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Digital EditionThe Weight of Workers’ Comp: Understanding the Impact of Obesity Drugs on Claims
Obesity is widespread among the American public.
The Centers for Disease Control and Prevention’s 2021 National Health and Nutrition Examination Survey estimates that clinical obesity prevalence was 41.9% in the period of 2017 through March 2020, and troublingly, this number constitutes a significant jump from 1999, when prevalence was estimated at 30.5%.
During the same time, the prevalence of severe obesity increased from 4.7% to 9.2%.
Typically, obesity is not a condition that is compensable under workers’ compensation, however, the delayed recovery and surgery risks associated with obesity may drive some payers to consider extraordinary measures.
“Obesity can place a person at a higher risk for an injury because of the increased demands it places on the body,” said Dr. Robert Hall, M.D., medical director for Optum Workers’ Comp and Auto No-Fault. “Once an injury occurs, there’s a number of different ways that obesity can worsen the injury and negatively affect function and mobility.”
GLP-1 agonists, known under the brands Ozempic, Trulicity and several others, could prove an effective treatment for certain injured workers whose weight might be a comorbidity, but payers need to be aware of the cost, potential side effects, management strategies and attempts to offload expenses to comp.
How Does Obesity Affect Workers’ Comp?
While obesity is well-known to complicate workers’ comp claims, the issues start before an injury even occurs.
Hall noted that if a person is overweight, an injury can make it more difficult to perform very basic movements, such as range of motion exercises in physical therapy. That makes it difficult to work on the more complex exercises and activities they need to recover, like strengthening and endurance activities.
Another factor familiar to workers’ comp professionals is the prevalence of certain comorbid conditions for people with obesity, like high blood pressure, diabetes, and heart disease. All of those issues might further inhibit or limit an injured worker’s ability to participate in therapy.
“And these other comorbid conditions that are commonly found in overweight people can complicate an otherwise routine path toward recovery from an injury,” Hall said.
“Let’s say their doctor prescribes a short course of steroids to help treat a low back injury. If the injured person also has diabetes as a result of their obesity, those steroids may substantially increase their blood sugar levels. I’ve seen patients in my clinic where their doctors ultimately decided against prescribing steroids that would have likely helped with recovery, but were considered too high of a risk for the patient’s blood sugar control.”
He added that injuries to weight-bearing joints like hips and knees can be complicated by obesity because of the higher amount of forces, from the patient’s increased weight, acting on those joints. This leads to more pain and likely less progress with therapeutic activities.
Weight Loss in Workers’ Comp
Given this reality, GLP-1 agonists that result in rapid weight loss may seem like a viable option, however, it is paramount for stakeholders to consider compensability.
Robert Hall, medical director, Optum Workers’ Comp and Auto No-fault
Hall gave the example of several catastrophic injuries like a lower limb amputation, a spinal cord injury, or a traumatic brain injury where obesity could be compensable because a formerly active person developed obesity as a direct result of inactivity during recovery from the injury.
Alternatively, obesity could be clearly limiting the patient’s potential for recovery. He noted that the easier of the two is whether it’s compensable.
“The cases where it may not be so clear is when a person has a low back injury or knee injury and it’s determined that the surgery should not be done until they have lost a certain amount of weight. The decision might be made to provide these medications in order to increase the chances of a favorable surgical recovery,” Hall said.
“I would say that making these decisions and determinations will become more common because of the prevalence of obesity in this country, and secondly because these medications are very expensive and there will be times when there’s going to be attempts to help get these medications paid for by comp instead of through a group health plan, which will be significantly more expensive for patients.”
Consider the Side Effects
Other considerations that should influence a payer’s decision on GLP-1 agonists include side effects that can be severe. Documented common side effects can range from mild nausea to severe diarrhea, dehydration, and constipation.
“These drugs have the potential to cause several side effects that the injured worker needs to be acutely aware of before taking the medication,” said Teresa Bartlett, managing director and senior medical officer at Sedgwick. “We would not want to add other resources other than utilization management to this situation.”
“With any kind of new medication or treatment it’s important that the patient receives adequate education and knows about the preventative measures that they can take to at least minimize side effects,” Hall added. “I think about these medications as almost being like a medical procedure, where there’s a dramatic change in the patient’s body and how they digest foods. This is not like the typical treatment you expect from other medications, let’s say to treat pain or anxiety.”
He noted that a nurse case manager could monitor the patient more closely, especially for cost drivers in the claim stemming from the treatment of the side effects or from emergency care for GI problems. These cost drivers could compound a significant investment just for the medication itself — the list price for a monthly semaglutide injection is $936.
“They are very expensive medications,” Bartlett said. “It is important that these decisions be made with the client, claims examiner, and case/pharmacy manager. If there is an injured worker that has a problem with obesity that is inhibiting their ability to have a surgery or the necessary treatment, there should be a discussion around how long the medication will be paid and document how it will only be paid for a defined duration.”
A defined duration and compensability and appropriateness assessments will be the key way that workers’ compensation can mitigate the incoming wave. &
Hear more from Hall, alongside a panel of presenters, at National Comp 2024. For more information on session “The Incoming Wave of Weight Loss Medications in Comp: Is Your Program Prepared?,” and other topics, visit here today.
