The Question That Makes Behavioral Health Difficult to Implement in Workers’ Comp: Who’s Paying?

A biopsychosocial approach helps injured workers achieve better outcomes, but jurisdictional obstacles remain. Joe Berardo, CEO of Carisk, outlines the challenges and benefits of a more holistic approach.
By: | June 17, 2019

In health care, it’s understood that physical and mental recovery from an injury go hand-in-hand. Multi-disciplinary teams treat a patient’s body along with their emotional state, which in turn is impacted by a variety of factors including their network of social support, financial stability, sense of self-efficacy and more. A holistic, biopsychosocial approach secures the best outcomes.

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In workers’ comp, however, health care providers face unique challenges. Coordinating the best care can be stymied by legal and jurisdictional guidelines and procedures that vary state by state.

We spoke with Joe Berardo Jr., CEO of Carisk, about why behavioral health can be hard to implement in workers’ comp and why it’s worth shouldering the extra administrative burden anyway.

Risk & Insurance: What is Carisk’s role in the workers’ comp landscape?

Joe Berardo: We’re a care coordination company built on the premise of taking a “behavioral health first” approach. We look at the biological, psychological and social issues surrounding each individual and then put together care plans that appropriately reflect all of those influences.

We are putting the patient at the center of the care plan, which runs counter to the traditional workers’ comp paradigm.

In my experience, it’s been much easier to bring the medical clinical expertise into a behavioral health environment, rather than backing the behavioral health component into an existing managed care organization.

R&I: What has your experience been in managed care, and how did you bridge the gap between managed care and behavioral health?

JB: Previously I ran a group health plan, MagnaCare. We started an alternative dispute resolution program that helped to shape my thoughts about how legal and jurisdictional hurdles in workers’ comp keep behavioral and mental health issues out of the conversation.

The program essentially took lawyers out of the mix for the first 30 days of a claim, where the injured worker and the employer would agree to get whatever care was necessary as quickly as possible. After the first 30 days, the injured worker was free to get an attorney if they felt their issues were not being addressed.

It turned out to be very successful. The medical component of the program ran 40% below the market average in New York.

We are putting the patient at the center of the care plan, which runs counter to the traditional workers’ comp paradigm.

At the same time, I was reading a lot of the emerging science on the impact of behavioral health on physical recovery and learning about the prevalence of substance use disorder related to opioids in workers’ comp.

Joseph Berardo, Jr., Chief Executive Officer, Carisk

Having run the managed care plan, I knew it’s very difficult to bring a behavioral health mindset into a traditional managed care organization, because it’s not how the typical workers’ comp clinician has been trained to manage those cases.

They treat the injury, period. There was no room to consider whether this person has a history of depression or a substance use disorder, is obese, or lives alone vs. having a strong support system. There are many factors to consider that can impact the injured worker’s journey to physical recovery.

I realized that to effectively bring behavioral health into workers’ comp and navigate the jurisdictional challenges, we had to start with behavioral health first. So, I launched the business by partnering with leaders with a demonstrated track record for success in the workers’ compensation market.

We first focused on acquiring a managed behavioral health care organization, Concordia Behavioral Health, which was the first and only with dual accreditations from both NCQA and AAAHC.

Right off the bat, Concordia was looking at a 360-degree view of the patient, considering all the biopsychosocial factors impacting their outcome and coordinating care at a customer satisfaction level higher than the average. We then combined the medical/surgical expertise for catastrophic and complex cases into that environment.

R&I: How do jurisdictional factors limit or block the inclusion of behavioral health issues in workers’ comp?

JB: We have a huge issue in this space where the clinical approach to many injuries is driven by a jurisdictional legal structure. There are essentially three different payment systems for the same injury, depending on where it happened.

If you break your arm in your backyard, or in your car, or at work, there will be different systems and processes around how that injury is treated and financed. If it’s a compensable work-related injury, the workers’ comp carrier is only required to pay for that injury, not any underlying contributing factors. A lawyer or adjuster might say, ‘We’re not responsible for the whole patient. We’re only responsible for their arm.’

