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

4 Companies That Rocked It by Treating Injured Workers as Equals; Not Adversaries

The 2018 Teddy Award winners built their programs around people, not claims, and offer proof that a worker-centric approach is a smarter way to operate.
By: | October 30, 2018 • 3 min read

Across the workers’ compensation industry, the concept of a worker advocacy model has been around for a while, but has only seen notable adoption in recent years.

Even among those not adopting a formal advocacy approach, mindsets are shifting. Formerly claims-centric programs are becoming worker-centric and it’s a win all around: better outcomes; greater productivity; safer, healthier employees and a stronger bottom line.

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That’s what you’ll see in this month’s issue of Risk & Insurance® when you read the profiles of the four recipients of the 2018 Theodore Roosevelt Workers’ Compensation and Disability Management Award, sponsored by PMA Companies. These four programs put workers front and center in everything they do.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top,” said Steve Legg, director of risk management for Starbucks.

Starbucks put claims reporting in the hands of its partners, an exemplary act of trust. The coffee company also put itself in workers’ shoes to identify and remove points of friction.

That led to a call center run by Starbucks’ TPA and a dedicated telephonic case management team so that partners can speak to a live person without the frustration of ‘phone tag’ and unanswered questions.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top.” — Steve Legg, director of risk management, Starbucks

Starbucks also implemented direct deposit for lost-time pay, eliminating stressful wait times for injured partners, and allowing them to focus on healing.

For Starbucks, as for all of the 2018 Teddy Award winners, the approach is netting measurable results. With higher partner satisfaction, it has seen a 50 percent decrease in litigation.

Teddy winner Main Line Health (MLH) adopted worker advocacy in a way that goes far beyond claims.

Employees who identify and report safety hazards can take credit for their actions by sending out a formal “Employee Safety Message” to nearly 11,000 mailboxes across the organization.

“The recognition is pretty cool,” said Steve Besack, system director, claims management and workers’ compensation for the health system.

MLH also takes a non-adversarial approach to workers with repeat injuries, seeing them as a resource for identifying areas of improvement.

“When you look at ‘repeat offenders’ in an unconventional way, they’re a great asset to the program, not a liability,” said Mike Miller, manager, workers’ compensation and employee safety for MLH.

Teddy winner Monmouth County, N.J. utilizes high-tech motion capture technology to reduce the chance of placing new hires in jobs that are likely to hurt them.

Monmouth County also adopted numerous wellness initiatives that help workers manage their weight and improve their wellbeing overall.

“You should see the looks on their faces when their cholesterol is down, they’ve lost weight and their blood sugar is better. We’ve had people lose 30 and 40 pounds,” said William McGuane, the county’s manager of benefits and workers’ compensation.

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Do these sound like minor program elements? The math says otherwise: Claims severity has plunged from $5.5 million in 2009 to $1.3 million in 2017.

At the University of Pennsylvania, putting workers first means getting out from behind the desk and finding out what each one of them is tasked with, day in, day out — and looking for ways to make each of those tasks safer.

Regular observations across the sprawling campus have resulted in a phenomenal number of process and equipment changes that seem simple on their own, but in combination have created a substantially safer, healthier campus and improved employee morale.

UPenn’s workers’ comp costs, in the seven-digit figures in 2009, have been virtually cut in half.

Risk & Insurance® is proud to honor the work of these four organizations. We hope their stories inspire other organizations to be true partners with the employees they depend on. &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]