We Surveyed 669 Workers’ Comp Pros About Their Critical Challenges for 2020. Here Are the Top 10

Some concerns were consistent with last year’s findings, but others show a shift in what worries WC professionals the most.
By: | January 27, 2020

For the second year running, Risk & Insurance®, sponsored by Healthesystems, canvassed attendees of the National Workers’ Compensation and Disability Conference© & Expo to determine what trends and challenges they’re focused on for the year ahead.

A total of 669 people responded, representing every corner of the workers’ comp industry — TPAs, PBMs, hospitals and other medical providers, employers, insurers, brokers and regulatory authorities.

Some of their top concerns remained consistent with last year’s findings — rising cost of care and claim complexity, for example — but other concerns made a conspicuous jump to the top of the list.

According to the survey results, here are the top 10 challenges workers’ comp professionals expect to contend with in 2020:

1) Changing Workforce Demographics

The top concern among workers’ comp professionals was changing workforce demographics — primarily, the rising average age of the American employee.

Seventy percent of survey respondents said that the aging workforce will make a big or very big impact on their workers’ compensation program next year.

According to the Bureau of Labor Statistics, more adults over age 55 are staying in the labor force longer. By 2026, participation on the workforce will increase among all Americans above retirement age.

That poses several challenges from a workers’ comp perspective.

For one thing, older workers are more prone to some injuries. For another, they are more likely to present with comorbidities, making their injuries more difficult, time-consuming and costly to treat.

Dr. Robert Goldberg, chief medical officer, Healthesystems

“The high incidence of chronic conditions among Americans aged 50 and over makes it more likely that these patients will experience complications and lengthier recovery times,” said Dr. Robert Goldberg, chief medical officer, Healthesystems.

“It’s important to note, however, that people of all ages suffer from chronic conditions, and it is the presence of comorbidities that increases risk, rather than age itself.”

Younger workers, however, are also introducing complex risks into the mix. Forty-one percent of respondents said younger workers will make a significant impact on their workers’ comp program.

Mental health is a larger concern among this demographic, and the entrance of a new generation into the workforce is driving up concern over mental health exposures overall.

“The increase in psychosocial issues that complicate a workers’ comp claim has been on the rise over recent years, with my employer seeing a profound uptick in this particularly among our under 30-year-olds,” said Caryl Russo, senior vice president, Corporate Care, RWJBarnabas Health.

2) Comorbidities and Poor Worker Health

Sixty-two percent of survey respondents placed comorbidities and poor worker health in their top five concerns for 2020.

Treatment of simple injuries can be hampered by the presence of conditions like obesity, diabetes, hypertension and chronic pain, among others.

One-third of American adults are obese. According to the American Diabetes Association, at least 9.4% of Americans have diabetes. About 20% report having chronic pain, and studies have shown the cost of care to be about three times higher for these patients.

Advertisement




When pharmacy is involved, drug safety and efficacy can be impacted by preexisting conditions and their accompanying medication regimens. The risk of adverse interactions increases. Physical therapy might also prove difficult for people who have limited mobility or difficulty exercising.

Having multiple health conditions delays recovery and is a recipe for depression and anxiety.

“The presence of one or more comorbidities — at any age — is a red flag for potential drug interactions and adherence issues that can complicate treatment,” said Dr. Goldberg. “Medication management is always important and even more so for patients with comorbidities.”

All of these issues are more ubiquitous among older workers. Among adults over 65, for example, the prevalence of diabetes is closer to 25%.

“The significant increase in employee obesity and decreased muscle health have contributed to the increase in both frequency and severity of injuries,” said Russo.

“This trend has been observed over the past decade with the average worker being 10-12 pounds heavier and nearly 13% weaker in muscle strength. This has compounded the nature of injuries, the occurrence of injuries and the slower recovery. When combined with an aging workforce, the risk is increasing exponentially,” Russo said.

3) Increasing Claim Complexity

In last year’s survey, the growth of complex claims made an appearance in respondents’ top five challenges, but results show that concern over this trend is strengthening.