That’s why behavioral health has historically not been part of the workers’ comp conversation, because it’s viewed as a separate issue, and one that payers don’t want to be held responsible for.

But the reality is nobody recovers in a vacuum. If you’re not acknowledging the relationship between catastrophic and complex injuries, pain and mental health and truly dealing with all systems of the body, you’re not going to recover optimally.

R&I: What types of injuries are most likely to require an emphasis on behavioral health in the treatment plan?

JB: We work with both acute and non-acute catastrophic cases.

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In acute cases, the patient is usually spending the first few weeks after the injury in the ICU. We’re talking about very significant injuries like amputations.

In these cases, we get called in right away. We’re sending in a field trauma nurse to gather information. We’re reaching out to the family. We’re collecting the clinical records. We get all the information before we build a care coordination plan to ensure we understand this individual’s needs.

But the reality is nobody recovers in a vacuum. If you’re not acknowledging the relationship between catastrophic and complex injuries, pain and mental health, and If you’re not dealing with all systems of the body, you’re not going to recover optimally.

Catastrophic injuries have a huge mental health impact. These patients are being introduced to a new normal. We help them understand what to expect and work to keep their outlook positive, as well as move them through the pain medication regimen safely to ensure they’re not taking something stronger than what they need. We want to keep them from getting addicted by managing the emotional aspects of recovery as well as the physical.

But there are thousands of other non-acute cases where the injury is not significant, but issues just keep compounding on each other, and the patient isn’t making any progress. It could be someone with carpal tunnel who is just not advancing medically, so the case stays open for four or five years and the costs are up over $1 million.

In these cases, there is almost always a substance abuse or underlying psychological disorder that remains unaddressed.

We’ll evaluate all of the records on the case, which could include up to 10 years of data, and do a full biopsychosocial assessment. Once we evaluate all of the risk factors, we can build a care coordination plan that incorporates the factors that have been ignored.

R&I: How do you get carriers to get past those jurisdictional hurdles and be open to treating the whole patient?

JB: Carriers may not want to “buy” the psych diagnosis — but they own it regardless, because that psychological factor may be what’s keeping the claim on their books for years and years. And there are evidence-based, clinical protocols for addressing these behavioral comorbid factors; they’ve just never made their way into workers’ comp.

Today, more carriers are starting to understand that, and this industry is really ready to shift to this approach as a way of managing costs and improving outcomes for the injured worker.

To navigate those separate payment structures, we subrogate and coordinate back to the group health plan for treatment and services related to behavioral health if appropriate.

In group health, there is regulation called “mental health parity,” meaning they are required to cover mental health issues the same as any medical or surgical issue. The coverage is there, we just have to bring everything together to align the right care at the right time for injured workers.

Think of us as the air traffic controller on the recovery plan. We’re anticipating if a case is at high risk for running off track, bringing in the appropriate multi-disciplinary care team, both behavioral and physical medicine, and then directing the costs to the appropriate payer.

R&I: Which is more difficult — providing the care or navigating the payment processes?

JB: The administrative part is actually much harder. But I don’t feel like we’re anybody’s adversary. Every stakeholder has an interest in getting a patient better.

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The only time we end up as somebody’s adversary is if there’s a bad actor — a physician prescribing what they shouldn’t, or a patient trying to take advantage of the system. We’ve had a few of those where we uncover redirection of medicine for example.

In reality, we have helped to bridge the gap between the patient and the payer and in the majority of cases this leads to solution-oriented plans that both are aligned to.

We hear often, “I don’t know what I would do without your help” and that gets to the heart of who we are. Our mantra inside the company is to do well by doing good and you’ll find that mindset at every level of this organization. &

Katie Dwyer is a freelance editor and writer based out of Philadelphia. She can be reached at [email protected]

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