The path to recovery from a work-related injury is not often linear; treatment, rehabilitation and return-to-work is not always simple. Injuries are about much more than a physical insult to the body. Dealing with pain involves psychological and social components as well.

Mismanaging these components could significantly lengthen a patient’s recovery, adding both time and cost to a claim.

“Approximately 20 percent of injured workers experiencing acute lower back pain never fully recover, instead developing a chronic pain condition that can extend the life of a claim for years,” said Kim Radcliffe, senior vice president, clinical operations, One Call.

The key to improving outcomes for both injured workers and workers’ comp payers is addressing all of the biopsychosocial factors that contribute to the experience of pain — both qualitative and quantifiable.

“This clinical approach considers all of an individual’s biological, social and psychological factors, and how each of those factors work individually and in tandem to impact perception of pain, coping mechanisms, and risk of recovery failure,” said Sean Sullivan, senior director of product management, One Call.

In this Q&A, Sullivan and Radcliffe describe what’s involved in a biopsychosocial approach to pain management, and how identifying risk factors early can translate to faster return-to-work and lower total claim costs.

R&I: What makes claims involving chronic pain so costly and complex?

Radcliffe: The amount of time off work for chronic pain can be anywhere from six months to four years. That’s obviously an extreme variation, but someone who does not develop chronic pain could be fully back to work in three to four months, maximum.

The longer a claim is open, the more the employment and indemnity costs pile up. The 20 percent of injured workers that develop chronic pain end up accounting for upwards of 85 percent of the costs associated with treating lower back injuries.

The 20 percent of injured workers that develop chronic pain end up accounting for upwards of 85 percent of the costs associated with treating lower back injuries.

Chronic pain patients are receiving more therapy and more medications, which increases the risk of abuse or misuse. Eventually, unnecessary surgical procedures may be performed to address that pain. The utilization of surgery to resolve chronic pain conditions and the failure rates of those surgeries are pretty high.

R&I: What are the psychological and social factors that contribute to the development of chronic pain from an acute injury?

Radcliffe: A person’s temperament is a big factor. Are they optimistic or pessimistic? Do they drive themselves to high levels of work focus, or do they lack motivation?

Kim Radcliffe, Senior Vice President, Clinical Operations, One Call

There are also psychological components in an individual’s perception of pain. One person might stub their toe and say the pain is a level two out of 10 and go about their day. Another person might say it’s an eight and sit on the couch because they’re afraid of making it worse. That’s not always a conscious choice … that person may just be prone to catastrophizing.

Catastrophizing and fear avoidance can impair a person’s ability to perform normal daily functions even when the injury itself is not severe. Everyone’s response to pain is different.

R&I: In workers’ compensation, what barriers exist to identifying and addressing biopsychosocial factors?

Sullivan: It comes down to compensability and a clear understanding of the inflection points in a claim lifecycle that drive costs. When you’re dealing with a specific physical injury incurred on the job, the impact to the musculoskeletal system can be black and white. But when you get into comorbidities, chronic conditions and the psychosocial components that aren’t as directly related to the injury event, it’s not as clear.

Addressing these types of cost drivers, however, is critical to any program that is advancing a clinically-driven and value-based model of care. I think people in the industry understand this, but may be hesitant to spend more money upfront, even when it means saving as much as 30-40 percent over the long run in appropriately identified claims.

Catastrophizing and fear avoidance can impair a person’s ability to perform normal daily functions even when the injury itself is not severe. Everyone’s response to pain is different.

Radcliffe: I think it’s important to recognize that addressing the psychological or behavioral components of a claim doesn’t mean we’re seeking out other illnesses to treat. People have a fear that digging into those factors will open up a whole other can of worms.

The goal is not to diagnose patients with a psychological condition. We’re addressing the psychological factors that are associated with healing.

R&I: How do you identify these factors in the first place for each patient?

