512 Workers’ Comp Professionals Identified Their Top 10 Challenges for 2019

Attendees of the 2018 National Workers’ Compensation and Disability Conference shared their thoughts on the challenges and trends unfolding ahead.
By: | March 5, 2019

Hundreds of workers’ compensation professionals converged in Las Vegas last December for the 2018 NWCDC & Expo to discuss their challenges and learn new techniques to manage them. We surveyed 512 attendees to find out what trends they’re watching and what challenges concern them most for the year ahead.

Respondents were predominantly claim managers and risk managers working for employers or insurance carrier/payers, though the entire field was represented in some capacity, including clinical providers, TPAs and brokers.

Here’s are the top 10 challenges that concern them most for 2019:

1) Rising Cost of Care

Almost half of respondents identified escalating medical costs as the biggest challenge facing their workers’ comp program in 2019 and beyond, and nearly everyone identified cost-containment as their top priority, aside from medical providers and nurse case managers who are more focused on clinical management.

The cost of healthcare in the U.S. continues to be unsustainably expensive. According to the Centers for Medicare & Medicaid Services, healthcare spending will grow around 5.5 percent per year between 2017 and 2026 — outpacing GDP growth by 1 percentage point. In 2026 total spending is projected to hit $5.7 trillion.

A number of reasons are behind the rising expense, but chief among them are increased utilization among an aging population, more technologically advanced equipment that adds cost to services, and bloated prescription drug prices. With no end to these trends in sight, treating injured workers will continue to get more expensive.

2) Comorbidities and Poor Worker Health

Older workers combined with the rising prevalence of obesity also gives rise to greater incidence of co-morbidities. Excess weight, diabetes, hypertension, sleep apnea, joint pain and other conditions that develop as a result of lifestyle factors or age can make recovery much more complicated.

Claims managers in particular were acutely concerned about the impact of comorbidities.

“Obesity, diabetes, respiratory problems — we develop certain conditions as we age that compound injury and make it more difficult to recover,” said Bill Spiers, vice president and Risk Control Strategies practice leader for Lockton. He spoke with our editors about his clients’ chief challenges at NWCDC.

“Because of HIPAA protections, it can also be difficult to get information regarding these other pre-existing conditions, which makes it harder for adjusters to determine the best course of care,” he said.

Patti Colwell, workers’ compensation program manager for Southwest, echoed that sentiment: “With HIPAA restrictions, it is often difficult to determine an appropriate action plan for the workers’ compensation claim as it is often a struggle to receive timely medical information relating to the non-OJI [on-the-job] condition.

“Often times medical conditions unrelated to the work injury prevent or significantly delay the ability of the injured employee to receive timely, appropriate medical treatment.”

“It becomes critical for treating and consulting physicians to be aware of all comorbid conditions, and include discussion of treatment ramifications in reporting to the claims professional,” said Robert Goldberg, MD, FACOEM, Chief Medical Officer for Healthesystems.

According to an analysis by Harbor Health, claims stay open 76 percent longer when they involve multiple comorbidities, temporary total disability days increase by 285 percent, and total incurred costs also increase by 341 percent. With at least 39 percent of U.S. adults considered obese, it’s increasingly likely that related comorbid conditions will be factors on a growing proportion of claims.

3) Opioids

The opioid crisis gripping America is a full-blown public health crisis, but the impact is even more acute in workers’ comp since nearly every claim has a pain component, and addictive painkillers have long been prescribers’ go-to when treating chronic pain.

Respondents in every role acknowledged that managing opioid and other substance abuse issues will be among their biggest hurdles.

According to the CDC, the U.S. prescribing rate for opioids was 61 prescriptions per 100 persons in 2016. NCCI data shows that injured workers were prescribed opioids at three times that rate.

According to the CDC, the U.S. prescribing rate for opioids was 61 prescriptions per 100 persons in 2016. NCCI data shows that injured workers were prescribed opioids at three times that rate.

Workers prescribed long-term painkillers often take longer to return to work. A 2018 study by the Workers Compensation Research Institute showed that workers who had longer-term opioid prescriptions received temporary disability benefits 251 percent longer than workers treated for musculoskeletal injuries without opioid prescriptions.

“The best solution to the opioid problem in workers’ comp is for physicians to adhere to current evidence-based treatment guidelines, which recommend more limited dosing for shorter durations and only after other pain control measures have been tried,” Dr. Goldberg said. “Acute use of opioids is indicated in limited circumstances, while chronic use must be curtailed if not avoided.”

On the upside, 43.8 percent of respondents working in claim management said they’ve had success implementing opioid and medication therapy management programs in 2018.

4) Mental Health Exposures

Most of the talk around the compensability of mental injuries has concerned post-traumatic stress disorder suffered by police, firefighters, EMTs and other first responders. In the past few years, states are slowly passing legislation recognizing PTSD as a compensable injury for this population.

But mental injuries are broader than those stemming from traumatic experience. Work-related stress and anxiety are more difficult to define and diagnose, but the frequency of claims alleging that unreasonable stress at work premeditated a physical injury like a heart attack is on the rise.

New Jersey passed a statute in 2018 stating that any injury or ailment, physical or mental,  is compensable if it is caused by the work environment. They may be in the minority, but with an unprecedented number of people reporting that they experience extreme stress, anxiety and depressive symptoms, that could soon change, especially in an increasingly connected culture where workers are always ‘on.’

Even when these injuries are not considers compensable, they can complicate recovery from a physical injury.  More than 50 percent of injured workers experience clinically-related depressive symptoms at some point, especially during the first month after the injury.

