11 Questions for CorVel’s Karen Thomas

Dan Reynolds, the editor in chief of Risk & Insurance, recently caught up with Karen Thomas, Vice President of Clinical Solutions with CorVel. The topic of the discussion was the pros and cons of the increased use of nurse practitioners and physician assistants in workers’ comp. What follows is a transcript of that discussion, edited for length and clarity.

Risk & Insurance: Thanks for meeting with us, Karen. What data from CorVel’s analytics demonstrate that NPs and PAs deliver quality initial care comparable to physicians in the workers’ compensation setting?

Karen Thomas: Glad to be here, Dan. As a clinician, I rely on science and evidence-based guidelines, examining recovery times and return to work timelines, factoring in comorbidities, age, and other relevant variables. We want to ensure there’s no deterioration in care or recovery when different levels of practitioners are involved.

At CorVel, we also analyze claim metrics, including claim duration and claim cost. We pay close attention to how NPs and PAs utilize diagnostics and whether usage increases or decreases. Then we correlate these findings back to suggested evidence-based outcomes.

R&I: As nurse practitioners and physician assistants are increasingly taking on more responsibilities amid physician shortages, are there identifiable drops in care quality resulting from this trend?

KT: There have been numerous studies — both related to workers’ compensation and other payer sources — examining this issue. The medical community is closely monitoring this area due to physician shortages and significant pipeline issues in training doctors, particularly specialists.

The use of NPs and PAs is a viable solution. We need to be very careful not to erode the quality of care. Studies show the quality of care provided by NPs and PAs is good. Keep in mind the physician is ultimately responsible for the decisions these NPs and PAs make and how they handle cases.

I’ll probably go down a bit of a rabbit hole here, but what is very important is the quality assurance piece. In health care, we always want to ensure the QA process is robust and used to improve medical outcomes.

At CorVel, our clinical services utilize highly involved and responsive quality assurance programs.  CorVel medical directors and nursing staff carefully review clinical decisions and medical outcomes. That piece is very important. We need to hold the treating physicians, and subsequently the nurse practitioners and PAs who report to them, accountable.

R&I: Do nurse practitioners and physician’s assistants have the authority to order diagnostic tests independently, or is physician oversight or CorVel intervention required?

KT: They do have the power by licensure to order whatever diagnostic is necessary. Again, physicians have the ultimate responsibility for PA and NP decision-making. CorVel has services such as utilization management to determine medical necessity.

R&I: What role does utilization management play in practices that employ nurse practitioners and physician assistants?

KT: The check-and-balance comes through utilization management. In states where it’s mandatory, treating providers’ medical orders are reviewed against state regulations or evidence-based guidelines. Provider requests can be approved, partially approved, or denied. For example, ordering an MRI for a back strain just two days after the date of injury would not meet guidelines. That provider request would not be approved and would require a peer review. This utilization management process can be very effective in states where it’s not mandated because you can still implement these types of checks and balances.

The most successful practices that use NPs and PAs maintain very close relationships with physician specialists. That’s where we strive to partner within our PPO network, ensuring true physician oversight and guidance for NPs and PAs.

R&I: How has CorVel’s approach to nurse case management evolved over time?

KT: In the workers’ compensation industry, nurse case management has historically been applied to claims in a reactive manner. For example, a nurse would be assigned to a claim after years of unsuccessful treatment or when an injured person had a poor medical outcome. The industry is finally embracing a more proactive approach to injury management, which always leads to improved medical and return to work outcomes.

CorVel utilizes triage nurses focused on delivering the right care at the right time immediately after injury. We also engage early intervention case managers who can follow a claim through the first 30 days.

Early intervention is crucial. When collaborating with nurse practitioners and physician assistants, it’s important to avoid unnecessary diagnostics while ensuring that cases requiring direct assessment by a physician are appropriately directed to them. This early intervention nursing team facilitates better care by fostering communication with NPs and PAs.

R&I: Where specifically are nurse practitioners and physician assistants proving most effective at filling workforce gaps?

KT: Our analytics team is closely monitoring states where nurse practitioners are permitted to treat workers’ compensation patients independently, particularly New York and Oregon. These states provide an apples-to-apples comparison, allowing us to assess the impact of independent oversight authority for an NP or PA. We want to understand how they’re utilizing their ability to order imaging and other diagnostics.

