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Some prominent workers compensation payers are taking an unusual step: actively recommending cognitive behavioral therapy for claimants who suffer from chronic pain and psychosocial issues that are hindering their recovery.
When properly applied, the psychotherapeutic approach can help workers comp and nonoccupational disability claimants return to work sooner by helping them cope with work-related problems and emotional issues, several insurance industry medical doctors and claims experts said.
Study results also have documented that directly linking CBT to workplace issues can help employees return to work sooner.
For example, a study published in the April issue of the American Psychological Assn.'s Journal of Occupational Health Psychology found that employees absent because of common mental health disorders, such as depression and anxiety, returned to the job an average 65 days sooner when provided “work-focused” CBT (see related story).
The study authors said CBT is based on the idea that people's thoughts and perceptions, rather than external factors, drive their attitudes and behaviors.
CBT helps injured workers change negative perceptions of supervisors and workplace conditions that hinder their motivation to return to work, experts said.
It also helps claimants address their perceptions of pain and their emotional response to it, said Dr. Bernyce Peplowski, medical director of California's San Francisco-based State Compensation Insurance Fund.
Using the approach, CBT can help reduce or even eliminate the use of opioid prescriptions or surgeries that have failed to address their chronic pain or are unlikely to address it, said Dr. Jacob Lazarovic, chief medical officer in Sunrise, Fla., at third-party administrator Broadspire Services Inc.
“The data is pretty impressive that a lot of these folks with chronic pain don't do better—and, in fact, do worse—when they are treated conventionally with opioid medications and with spinal fusions and aggressive interventions,” Dr. Lazarovic said. However, injured workers “do much better when you are addressing the psychosocial aspects of their condition and using a tool like CBT.”
Broadspire analyzes pharmaceutical data and other treatments to identify injured workers suffering from pain who might benefit from the therapy, Dr. Lazarovic said.
A Broadspire peer review team, including a psychologist or psychiatrist, then helps determine whether a potential candidate may benefit from CBT.
Broadspire nurses also use a pain screening questionnaire developed in Denmark when talking to potential CBT candidates, which helps triage claimants at high risk of developing “chronic pain syndromes,” he said.
“In our experience, (CBT) hasn't been used enough,” Dr. Lazarovic said. However, “it will be used more in the future as we very deliberately select the right patients.”
Injured workers who are chosen “have significant pain complaints as part of their injuries” and are “not becoming as functionally active as they should be because of the pain complaints, and the CBT is structured to train them in some coping mechanisms,” he said.
SCIF is taking a different approach.
It encourages doctors who treat claimants covered by its workers comp insurance to use a questionnaire that patients can complete in the waiting room, Dr. Peplowski said.
Depending on the answers, a patient ranks at low, medium or high risk of a prolonged absence from the job. For claimants at medium risk, the doctor may spend more time discussing certain psychological issues with them, Dr. Peplowski said.
“If you find they are high-risk, that is when you send them to a cognitive behavioral therapist who could be a psychologist, who could be social worker,” she said. “There are many people providing that type of therapy.”
SCIF adjusters are allowed to authorize six CBT treatments “right off the bat” if a doctor reports that a claimant is at high risk, “because we realize that time is of the essence,” Dr. Peplowski said.
CBT can help patients accept their condition, whether it's an ankle sprain or diabetes. But the sooner therapy is started, the sooner it can help avoid chronic pain problems, she said.
In addition, SCIF adjusters are also instructed to contact the claimant's doctor and suggest CBT for patients who are not progressing as expected after six weeks of medical treatment.
Several risk managers and payers said they have not applied CBT to their workers comp claims, and some decline to authorize it.
“So when we call doctors and say, "It's all right' (to recommend CBT), doctors often say to us, "Wow, I didn't offer it because I didn't think you would be willing to pay for it,'” Dr. Peplowski said. “So there is a cultural shift that needs to happen.”
When CBT is introduced to employees away from work, it often is separate from workplace problems that may be hindering an employee's return, sources said.
Dr. Andrew Brown, lead psychiatrist for the Boston Police Department, said that when reviewing disability cases as a consultant for Boston-based Liberty Mutual Group Inc., he often notices that CBT is applied without considering a worker's attitude toward their job or their separation from the job.
“What seems to be happening is their ostensible disease state or illness is seen and treated as if it is something separate and distinct from their leaving their employer,” Dr. Brown said.
Depending on certain employer characteristics, anywhere from 5% to 30% of a company's nonoccupational disability claims may result primarily from behavioral issues, said Dr. Ed Crouch, national medical director for a Liberty Mutual unit providing group non-occupational disability and life insurance.
That led Liberty Mutual to contact medical providers and recommend psychotherapeutic treatment for appropriate cases.
“Because we do that, we have dramatically improved our outcomes over time,” Dr. Crouch said.
A recent study found that using “work-focused” cognitive behavioral therapy to help employees suffering from common mental health disorders can lower employer costs by reducing injured workers' time off the job.