That risk scenario has yet to fully play out — it will be decades in doing so — but it is already producing claims in the billions.

This year’s edition of our national-award winning coverage of the Most Dangerous Emerging Risks focuses on risks that have always existed. The emergent — and more dangerous — piece to the puzzle is that these risks are now super-charged with risk multipliers.

Take reputational risk, for example. Businesses and individuals that were sharply managed have always protected their reputations fiercely. In days past, a lapse in ethics or morals could be extremely damaging to one’s reputation, but it might take days, weeks, even years of work by newspaper reporters, idle gossips or political enemies to dig it out and make it public.

Brand new technologies, brand new commercial covers. It all works well; until it doesn’t.

These days, the speed at which Internet connectedness and social media can spread information makes reputational risk an existential threat. Information that can stop a glittering career dead in its tracks can be shared by millions with a casual, thoughtless tap or swipe on their smartphones.

Aggregation of uninsured risk is another area of focus of our Most Dangerous Emerging Risks (MDER) coverage.

The beauty of the insurance model is that the business expands to cover personal and commercial risks as the world expands. The more cars on the planet, the more car insurance to sell.

The more people, the more life insurance. Brand new technologies, brand new commercial covers. It all works well; until it doesn’t.

As Risk & Insurance® associate editor Michelle Kerr and her sources point out, growing populations and rising property values, combined with an increase in high-severity catastrophes, threaten to push the insurance coverage gap to critical levels.

This aggregation of uninsured value got a recent proof in CAT-filled 2017. The global tally for natural disaster losses in 2017 was $330 billion; 60 percent of it was uninsured.

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This uninsured gap threatens to place unsustainable pressure on public resources and hamstring society’s ability to respond to natural disasters, which show no sign of slowing down or tempering.

A related threat, the combination of a failing infrastructure and increasing storm severity, marks our third MDER. This MDER looks at the largely uninsurable risk of business interruption that results not from damage to your property or your suppliers’ property, but to publicly maintained infrastructure that provides ingress and egress to your property. It’s a danger coming into shape more and more frequently.

As always, our goal in writing about these threats is not to engage in fear mongering. It’s to initiate and expand a dialogue that can hopefully result in better planning and mitigation, saving the lives and limbs of businesses here and around the world.

2018 Most Dangerous Emerging Risks

Critical Coverage Gap

Growing populations and rising property values, combined with an increase in high-severity catastrophes, are pushing the insurance protection gap to a critical level.

Climate Change as a Business Interruption Multiplier

Crumbling roads and bridges isolate companies and trigger business interruption losses.

 

Reputation’s Existential Threat

Social media — the very tool used to connect people in an instant — can threaten a business’s reputation just as quickly.

 

AI as a Risk Multiplier

AI has potential, but it comes with risks. Mitigating these risks helps insurers and insureds alike, enabling advances in almost every field.

 

Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]