Catastrophic Thinking Derails Injured Worker Recovery; Here’s How to Manage It

By: Mariellen Blue | April 9, 2019

Mariellen Blue, RN, CCM, is national director of case management at Genex Services where she is responsible for overall product management and development, as well as regulatory compliance, accreditation, and quality assurance initiatives related to utilization management, telephonic and field case management, IME, and MCO services. A graduate of the Helene Fuld School of Nursing, Ms. Blue has an extensive background in nursing, case management and utilization review.

Delayed recovery is a challenge coming to the forefront of workers’ comp. It’s defined as a lack of anticipated functional recovery in a medically reasonable period of time. Recently, many organizations have been seeking new ways — whether through telephonic or field case management services — to identify injured employees who are at risk for delayed recovery.

For years, we’ve used predictive modeling to identify cases that score high for delayed recovery, using factors like age, gender and comorbidities, such as diabetes, obesity, smoking or substance abuse. These are proven biological factors that can lead to delayed recovery, and we’ve implemented clinical interventions to address them.

However, there are still many delayed cases that aren’t attributable to these traditional biological factors. Today, the industry must delve deeper into cases and identify potential psychosocial issues that could be at the root of the reason why certain cases don’t progress as expected.

Delayed Recovery: A Tale of Two Cases

Let’s consider two individuals. Both are men of the same age with approximately the same health status. They hold the same position and sustain the same low-back injury. Neither individual has a comorbidity. On paper, the cases seem identical. However, each case results in significantly different outcomes.

The first patient attends all of his medical appointments. His pain level gradually decreases, while his functionality improves. This individual returns to work within a reasonable period of time, slightly ahead of evidence-based guidelines.

There have been studies that show 64 percent of people who have low back pain are actually afraid to move.

Meanwhile, the second patient struggles. He has difficulty keeping his appointments. He seems to experience a higher level of pain. He’s not compliant with his prescribed at-home exercise program.

The case soon exceeds typical treatment guidelines for this type of injury. The patient ends up staying on pain medication for a much longer period of time and is not experiencing the expected level of recovery. What factors make this second case different from the first?

Identifying Psychosocial Issues

Research over the past few decades has shown that psychosocial issues can have a significant impact on recovery rates. Having psychosocial issues doesn’t mean individuals have a psychiatric disorder; instead, they may exhibit minor cognitive distortions, which relate to how they think and feel about a situation. These individuals are fine during the course of normal life, but when presented with an added stressor, like a painful work-related injury, they may experience a tense and fearful response.

Nurse case managers are uniquely positioned to recognize when cognitive, emotional or social barriers may be at play. For example, injured employees may not tell supervisors or doctors about their fears or family problems, but they may have built up enough rapport with case managers to share such information with them.

In addition, nurse case managers are trained to listen for queues that may indicate cognitive distortions. For example, in talking with an injured employee, a nurse case manager may sense an exaggerated fearful response to pain.

There have been studies that show 64 percent of people who have low back pain are actually afraid to move. Since they’re experiencing pain, they think that if they move — such as doing their prescribed home exercises — the condition will become worse, so they don’t comply.

However, by remaining immobile, they become stiffer. Their muscles tighten up, and the pain might increase due to a lack of movement. This is condition is called “disuse syndrome” and as the name implies the individual may experience muscle atrophy from a lack of activity. Their initial fear — that pain will cause their condition to become worse — has become a self-fulfilling prophesy.

Recognizing Maladaptive Coping Strategies

Injured employees may exhibit other irrational fears.

A 2015 WCRI study showed that people who had a fear of being fired due to their workplace injuries could experience a four-week increase in their average duration of disability.

A big issue may be “catastrophic thinking,” where injured employees may feel as if their injury is the end of the world. Their thoughts may go something like this: I have a low back injury. It’s really painful. I’m never going to recover. I’m going to be disabled for the rest of my life, and I’ll never be able to provide for my family again.

The fears create a snowball effect, becoming bigger and bigger in their minds. Nurse case managers will identify individuals with this type mindset. For example, closely related to catastrophic thinking is a feeling of fateful injustice: If only I hadn’t come to work that day, this never would have happened to me.

These expressed feelings often indicate maladaptive coping mechanisms. Perhaps these individuals have not had to develop positive adaptive behaviors to get them through a time of crisis or stress. Because of this, when something stressful happens, they become practically incapacitated by their own negative thoughts and fears.