This year, 65% of respondents ranked this as one of their top challenges for 2020, just behind an aging workforce.

Caryl Russo, senior vice president, Corporate Care, RWJBarnabas Health

Claims complexity is a summary of all the individual challenges that keep workers’ comp professionals up at night.

Factors that create complex cases include worker age, comorbidities both physical and mental, high cost of care, substance dependence and abuse, and ineffective clinical decision making.

Poor decisions may result from lack of adherence to evidence-based guidelines or lack of alignment around a treatment plan.

Some or all of these issues can converge to send a seemingly simple claim off the rails, but case manager workload is part of the problem, too.

Many claims professionals simply don’t have the time or resources to check in on cases as frequently as they should or to examine alternative treatment plans. Getting complex cases back on track will require more investment in proactive claim management that brings medical professionals, adjusters and case managers together at one table.

4) Mental Health Exposures

Consideration of mental health has previously been restricted to post-traumatic stress disorder (PTSD) in first responders, but more states are acknowledging “mental-only” injuries as compensable.

According to a 2018 report by NCCI, at least 16 states have considered legislation expanding coverage for mental-only injuries, including but not limited to PTSD.

It is still difficult, however, for employees to file claims purely related to work-related stress because the burden of proof is high.

They must prove that the stress they experienced was out of the ordinary and that they suffered demonstrable harm because of it.

“It’s interesting to note that claims managers and medical program managers ranked mental health concerns more highly than other survey responders,” Dr. Goldberg noted.

Advertisement




“That could mean that they are seeing more mental health issues among their claims populations, which might be expected since reported symptoms of anxiety, stress and depression have been increasing over the past several decades.”

But even if the claim isn’t directly related to a mental health condition, it’s indisputable that emotional stress, depression and anxiety not only increase the likelihood of physical injury but also inhibit a full and quick recovery.

“The approach I have implemented and seen mirrored by other large employers has been to carefully identify neuropsychologists who can provide in-depth testing to determine the extent of the condition and to provide an assessment of causality,” Russo said.

“Although this is a more expensive approach, my experience has been that it is a resource well utilized, and it enables us to get employees to the right level of care — whether through comp or personal health insurance — much quicker.”

5) Regulatory and Legislative Changes

As always, staying current on workers’ comp legislation is a moving target. According to the NCCI, there were nearly 700 state and federal workers’ comp bills introduced in 2019, 84 of which had been passed in the first half of the year.

Most of them had to do with fee schedules and treatment guidelines meant to optimize quality of care while containing cost. Another trend, however, has seen the broadening of employee rights, allowing them to sue employers over their injuries or for a lack of compliance with paid leave regulations.

Monica Manske, senior manager of workers’ compensation and employee safety at Rochester Regional Health

“Most concerning is not a concern but a recognition of additional complexity is the increasing number of paid and unpaid family leave programs,” said Monica Manske, senior manager of workers’ compensation and employee safety at Rochester Regional Health

“The increase in opportunity for leave provides a greater work-life balance, certainly responds to concerns with a larger aging population, which are all the right thing to do.  From an operational perspective it provides additional complexity in how you manage your leave programs,” she said.

6) Opioids and Substance Abuse

Though opioids still rank as a top challenge for 2020, concern over the addictive painkiller has waned slightly.

Opioids are still prevalent and problematic, but greater awareness of their deleterious long-term effects has helped to curb prescribing in the workers’ compensation industry.

“We have made progress in limiting opioid use in workers’ comp,” confirmed Dr. Goldberg.

“But there is still a great deal of opportunity for further improvement, and we must remain vigilant. There are other medication classes that are increasing in use to treat pain, such as NSAIDs and anticonvulsants, which are not addictive like opioids but do carry their own risks and potential side effects.”

A drug utilization study from California showed that NSAIDs have surpassed opioids as the most commonly prescribed pain medication for injured workers.

According to Manske, however, opioids will likely never stop being a challenge, because they still have a place in the care plans of seriously injured workers.