There has been some concern that NPs and PAs are more likely to order higher-level diagnostics. The key questions are whether this increases claim costs and whether it actually improves outcomes. Our analysis shows referral and physical therapy prescription rates for NP- and PA-led cases remain consistent with, and in some instances slightly lower than, those for physician-led care, indicating efficient and conservative utilization patterns.

Looking at the data, PAs and NPs, particularly in states where they have independent oversight capabilities, are seeing patients much more quickly than specialists are. Because they’re seeing the patient over time and observing how the case evolves, these are all positive developments. Across CorVel’s book of business, injured workers treated by NPs and PAs are seen an average of nine days sooner than those treated by primary care physicians — roughly 11.5 days versus 20.5 days. That earlier access allows care plans and recovery expectations to be established sooner.

That said, we’re paying close attention to ensure that when a case becomes complicated or isn’t progressing as expected, the NP or PA escalates it to a physician for involvement.

It’s particularly important in states where, geographically, there are fewer physicians per square mile. We need to address that challenge while ensuring quality care is not compromised.

From my time teaching in academia, I know it’s critical that nurse practitioners and physician assistants understand the limits of their licensure and experience. We need to ensure the right cases and claims are matched to the appropriate practitioner level. We don’t want to bog down a specialist with a case that doesn’t require that level of clinical expertise.

R&I: What analytical benefits does AI provide to nurse practitioners and physician assistants?

KT: AI is a double-edged sword, and we have to be very careful with it. Certainly, AI has the ability to hallucinate and produce data that may not be accurate.

In science and medicine, it’s critical that we educate clinicians. AI is a helpful tool when coupled with the human in the loop. It can potentiate the clinician’s knowledge and experience.

In analytics, AI is highly exciting for leveraging trends and conducting in-depth analyses.

R&I: What distinguishes nurse practitioners and physician assistants in the context of patient care and clinical oversight?

KT: Anyone who has interacted with the medical community knows that wait times to see a physician are extremely long these days. The more specialized the physician, the longer the wait, typically 3 to 6 months or more.

The advantage of nurse practitioners and PAs is that patients can access care much more quickly. Once in the pipeline, patients also gain faster access to specialists when needed.

However, we must ensure quality of care is maintained. A PA or NP who lacks strong diagnostic skills or fails to identify recovery trends can adversely impact patient outcomes. This is where quality assurance programs become essential.

At CorVel, we hold these clinicians accountable through multiple methods, quality assurance reviews within our PPO network, nurse monitoring of recovery trajectories, and medical director involvement. This accountability is absolutely critical.

R&I: What outcome metrics should employers and insurers track to ensure quality while controlling costs in workers’ compensation?

KT: We’re looking at recovery metrics. If evidence-based guidelines indicate that an individual doesn’t require surgery, but they underwent surgery, we need to understand what that means. Similarly, if we’ve ordered expensive diagnostics when evidence-based guidelines say we don’t need them, we need to ask why and evaluate how that affected the claim.

Return to work is always critical in workers’ compensation. We also track all the key financial metrics: claim duration, claim cost, and TTD (Temporary Total Disability). Additionally, we monitor whether claims are being classified as medical-only or are escalating to TTD status. When we compare outcomes, NP- and PA-led claims average about 10 fewer lost workdays, approximately 15 days versus 25.  Return-to-work rates and TTD outcomes remain comparable to physician-led care; this tells us access gains are not coming at the expense of outcomes.

Finally, something often overlooked is the injured worker’s satisfaction. Really, it extends to all claim stakeholders. Have we met our customer service obligations to them?

R&I: And of course, injured worker satisfaction is vitally important in the workers’ compensation system.

KT: Absolutely. If injured workers are dissatisfied, it can lead to litigated claims or dissatisfaction with the employer. We cannot allow that to happen; therefore, factoring in injured workers’ satisfaction is critical.

R&I: What obligation does the workers’ compensation industry have regarding the anticipated physician shortage?

KT: This is a trend we cannot ignore. Today, nurse practitioners and physician assistants lead nearly 40% of first-injury evaluations across CorVel’s book of business, underscoring the central role advanced practitioners play in maintaining access without sacrificing quality. Given the shortages we will face in the future for physicians and specialists, we have an obligation as an industry to cultivate and support this talent. However, we must also hold accountable the outcomes we need within workers’ compensation. &