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PERSPECTIVES: Setting the right strategy for managing care for injured workers

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PERSPECTIVES: Setting the right strategy for managing care for injured workers

The best way to manage care for employees injured on the job is to develop a strategy. Products and services will certainly be part of the solution, but they will not work nearly as well in isolation.

It's not just an injury or a claim that needs managing, it's a person who requires medical care. When injured employees do not receive the right level of care at the right time, it can have devastating effects on both the company's financial picture and on employees' long-term well-being.

Employers must take control and assume responsibility from the moment an injury occurs. If the employer fails to take charge, the employee or attorney will, by default, be in charge.

Establish contact with the treating physicians in your network, even if it's just one or two doctors. Visit the clinic for an initial interview and bring a letter or brochure describing employer expectations and 24/7 contact numbers for the employer and the insurer or third-party administrator. Expectations should include attention to rapid return to work, medical restrictions for transitional-duty tasks, excellent communication with the employee including written instructions about care and treatment, and a follow-up phone call within 48 hours to make sure recovery is going as anticipated.

Make sure the employee gets to the right level of care on the first try. The most common way is to post a list of doctors for employees to choose. However this option is fraught with problems because the employee who has no medical expertise is selecting when and where to be treated. Furthermore, employees and supervisors may not recognize the early signs of a serious condition and, therefore, not seek care soon enough. They also may seek care when it isn't needed.

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Injury triage is an effective way to get the right level of care immediately. An injury triage service can assess the seriousness of the injury and determine the level of care that's needed, getting control of the case from the beginning. The best triage services use software to ensure standardized, efficient assessments, provide in-network referrals, and operate without financial incentives to produce higher claim counts. Most triage is done by nurses and, just as the best doctors follow evidence-based guidelines, the best triage nurses follow evidence-based triage guidelines built into the software.

Here's a common example. Many back-pain cases are referred off-site for evaluation and care, and many employees receive X-rays or even MRIs, even though the American College of Occupational and Environmental Medicine and the Medical Disability Advisor both state X-rays are not usually necessary. A good triage nurse can avoid unnecessary procedures and identify the cases needing more extensive evaluation, taking control to use resources effectively.

When the injury occurs, the injured employee reports to the supervisor, and together they call the triage service. The triage nurse asks questions about what happened, and speaks with the employee privately to get details about the injury and relevant medical information. Using software, the nurse makes recommendations based on medical need.

This approach ensures that every injured employee gets the correct level of care immediately and that the employer is compliant with workers comp laws. Depending on the injury, the employee is directed to a hospital emergency department or a clinic, is given first aid or is given instructions for self-care. In this way, injured employees get the correct level of care immediately.

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In addition, the triage service should pre-load each employer's network of providers, so that the employee is guided to an in-network provider. The best services not only help employers comply with state regulations, but also provide third-party documentation of compliance.

Make sure the doctors in the network are the most qualified and, arguably, deserve to be paid more than the state-mandated rate. Pay them more and ask them to spend more time with your employees and complete the paperwork to provide modified duty. You can expect the best outcomes, fastest return to work and lowest litigation rate from an arrangement where doctors receive excellent pay for excellent work.

Conversely, the worst doctors cost employers a fortune. A study conducted by Dr. Edward Bernacki of Johns Hopkins University Hospital published in the Journal of Occupational and Environmental Medicine described several characteristics of “cost-intensive” physicians. The study, using five years of data from the Louisiana Workers' Compensation Corp., found that fewer than 4% of doctors generated more than 70% of costs. These cost-intensive physicians were associated with longer treatment duration, longer claim duration and higher indemnity costs. Another study revealed similar results in California, Texas and Florida.

Increase the in-network penetration rate. An average penetration rate is about 60%. That means that 40% of injured employees are not going to qualified doctors in the network. Get them to your doctors, then make sure your doctors are the best doctors.

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Make sure employees take a work ability form to the provider. If the injured employee does not bring this form to the doctor and get medical restrictions on the first visit, the claim will automatically be converted from a medical only claim to a lost-time claim. The medical provider must complete a work ability form at each medical visit.

If the employee has not returned to work, have a senior nurse reviewer contact the treating physician after each medical visit to discuss the employee's condition. If there are any complicated medical issues or return to work is not progressing, a physician reviewer should contact the treating physician.

Conduct a weekly meeting with all injured employees to discuss any problems they are experiencing and how medical care and transitional duty is progressing. The meetings should be conducted onsite; if the employee is unable to drive, provide transportation. At weekly meetings, the employee can demonstrate any problems he or she may be experiencing with transitional duty. The return-to-work coordinator can show the employee the next step in increasing transitional-duty capability. Include your medical director in the meetings.

Treatment of an injured worker can go off the rails at many points, whether it's the employee choosing the wrong provider or lack of communication with the medical provider, employee, and employer. By adopting a comprehensive strategy, employers can keep the process on track and provide better treatment and save money.

Rebecca Shafer, JD, president of Amaxx Risk Solutions, has helped employers reduce workers' compensation costs for more than two decades and can be reached at 860-553-6604 and rshafer@reduceyourworkerscomp.com.

Michael Stack, director of operations and senior editor with Amaxx Risk Solutions, can be reached at 781-561-5222 and mstack@reduceyourworkerscomp.com.