Advertisement




“The industry has a better handle on opioid use. States are now installing treatment guidelines related to opioid use, there are more checks and balances in the workers’ comp system, the insurance carriers and TPAs have pharmacy consults, PBMs have greater infrastructure,” she said.

“What I do not want to lose sight of in all of the checks and balances related to prescribing opioids is the patient — the employee who has had an injury. What is the best plan of care for them?”

7) Soaring Drug Prices

The sky-high cost of prescription medication is nothing new, and pharmacy remains a top driver of overall claim costs.

The Journal of the American Medical Association reported that, in 2018, three-quarters of the top-selling brand name drugs had increased in cost by more than 50%, and nearly half had doubled in price.

The workers’ compensation industry has been able to combat this trend by reining in utilization and taking advantage of generic alternatives. According to a 2018 report the NCCI, pharmacy costs as a share of total medical spend have remained stable, hovering around 13.7%.

Nonetheless, 26% of respondents said prescription drug costs were the medical cost component they were most focused on for 2020.

The only cost driver demanding more attention was hospital costs.

The development of new medications, unpredictable fluctuation in market value, and a general lack of transparency in drug pricing all make this challenge an ongoing one.

8) New and Expensive Medical Treatments

Advances in medical treatment often promise safer, more efficient and less invasive ways to help patients get better, but it takes time to prove these assertions true. The unconfirmed potential of new treatments and medications also comes with an increased risk of failure, which translates to wasted time and money.

Patti Colwell, workers’ compensation program manager, Southwest Airlines

“Medical technology continues to advance quickly and often turns out attractive new modalities that hold promise; however, the science to determine what is evidence-based treatment takes longer. Accordingly, payers and injured workers need to be patient and not jump quickly at the next great shiny technology that hits the marketplace,“ Dr. Goldberg said.

Fifty-six percent of survey respondents agreed with the statement “medical advances and new treatments present new opportunities for fraud, waste and abuse.”

Reliance on evidence-based guidelines and utilization review can help to minimize these risks, but they are likely to be become more challenging as technology enables the rapid emergence of new treatment modalities.

Increasing cost of care complicates the matter. According to The Center for Medicare and Medicaid Services, health care costs have increased from 5% of the GDP in 1960 to 18% in 2017 and will likely represent 19% of the GDP in 2027.

By that time, annual costs will break down to about $17,000 per person.

Employers and adjusters will be faced with difficult decisions as they struggle to balance the quality and cost of care.

“New medications coming down the pipeline are often a cause for concern since they are often extremely expensive,” said Patti Colwell, workers’ compensation program manager, Southwest.

“That said, if a specific medication or other treatment can enable an injured worker to resume prior lifestyle, improve quality of life or enable an injured worker to recover/rehab more quickly, it should be evaluated no matter what the cost,” Colwell said.

“I believe it will be incumbent upon TPAs and self-insured employers to curb rising costs by contracting directly with care providers and negotiating bundled fees, which will help to control administrative costs, medical review, and oversight,” Russo said.

9) Cyber Security and Protection of Private Data

Technology is reshaping the way that providers deliver care and the way that the industry manages claims.

More providers and insurers are interested in telemedicine as a way to deliver quality care while increasing efficiency. For injured workers, attending medical appointments from the comfort of home eliminates transportation barriers and reduces the frequency of missed appointments.

These platforms also help administrators collect data.

Advertisement




Data-driven predictive analytics are playing a bigger role in clinical decision making and claim management. Nearly all TPAs and PBMs are using a predictive analytics platform to help prioritize and flag high-risk claims.

Automated claims processing solutions have also been identified as an emergent tool in workers’ compensation. These help adjusters better allocate their time for high- and low-risk claims, respectively.

All of these tools, though, offer hackers another entry point to private claim information. The more technology is brought to bear, the more cyber risk increases. A breach of claims data can result in steep fines for HIPAA violations, reputational damage and, at worst, interruptions in care for injured workers.

“Cyber risk is a fact of life now in every venue of our lives; medicine is no exception but with more serious consequences,” Russo said.