Sullivan: At One Call, we have a broad biopsychosocial solution that consists of two core components — analytics and product diversity. That boils down to first identifying patients at higher risk and then providing them with the right solution to mitigate identified risk. The first component involves stand-alone tools that we’ve continued to refine, in part through collaborations with our analytics partners, like High Line Health. We are also uniquely positioned in the marketplace to tackle population-level risk identification in partnership with health plan administrators and risk managers.

Radcliffe: We use data analytics to look for trends in patient demographics or injury characteristics to identify at-risk patients at a population level. Then, on a case-by-case basis, we use individual screening tools like questionnaires that assess that person’s psychological predisposition as well as their social environment.

The surveys evaluate tendencies like fear avoidance and include a pain catastrophizing scale. Based on the patient’s responses, we look for the specific psychosocial components that could complicate their recovery. Now we can start implementing an approach that takes those factors into consideration.

Sullivan: While surveys just scratch the surface, they provide a host of information to providers who then make small, supplemental changes to the care plan that make a big difference.

R&I: Do providers know what changes to make in their approach to a patient with a psychosocial red flag?

Sullivan: Quality providers often identify and document these types of flags in their treatment notes as variables that may be impacting progress. On one end of the spectrum of providing a holistic solution is provider engagement. This is as simple as calling up the provider when we see red flags on a patient’s file and offering them coaching and support to drive improved injured worker interactions.

Sean Sullivan, senior director of product management, One Call

Further down the spectrum, we make biopsychosocial solutions recommendations for at-risk patients that help physical therapy or home health providers achieve better outcomes.

Radcliffe: We are training our physical therapists, for example, to communicate differently and make sure we focus on function versus pain. Physical therapists can help patients move beyond fear avoidance and understand that they can still move even if they have pain. So we start there.

With no early interventions, only 60 percent of chronic pain patients are back at work one year after injury. When you do bring in the psychological and behavioral services early, that percentage goes up to 90 percent.

Sullivan: For more complex claims, we move into direct patient engagement, so we’re checking in with the injured worker, providing them educational materials on chronic pain and safe use of opioids, or possibly setting up weekly telehealth visits with a behavioral specialist who can help them develop clear recovery and return-to-work goals.

In the most serious cases, we can coordinate cognitive behavioral therapy or in-patient functional restoration programs, but our goal is to identify these issues early enough to prevent utilization of these services.

R&I: How prominent or effective are telehealth services in addressing psychosocial factors?

Sullivan: Telehealth is a really important part of this solution because it allows patients to see a behavioral health specialist from the comfort and privacy of their own home. There is still a stigma attached to receiving help for psychological or behavioral health issues. The telehealth ‘service from anywhere’ model offers convenience, reduces stigma, and can increase engagement.

R&I: Others have used predictive analytics and telehealth services in workers’ comp claims. What makes One Call’s biopsychosocial solution unique?

Radcliffe: The big differentiator of our program is that it combines prediction and prevention. The traditional approach to treating work-related injuries is just biological in nature. So for chronic pain, that means chronic pharmacological intervention in the form of opioids.

That has resulted in a portion of the population with opioid dependency still struggling with chronic pain. That biomedical approach is just not enough.

We’re trying to get to patients before they become part of that population. By identifying the psychosocial factors that put injured workers at-risk, and taking it one step further to connect them with the right services, we’re proactively mitigating the development of chronic pain.

R&I: How do you measure the success of using a full biopsychosocial solution? What improvement in claim outcomes have you seen?

Radcliffe: With no early interventions, only 60 percent of chronic pain patients are back at work one year after injury. When you do bring in the psychological and behavioral services early, that percentage goes up to 90 percent. That also means reduced health care utilization and fewer missed work days, meaning reduced medical and indemnity spend.

Sullivan: We will measure success by objective spend outcomes and qualitative injured worker experience.

As an example, a 2014 JAMA study reported employers spend about $15,000 more for each covered individual who abuses opioids. Some of the One Call solutions on the less-complex side of the spectrum — like provider engagement or using a health coach — cost less than $1,000. You can see how spending a little more on early interventions saves a significant amount over the life of the claim. &