Much of the discussion around coverage of PTSD by worker’s compensation has centered on first responders, and more state workers’ comp bureaus are recognizing PTSD as a compensable injury among this population.
While that’s a step in the right direction, the prevalence of PTSD among injured workers in other occupations remains underestimated. Anyone who has suffered a life-changing catastrophic injury or witnessed a violent event can experience the symptoms of PTSD.
The impact of PTSD on physical health outcomes likewise remains underappreciated. That prevents injured workers from receiving the multidisciplinary care they need to fully recover. A lack of understanding around how best to treat PTSD persists in workers’ comp.
However, the industry is waking up to the importance of taking a more holistic approach to treating injured workers — one that considers physical, mental and social factors together. That shift is driven by the entrance of new leaders who have a 360-degree perspective on the barriers that exist in healthcare and workers’ comp — and want to tackle them head-on.
One of those new leaders, Alana Letourneau, is not your typical MD. In addition to a medical degree, she also earned an MBA from NYU and a neuroscience degree from Princeton. Her experience includes conducting research on neuroplasticity, traumatic brain injury and PTSD, as well as working with data analytics and health technology.
As Vice President of Clinical Strategy for Carisk, Letourneau has found a way to pull all of this together to make a difference in the lives of injured workers.
“I’ve always noticed a number of barriers within our healthcare system that exist around the psychosocial aspects of recovery. For the most part, the connection between mental and physical health is simply not addressed in patient care, especially in workers’ comp,” she said.
Letourneau has worked to break down those barriers by demonstrating the impact of PTSD on medical outcomes and building a model to capture mental health factors that too often slip through the cracks.
At NYU, Letourneau led a study examining the correlation between traumatic brain injury (TBI) and PTSD among 150 survivors of torture. Some of these participants had experienced either a TBI alone or PTSD alone, while others experienced both.
“There’s a common cluster of physical symptoms following traumatic brain injury known as post-concussion syndrome, which can include headache, dizziness, ringing in the ears and difficulty sleeping,” Letourneau said. The severity of these symptoms, in conjunction with PTSD criteria established by the Harvard Trauma Questionnaire, were used to create a physical health score for each patient.
Those scores —representative of overall health outcomes — were subsequently tracked over a four-year span. The results highlight how tightly PTSD is bound to physical health.
“We discovered that individuals with more severe PTSD scores experienced worse physical health. Those patients who only had traumatic brain injury but did not have PTSD had fewer physical symptoms than patients who had both traumatic brain injury and PTSD,” Letourneau said.
“In other words, PTSD was driving the severe physical health symptoms, not just the head injury. Addressing psychological health, therefore, can really improve physical function.”
Within the realm of workers’ comp, other studies have shown how PTSD contributes to poor outcomes. Claimants with PTSD have more medical visits and higher rates of absenteeism over the long term, and therefore are more likely to become unemployed. This occurs independent of any other physical injury involved.
“In general, research has shown improved health outcomes in injured workers who participate in a biopsychosocial model of care. Those improved outcomes include reduction of pain, reduction of mental health symptom severity, as well as a reduction in the time it takes to return to work,” Letourneau said.
Workers’ comp payers and the healthcare system in general are increasingly recognizing the importance of addressing psychological, emotion and social factors in order to achieve optimal medical outcomes. But that hasn’t translated into a consistent, evidence-based approach to care.
Potentially the biggest barrier to treating PTSD in workers’ comp is the determination of compensability. Every state seems to treat PTSD differently; some recognize it as a compensable injury among first responders only; others require an underlying physical injury that gives rise to PTSD; still others address the issue on a case by case basis, placing the burden of proof on claimants to show that the conditions that caused their PTSD are outside the normal conditions of their employment.
Payers often hesitate to delve into mental health conditions because unlike physical injuries, their cause is not always cut-and-dry.
“In our referred cases, we find we have the most success by proposing multi-disciplinary, integrated solutions. Not surprisingly, research has shown significant co-occurrence of mental health conditions, including PTSD, in chronic pain cases. Other research has demonstrated that psychosocial factors are the number one barrier in cases of delayed recovery. Since the relationship between mental health and physical health conditions is bidirectional, determining the direction of causality can be indistinct. Therefore, it’s important to address both aspects equally,” Letourneau said.
Along with Carisk’s Vice President of Clinical Services David Vittoria, Letourneau helped to develop a biopsychosocial model that identifies mental health and social risk factors and connects patients to the appropriate services and providers.
“We conduct a biopsychosocial assessment that covers the patient’s medical, psychological and social needs. We’ll also speak with their current providers and their social support system, whether that’s friends or family members or another caretaker,” Letourneau said. “Through that assessment, we’re looking to identify potential barriers, risks, interventions, as well as expected outcomes on the case.”
That information is synthesized into a detailed recommendation for the treatment and services required for this patient and delivered to the payer in the form of a Care Coordination plan. The Carisk team’s research and direct clinical experience with trauma and PTSD patients enables them to make sound, scientifically-backed recommendations that payers can trust.
“Having that in-house expertise is critical. We know what types of therapy would be most appropriate for this individual and we can direct them to the right specialists. We often will match the therapist with the patient based on the therapist’s level of experience, treatment modality, location, and other characteristics,” Letourneau said.
For example, a recent female patient with PTSD was specifically matched to a female therapist because of her prior history as a victim of abuse. “Having a female trauma counselor was really important to this patient,” Letourneau said.
“At Carisk we truly approach the patient from an integrated care perspective. As a managed behavioral healthcare organization, we’re positioned to connect all the right providers and services to address the psychological and social factors underlying an injury.”
To learn more about Carisk’s services, visit http://www.cariskpartners.com/main/.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Carisk Partners. The editorial staff of Risk & Insurance had no role in its preparation.
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.
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.
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. &