10) Medical marijuana

Medical marijuana is legal in at least 33 states, and it’s likely the remaining states will join them sooner rather than later.

More than half of survey respondents (57%) think medical marijuana will be covered by workers’ compensation insurance in more states over the next two to five years.

Cannabis has been touted as a safe, less addictive pain treatment and as a way to fight the scourge of opioids.

But weed in the workplace also presents its own safety risks. Especially in sectors like construction and manufacturing, where impaired workers operating heavy machinery could cause severe injury or death. Yet, employers in states with legalized weed have been met with legal challenges over the use of impairment testing.

“We need more research regarding medical marijuana,” said Dr. Goldberg.

“There is some clinical evidence that cannabinoids are effective in treating pain and that products with low amounts of THC may offer clinical benefit without euphoric effects. But more clinically valid studies are needed to determine efficacy, safety and proper dosing.”

Though the industry is seeing more requests for reimbursement for medical marijuana, there remain many myths and misconceptions about its safety and efficacy. The variance in state regulations also makes it difficult for employers spanning multiple regions to form a consistent approach.

Only time will tell how all of these challenges take shape in 2020, but all are likely to remain topics of discussion at this year’s NWCDC. &

Katie Dwyer is a freelance editor and writer based out of Philadelphia. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

Risk Scenario

The Betrayal of Elizabeth

In this Risk Scenario, Risk & Insurance explores what might happen in the event a telemedicine or similar home health visit violates a patient's privacy. What consequences await when a young girl's tele visit goes viral?
By: | October 12, 2020
Risk Scenarios are created by Risk & Insurance editors along with leading industry partners. The hypothetical, yet realistic stories, showcase emerging risks that can result in significant losses if not properly addressed.

Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.

PART ONE: CRACKS IN THE FOUNDATION

Elizabeth Cunningham seemingly had it all. The daughter of two well-established professionals — her father was a personal injury attorney, her mother, also an attorney, had her own estate planning practice — she grew up in a house in Maryland horse country with lots of love and the financial security that can iron out at least some of life’s problems.

Tall, good-looking and talented, Elizabeth was moving through her junior year at the University of Pennsylvania in seemingly good order; check that, very good order, by all appearances.

Her pre-med grades were outstanding. Despite the heavy load of her course work, she’d even managed to place in the Penn Relays in the mile, in the spring of her sophomore season, in May of 2019.

But the winter of 2019/2020 brought challenges, challenges that festered below the surface, known only to her and a couple of close friends.

First came betrayal at the hands of her boyfriend, Tom, right around Thanksgiving. She saw a message pop up on his phone from Rebecca, a young woman she thought was their friend. As it turned out, Rebecca and Tom had been intimate together, and both seemed game to do it again.

Reeling, her holiday mood shattered and her relationship with Tom fractured, Elizabeth was beset by deep feelings of anxiety. As the winter gray became more dense and forbidding, the anxiety grew.

Fed up, she broke up with Tom just after Christmas. What looked like a promising start to 2020 now didn’t feel as joyous.

Right around the end of the year, she plucked a copy of her father’s New York Times from the table in his study. A budding physician, her eyes were drawn to a piece about an outbreak of a highly contagious virus in Wuhan, China.

“Sounds dreadful,” she said to herself.

Within three months, anxiety gnawed at Elizabeth daily as she sat cloistered in her family’s house in Bel Air, Maryland.

It didn’t help matters that her brother, Billy, a high school senior and a constant thorn in her side, was cloistered with her.

She felt like she was suffocating.

One night in early May, feeling shutdown and unable to bring herself to tell her parents about her true condition, Elizabeth reached out to her family physician for help.

Dr. Johnson had been Elizabeth’s doctor for a number of years and, being from a small town, Elizabeth had grown up and gone to school with Dr. Johnson’s son Evan. In fact, back in high school, Evan had asked Elizabeth out once. Not interested, Elizabeth had declined Evan’s advances and did not give this a second thought.