“When there is unresolved or chronic pain, we start to consider the psychological component Spiers said. “When physical treatments aren’t making any progress, we have to think about the possibility of an underlying mental health problem — short term depression, anxiety about going to the doctor, or about being our of work, family issues, etc., could all be influencing factors.”

5) Growth of Complex Claims

According to Spiers, “3 to 5 percent of claims drive roughly 50 to 60 percent of costs.”

“The issue is delayed recovery. Some claimants are slow to heal, and the doctor will keep running tests, keep ordering treatments, sometimes surgeries. And if they’re not effective it’s just running the meter in terms of medical costs. And the claimant in the meantime is experiencing additional wear and tear,” he said.

According to Spiers, “3 to 5 percent of claims drive roughly 50 to 60 percent of costs.”

It doesn’t take a catastrophic injury to create a complex claim. Any one component — prescription abuse or misuse, physical comorbid conditions, psychological factors or attorney involvement can drastically increase duration and cost.

“Many complex claims develop due to the psychological aspects of the injured worker that either pre-date the injury or are caused directly or indirectly by the injury,” Dr. Goldberg said. “Early identification and intervention are required to short-circuit the development of such claims.”

“Complex claims come in all shapes and sizes,” Southwest’s Colwell said. “Some are complex because of co-morbid or underlying, unrelated medical conditions, some because of psychological issues, some because of employment/performance-related issues, and some because of the severity of the injury. Each of these complexities presents challenges to claim resolutions.”

6) Regulatory and Legislative Changes

A variety of both national and state legislative updates will change the way workers’ comp providers and payers do business.

Through the first half of 2018 alone, the NCCI tracked 814 state and federal workers compensation bills, 76 of which became law by the end of June, as well as 197 proposed regulation changes, 83 of which were adopted. Most pertained to medical fee schedules and treatment guidelines.


More such regulatory changes are expected in 2019, when CMS is expected to update coding and document requirements around remote patient monitoring, evaluation and management. As telehealth begins to play a larger role in workers’ comp care, these changes could add expenses for those providers offering virtual platforms. CMS is also proposing major changes to the Medicare Fee Schedule Evaluation and Management reimbursement model for office and outpatient services.

On the legislative side, medical marijuana continues to be a thorn in the side of case managers and payers. Thirty-three states and the District of Columbia have legalized medical marijuana in some form, but debate over whether workers’ comp insurers should pay for treatment that remains a Schedule I drug in the eyes of the federal government has so far been settled in court. New Mexico is the only state thus far that has a fee schedule for medical marijuana.

7) Distracted Drivers and Auto Collisions

Auto insurers are not the only ones suffering from the plague of distracted driving. Commercial drivers and employees who regularly drive as part of the job or use a company car can are just as susceptible to crashed and represent a growing proportion of workers’ comp claims.

An injury from a motor vehicle accident can cost around $150,000, and a fatality as much a $3.6 million.

Not only are these cases becoming more frequent, but he injuries are more likely to be catastrophic and therefore carry more significant medical and lost time components. According to Concentra, an injury from a motor vehicle accident can cost around $150,000, and a fatality as much a $3.6 million.

Data compiled by the U.S. Bureau of Labor Statistics (BLS) and the National Academy of Social Insurance indicates that injuries from auto collisions cost employers $3.2 billion per year.

8) Claims Data Breach

Workers’ comp claim administrators are responsible for scores of private data, including both personally identifiable information and protected health information. Should any claims data be unlawfully accessed, the breach could violate HIPAA as well as non-health-related privacy protections.

Last year, Oregon’s State Accident Insurance Fund Corp., the state workers’ comp insurer, fell victim to a phishing attack that compromised the information of 1,750 people, including Social Security numbers in some cases.

A breach could trigger notification obligations and, as in the case of the Oregon state fund, provision of free credit monitoring for any account that may have been impacted. If any medical records are involved, there could be further fines or legal action.

9) Cumulative Trauma

Soft-tissue musculoskeletal injuries arising from overuse or poor ergonomics are persistent claim drivers. According to WCIRB, a California-based research and advisory firm, that state’s cumulative trauma (CT) claims have grown by 50 percent over the past decade.

This type of injury typically takes longer to heal and overall incur higher medical costs. WCIRB’s study found that at 18 months, “average CT claim medical costs are lower than those for specific injury claims,” but 80 percent of CT claims are open much longer than 18 months — sometimes a decade or more.  Over their lifespan, CT claims end up being 15 percent more expensive than an average specific injury claim.

10) Litigation Management

Going to court is a surefire way to dramatically drive up claim cost. Redentor Villanueva, workers’ compensation specialist for Panasonic Energy North America, said that “trying to walk the tight rope between workers’ comp and ADA accommodations” is a constant challenge, and workers’ comp litigation is one of his top concerns.

He said it is a top priority to “make sure we dotted our i’s and crossed our t’s, and haven’t violated any part of the ADA in terms of bringing injured workers back to modified duty positions.”

Several attendees emphasized the importance of communication in managing expectations and assuaging claimants’ fears. “Ultimately, improving communication for everyone involved should lead to an improved experience for all and more timely care,” commented one respondent.

Taking a claimant to court over suspected fraud is also a risky proposition. No payer want to waste money on rewarding a fraudster, but the legal expense might not be worth the battle.

“In civil cases, most juries will rule in favor of the claimant,” said Mario Pecoraro, president and CEO of Alliance Worldwide Investigation Group Inc.

In addition to their top challenges, attendees were also queried on the trends they believe will have the greatest impact on their program in 2019, the initiatives they’ve had success with so far, their priorities for the coming year, and the areas in which technology may have the greatest impact on their program. &

The R&I Editorial Team can be reached at [email protected].

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