Late Medical Interventions Drive Workers’ Comp Costs as Back, Shoulder Claims Show Wide Cost Variation

New WCRI research reveals surgical claims are up to nine times more likely to become high-cost cases, with timing of intensive care emerging as critical factor.
By: | August 13, 2025
back injury

A comprehensive analysis of workers’ compensation claims reveals that late resource-intensive medical care is the primary driver of high-cost claims across seven common back and shoulder injury categories, with costs varying dramatically by specific injury type, according to a new study by the Workers Compensation Research Institute.

The research examined nearly 195,000 claims across four back injury categories and three shoulder conditions, finding significant variation in both frequency and costs of high-cost cases.

“In a previous WCRI study, we identified factors that increase the likelihood of high medical payments by looking at all injury types together,” said Sebastian Negrusa, WCRI’s vice president of research. “This new study refines that analysis by focusing on back and shoulder injuries to better understand what contributes to higher claim costs.”

Injury Types Show Dramatic Cost Disparities

Degenerative back conditions led the way with 42% of claims exceeding $65,000 in medical payments within 36 months, while sprains and strains produced high-cost claims in just 1% of cases, according to the WCRI. Neurologic back pain and disc disorders generated high-cost claims in 10% and 13% of cases, respectively, while the three shoulder injury categories clustered in the 8-10% range.

However, the financial impact extended beyond frequency rates, according to the study. Medical payments for high-cost claims were six to seven times larger than non-high-cost claims for neurologic back pain and disc disorders, and roughly four times larger for shoulder injuries.

Two injury categories dominated both volume and costs: neurologic back pain and rotator cuff disorders represented 26-28% of all claims studied but accounted for 30-38% of total medical payments, the study found. Despite their lower frequency, degenerative back conditions commanded the highest per-claim costs, averaging $67,103 in medical payments and $150,455 in total costs.

Surgery and Care Timing Emerge as Cost Accelerators

The WCRI analysis identified several key factors that significantly increase the likelihood of high-cost outcomes. Surgical intervention emerged as a powerful predictor, with back surgery claims 8-9 times more likely to generate high costs compared to non-surgical cases. Rotator cuff surgery increased the likelihood of high costs by four times, the report noted.

The timing of resource-intensive care proved even more critical. Claims with late resource-intensive care patterns were 25 times more likely to become high-cost cases compared to those with no intensive care months. This late pattern, defined as having at least one month of medical payments exceeding $10,000 after the first year of treatment, appeared consistently across all injury categories studied, according to the study.

Comorbid conditions also played a substantial role in cost escalation. Claims involving degenerative comorbid conditions were 58% more likely to become high-cost, while mental health issues and sleep disorders increased the likelihood by 60-70%. These psychological and sleep-related conditions often go unaddressed in standard treatment protocols, despite their significant cost implications, the WCRI report noted.

Care coordination emerged as a protective factor. Claims where the initial provider continued delivering most services were less likely to become high-cost cases, the research showed. When surgical care remained with the same provider organization, the odds of high costs decreased by 62% compared to cases involving multiple surgical providers.

Strategic Implications for Claims Management

The study’s authors said their findings suggest several strategic opportunities for managing workers’ compensation costs more effectively. The identification of late resource-intensive care as the primary cost driver points to the importance of early intervention and proactive case management, particularly for the high-risk injury categories identified in the study.

The research also highlights the need for enhanced screening and treatment of mental health issues and sleep disorders, conditions that significantly impact claim costs but receive limited attention in current treatment guidelines. Early identification of these comorbidities could enable more targeted interventions to improve outcomes while controlling expenses.

Obtain the full WCRI report here.

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

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