Dr. Johnson’s practice had recently been acquired by a Virginia-based hospital system, Medwell, so when Elizabeth called the office, she was first patched through to Medwell’s receptionist/scheduling service. Within 30 minutes, an online Telehealth consult had been arranged for her to speak directly with Dr. Johnson.

Due to the pandemic, Dr. Johnson called from the office in her home. The doctor was kind. She was practiced.

“So can you tell me what’s going on?” she said.

Elizabeth took a deep breath. She tried to fight what was happening. But she could not. Tears started streaming down her face.

“It’s just… It’s just…” she managed to stammer.

The doctor waited patiently. “It’s okay,” she said. “Just take your time.”

Elizabeth took a deep breath. “It’s like I can’t manage my own mind anymore. It’s nonstop. It won’t turn off…”

More tears streamed down her face.

Patiently, with compassion, the doctor walked Elizabeth through what she might be experiencing. The doctor recommended a follow-up with Medwell’s psychology department.

“Okay,” Elizabeth said, some semblance of relief passing through her.

Unbeknownst to Dr. Johnson, her office door had not been completely closed. During the telehealth call, Evan stopped by his mother’s office to ask her a question. Before knocking he overheard Elizabeth talking and decided to listen in.

PART TWO: BETRAYAL

As Elizabeth was finding the courage to open up to Dr. Johnson about her psychological condition, Evan was recording her with his smartphone through a crack in the doorway.

Spurred by who knows what — his attraction to her, his irritation at being rejected, the idleness of the COVID quarantine — it really didn’t matter. Evan posted his recording of Elizabeth to his Instagram feed.

#CantManageMyMind, #CrazyGirl, #HelpMeDoctorImBeautiful is just some of what followed.

Elizabeth and Evan were both well-liked and very well connected on social media. The posts, shares and reactions that followed Evan’s digital betrayal numbered in the hundreds. Each one of them a knife into the already troubled soul of Elizabeth Cunningham.

By noon of the following day, her well-connected father unleashed the dogs of war.

Rand Davis, the risk manager for the Medwell Health System, a 15-hospital health care company based in Alexandria, Virginia was just finishing lunch when he got a call from the company’s general counsel, Emily Vittorio.

“Yes?” Rand said. He and Emily were accustomed to being quick and blunt with each other. They didn’t have time for much else.

“I just picked up a notice of intent to sue from a personal injury attorney in Bel Air, Maryland. It seems his daughter was in a teleconference with one of our docs. She was experiencing anxiety, the daughter that is. The doctor’s son recorded the call and posted it to social media.”

“Great. Thanks, kid,” Rand said.

“His attorneys want to initiate a discovery dialogue on Monday,” Emily said.

It was Thursday. Rand’s dreams of slipping onto his fishing boat over the weekend evaporated, just like that. He closed his eyes and tilted his face up to the heavens.

Wasn’t it enough that he and the other members of the C-suite fought tooth and nail to keep thousands of people safe and treat them during the COVID-crisis?

He’d watched the explosion in the use of telemedicine with a mixture of awe and alarm. On the one hand, they were saving lives. On the other hand, they were opening themselves to exposures under the Health Insurance Portability and Accountability Act. He just knew it.

He and his colleagues tried to do the right thing. But what they were doing, overwhelmed as they were, was simply not enough.

PART THREE: FALLING DOMINOES

Within the space of two weeks, the torture suffered by Elizabeth Cunningham grew into a class action against Medwell.

In addition to the violation of her privacy, the investigation by Mr. Cunningham’s attorneys revealed the following:

Medwell’s telemedicine component, as needed and well-intended as it was, lacked a viable informed consent protocol.

The consultation with Elizabeth, and as it turned out, hundreds of additional patients in Maryland, Pennsylvania and West Virginia, violated telemedicine regulations in all three states.

Numerous practitioners in the system took part in teleconferences with patients in states in which they were not credentialed to provide that service.