Related: Less CBD, More CBT: Exploring the Mind/Body Connection in Workers’ Compensation

Social factors can also contribute to an inability to cope. For example, an injured employee may have a difficult home life. This situation may not impact everyday life, but a weak social support system could fall apart in the face of an added stressor, like an injury.

Utilizing Questionnaires to Identify Psychosocial Risks

To pinpoint psychosocial issues, nurse case managers may use a patient questionnaire. An example of one that’s used to identify delayed recover is the Örebro Musculoskeletal Screening Questionnaire (OMSQ) Short Form (Gabel, C. P 2012). This short version uses 12 questions.

The questionnaire is filled out by the patient, and it collects information about how the person is feeling, if he or she is able to manage a daily routine, and it detects unhealthy perceptions or low social support.

The OMSQ Short Form produces a score, which can then be used as a predictor for risk of delayed recovery or the potential for chronic symptoms, including delayed return to normal daily activities or work. A higher score indicates a higher risk. The resulting score would be categorized as follows:

Low risk — below 57 points
Medium risk — between 57 and 72 points
High risk — greater than 72 points

Ideally, the questionnaire would be administered within the first 30 days of an injury or within the first two visits to a treating physician. If the injured employee has already exceeded treatment guidelines, the questionnaire can still be administered and can still be useful. But optimally, the earlier the risks are identified, the earlier that strategies can be applied to prevent a case from going off track.

The risk factors could also be discussed with treating physicians, so they’re aware of the non-medical issues affecting the patient. Physicians may decide to handle treatment differently. For example, they might prescribe cognitive behavioral therapy to help alleviate fears or other distorted thoughts.

The Role of Case Management

Nurses are trained to listen to what injured employees say, why they’re saying it, and if they represent issues hindering their recovery. That’s why they’re often the ones to suggest a questionnaire be administered, although treating physicians may also request them.

Throughout a claim’s duration, nurse case managers will encourage injured employees to take responsibility and play an active role in their own care and recovery. With added information from the questionnaire, they can better understand the underlying thoughts and feelings delaying progress.

Once high-risk cases are identified, nurses work with employers to aggressively utilize transitional or modified duty. It’s important to get these individuals re-engaged in the work setting and have a return-to-work mindset as soon as possible.

Nurse case managers also work to reframe an injured employee’s unhealthy thought process by establishing proper expectations: Yes, you’re injured but you’re going to gradually recover, and the pain will eventually go away. You’ll actually make faster progress if you consistently perform your home exercises.

They also get injured employees to focus on function rather than pain. For example, they may set functional goals: Within two weeks, if you consistently attend your physical therapy appointments, you should be able to walk your dog again and take the stairs.

And of course, case managers are also there to provide positive reinforcement: Fantastic! Look at the progress you’ve made!

In the end, the longer injured employees are out from work, the less likely they’ll be able to return. That’s why it’s vital to catch psychosocial issues early, so injured employees can be provided with the cognitive behavioral tools they need to successfully cope with a stressful, painful injury, to comply with care, and not reach a state of delayed recovery.

Vermont’s Future Is Golden

Challenging market conditions are driving insureds to captives. Vermont offers a reliable domicile.

By: State of Vermont | November 21, 2024

Hard markets in commercial insurance lines have been a problem for years now. Many lines don’t show signs of softening, though some, like cyber, have ebbed over the past few years.

High claims volumes and costs have caused carriers to tighten terms and conditions, introduce new exclusions and increase premiums. A variety of different risks are included in this market tightening, and it’s affecting both public and private companies.

As Sandy Bigglestone, deputy commissioner for the State of Vermont’s captive insurance division, explained, schools, churches and other nonprofits are contending carriers are “excluding sexual abuse and molestation from coverage for a lot of these types of entities. These organizations understand the risk and the public needs to have confidence the organizations are addressing the risks, so they must have the coverage.”

Though many commercial lines are affected, property has perhaps been hit the hardest. Increased claims, inaccurate property valuations and other challenges have caused insurers to tighten their books in recent years. 2024’s spate of hurricanes will likely make matters worse.

“There continues to be challenges in the commercial market,” Bigglestone said. “Some companies are coming to us with risks that they say they’ve been self-insuring on their balance sheet, and why not transfer that to a captive to receive greater benefits?”

Consistency and Stability

Sandy Bigglestone, Deputy Commissioner for the State of Vermont’s Captive Insurance Division

With the commercial insurance market so unstable, companies are turning to captives to house their exposures. Vermont, a long-time domicile, is getting increased attention because of their strong reputation and their leadership as the top domicile worldwide.

