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Catastrophic workers compensation claims are becoming more complex as the cost of medical care increases and workers recover from injuries that would have been fatal as recently as five years ago, experts say.
Catastrophic injuries traditionally include traumatic brain injuries, spinal cord injuries, amputations, severe burns, blindness and multiple trauma, according to experts. However, many payers of workers comp claims now also consider any claim that reaches around $1 million to be catastrophic, said Dr. Michael Choo, chief medical officer and senior vice president at Paradigm Management Services L.L.C., a medical management company in Walnut Creek, California.
A worker with a low-back injury who has “three, four, five surgeries — they're out of work for an indefinite period of time, they might be addicted to opioids,” and the claim ends up costing more than $1 million, which is, “by our definition, a catastrophic claim,” said Sherri Hickey, director of medical management for Safety National Casualty Corp. in St. Louis.
Catastrophic injuries usually require an immediate response, but “acute symptoms of underlying conditions may result in death or significant permanent injury,” said Diane Blaha, Chicago-based senior vice president at third-party administrator and managed care services provider Corvel Corp.
“It could be that (an injured worker) fell off the cart in the emergency room and lost consciousness, they were given the wrong dose of medication, or they had a bad response to the medication,” Ms. Blaha added.
Denise K. Evans, Cincinnati-based director of workers comp claims for staffing company Staffmark, said she had a California employee suffer a heart attack as he was about to undergo surgery for a work-related hernia.
The fact that “people are surviving injuries they did not survive five, 10 years ago” is also causing catastrophic claims to become more complex and, therefore, more expensive, Ms. Hickey said.
“What we're seeing is that we're taking care of more complex patients because they survive,” Dr. Choo said. “It's not unusual now for us to see referrals for patients with 70% burns, 90% burns. What's amazing is that 10 years ago they would have died, but not today.”
Return to productive life
Not only are medical and technological advances keeping more injured workers alive, they're making return to work a possibility, Ms. Blaha said.
“What we're able to do today with mechanics and robotics is amazing,” Ms. Blaha said. “Yes, it's going to cost you a whole lot more from a medical expense (standpoint), but you are getting these people back to work, which five, 10, 15 years ago you didn't see.”
She said that most employers do whatever it takes to return injured employees to work and to productive lifestyles, as “the cost of that medical care is going to be less than supporting (an injured worker) for the rest of their life.”
For example, Ms. Hickey said, standard prosthetics that cost around $25,000 generally are considered to be medically necessary. But it makes sense to pay about $100,000 more for a less rigid prosthetic with microprocessor technology if it allows a worker to be more functional, independent and return to work, she said.
“Sometimes you have to just do your research, and sometimes you've got to just go out on a limb and say maybe it is worth looking into some new technology,” Ms. Evans of Staffmark said. “It depends on a company's appetite for risk.”
One way Ms. Evans said she controls costs is by using MedicalServiceQuotes.com to get the “lowest possible cost with best possible service.”
Catastrophic claims account for less than 1% of all workers comp claims, but they account for about 20% of costs, experts said, adding that the number of claims is slightly higher in safety-sensitive industries, such as trucking.
Traumatic brain injuries are the most common catastrophic claim employers see, since anyone can slip and fall, Ms. Hickey said.
She added that because she works at an excess workers comp insurer, she sees about 50 catastrophic claims each year, but that most claims adjusters and risk managers only see one or two in their entire career.
One best practice for managing catastrophic claims is immediately involving a nurse case manager who will meet the worker's family at the hospital, experts say.
“They're your eyes and ears right away,” Ms. Evans said. “The family is upset. An awful incident occurred to their loved one … That's not the time (for an employer) to be right in their faces … with them asking questions you might not have the answers to yet.”
Having expert physicians work alongside treating physicians is also a best practice, according to experts. So is having a worker's family member, as opposed to a registered nurse, serve as the primary caregiver to help reduce the cost of attendant care and make injured workers more comfortable at home, they say.
Regarding home or vehicle modifications, Ms. Hickey said she recommends having an occupational therapist work with contractors to identify what's medically necessary, in addition to added conveniences.
“You need to know exactly what an individual's capabilities are” before making modifications, she said. “Would they be able to open up a refrigerator or use a sink, or do they have to have somebody do that for them? … If they go into the shower, do you need the shower to be big enough for the caregiver or not?”
Experts say it's important to remember that the injured worker isn't always the only employee affected by a catastrophic injury.
“What happens to the employees that are left at the job site?” Ms. Blaha said. “(They're) working together and witness (someone) crushed between a truck and a wall as it's backing up. (They) witness (a worker) jumping or falling off a building during construction.”
“Think about the people left at a job site that have witnessed the catastrophic injury,” she said, noting that they might develop post-traumatic stress disorder. “This is where we find employers aren't prepared.”