Even if Evan hadn’t cracked open Dr. Johnson’s door and surreptitiously recorded her conversation with Elizabeth, the Medwell telehealth system was found to be insecure — yet another violation of HIPAA.

The amount sought in the class action was $100 million. In an era of social inflation, with jury awards that were once unthinkable becoming commonplace, Medwell was standing squarely in the crosshairs of a liability jury decision that was going to devour entire towers of its insurance program.

Adding another layer of certain pain to the equation was that the case would be heard in Baltimore, a jurisdiction where plaintiffs’ attorneys tended to dance out of courtrooms with millions in their pockets.

That fall, Rand sat with his broker on a call with a specialty insurer, talking about renewals of the group’s general liability, cyber and professional liability programs.

“Yeah, we were kind of hoping to keep the increases on all three at less than 25%,” the broker said breezily.

There was a long silence from the underwriters at the other end of the phone.

“To be honest, we’re borderline about being able to offer you any cover at all,” one of the lead underwriters said.

Rand just sat silently and waited for another shoe to drop.

“Well, what can you do?” the broker said, with hope draining from his voice.

The conversation that followed would propel Rand and his broker on the difficult, next to impossible path of trying to find coverage, with general liability underwriters in full retreat, professional liability underwriters looking for double digit increases and cyber underwriters asking very pointed questions about the health system’s risk management.

Elizabeth, a strong young woman with a good support network, would eventually recover from the damage done to her.

Medwell’s relationships with the insurance markets looked like it almost never would. &

Bar-Lessons-Learned---Partner's-Content-V1b

Risk & Insurance® partnered with Allied World to produce this scenario. Below are Allied World’s recommendations on how to prevent the losses presented in the scenario. This perspective is not an editorial opinion of Risk & Insurance.®.

The use of telehealth has exponentially accelerated with the advent of COVID-19. Few health care providers were prepared for this shift. Health care organizations should confirm that Telehealth coverage is included in their Medical Professional, General Liability and Cyber policies, and to what extent. Concerns around Telehealth focus on HIPAA compliance and the internal policies in place to meet the federal and state standards and best practices for privacy and quality care. As states open businesses and the crisis abates, will pre-COVID-19 telehealth policies and regulations once again be enforced?

Risk Management Considerations:

The same ethical and standard of care issues around caring for patients face-to-face in an office apply in telehealth settings:

  • maintain a strong patient-physician relationship;
  • protect patient privacy; and
  • seek the best possible outcome.

Telehealth can create challenges around “informed consent.” It is critical to inform patients of the potential benefits and risks of telehealth (including privacy and security), ensure the use of HIPAA compliant platforms and make sure there is a good level of understanding of the scope of telehealth. Providers must be aware of the regulatory and licensure requirements in the state where the patient is located, as well as those of the state in which they are licensed.

A professional and private environment should be maintained for patient privacy and confidentiality. Best practices must be in place and followed. Medical professionals who engage in telehealth should be fully trained in operating the technology. Patients must also be instructed in its use and provided instructions on what to do if there are technical difficulties.

This case study is for illustrative purposes only and is not intended to be a summary of, and does not in any way vary, the actual coverage available to a policyholder under any insurance policy. Actual coverage for specific claims will be determined by the actual policy language and will be based on the specific facts and circumstances of the claim. Consult your insurance advisors or legal counsel for guidance on your organization’s policies and coverage matters and other issues specific to your organization.

This information is provided as a general overview for agents and brokers. Coverage will be underwritten by an insurance subsidiary of Allied World Assurance Company Holdings, Ltd, a Fairfax company (“Allied World”). Such subsidiaries currently carry an A.M. Best rating of “A” (Excellent), a Moody’s rating of “A3” (Good) and a Standard & Poor’s rating of “A-” (Strong), as applicable. Coverage is offered only through licensed agents and brokers. Actual coverage may vary and is subject to policy language as issued. Coverage may not be available in all jurisdictions. Risk management services are provided or arranged through AWAC Services Company, a member company of Allied World. © 2020 Allied World Assurance Company Holdings, Ltd. All rights reserved.




Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]