“All stakeholders enjoy the stable political and regulatory environment Vermont has to offer to operate in,” Bigglestone said.

Of course, a lot of consideration goes into deciding whether or not a captive is the right choice for a particular company. Businesses need to assess their exposures and their books to make sure they can adequately operate a captive.

There are significant advantages, however. “For low frequency, high severity risks, captives can access the reinsurance markets directly, so it’s very attractive for businesses to put a captive in place,” Bigglestone said.

And carriers are more accepting of captives as part of a broader insurance program.

“Captives are changing the relationship businesses have with commercial carriers,” Bigglestone said. “Commercial carriers are wanting to see companies with skin in the game; therefore, the relationships have evolved to be less transactional and more strategic.”

Balancing Bureaucracy

With 76 global domiciles, companies have a lot of options when it comes to selecting a captive partner. “Captive insurance domiciles compete globally for the business,” Bigglestone said. “If you were to put all 7,000-plus captive insurance companies around the world, all in New York, it wouldn’t have the same economic impact as 700 captives in Vermont does. The captive insurance industry is very important to our state and we will continue to support it in any way we can.”

Businesses should look for domiciles that balance a need for quality regulations with a process that isn’t overly bureaucratic and is seamless for business owners to navigate.

“Companies are attracted to an environment with quality regulatory standards and a stable regulatory environment,” Bigglestone said. “Vermont sets the regulatory standard in terms of financial analysis and examinations.”

In addition to quality regulations, firms will want to seek out a domicile that is agile enough to license captive insurance companies that fit their unique needs. It is important that a domicile have firm but fair regulation and the experience to consider new ideas and implement them. Companies must consider a variety of factors when choosing a domicile and not everyone will be the right fit for every company.

“You have to consider the captive owner and the industry sector that that owner operates in, as well as the insurance risks that are going into the captive program,” Bigglestone said. “Captive laws and regulations have to have a reasonable degree of flexibility to accommodate all the varying needs of owners and then impose rules based on the merits of each captive program.”

She added that creativity is a critical part of the process: “The ability to vet concepts and ideas with trusted individuals is key to having quality standards,” Bigglestone said. “And it can make captives appealing to insureds who are tired of commercial carriers not meeting the needs of the business, and who desire more control over their insurance programs.”

“When you think about the commercial marketplace, commercial insurers are supposed to operate in each jurisdiction in a competitive manner. Commercial carriers often look the same. They sell auto coverage to anyone with a driver’s license. The rules and regulations imposed upon commercial insurance companies are designed to be more formulaic for that reason,” Bigglestone said.

“Uniform regulatory standards apply to commercial carriers for the protection of the policyholders. These are standards all insurance regulators focus on, and standards captive insurance regulators need to understand, but with a specialized focus.”

A Quality Domicile Built for the Future

A combination of experience, regulatory standards and talent make Vermont a top domicile for companies looking to form a captive. The longevity of licensing captive insurance companies for over forty years is a testament to the quality work they’ve provided in the past and will continue to provide for many years to come.

Vermont’s reputation has helped the state attract and retain top captive talent, ensuring the businesses it serves are in good hands. The state has 32 employees dedicated to captives, and their average employee retention is 15 years. The Vermont Captive Insurance Association, the largest captive insurance trade organization, also helps companies connect with professional services needed to make their captive successful.

“There’s a whole host of service providers with proven expertise right here in Vermont,” Bigglestone said.

Taken together, Vermont’s resources, expertise and talent make it a prime domicile. They’ve been on a growth trajectory over the last few years and that’s unlikely to change anytime soon. Companies can trust their captive will be in good hands when they choose Vermont.

“Vermont has always competed on quality,” Bigglestone said. “We do have a mission and that hasn’t changed in over 40 years. It’s to maintain a system, or domicile that attracts quality business to Vermont, to promote our reputation in the industry, and to uphold a regulatory framework to protect the solvency of the companies that choose to place their business here.”

To learn more, visit: www.vermontcaptive.com

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with State of Vermont. The editorial staff of Risk & Insurance had no role in its preparation.

The State of Vermont, known as the “Gold Standard” of captive domiciles, is the leading onshore captive insurance domicile, with over 1,200 licensed captive insurance companies, including 48 of the Fortune 100 and 18 of the companies that make up the Dow 30.