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Mental health treatment, once avoided in workers compensation claims that did not involve a compensable psychological injury, is now on the table in the claims management arena as employers and insurers increasingly accept that many physical injuries often include a mental component.
Failure to address mental health issues can prolong a claim, leading to more time off work and higher costs, experts say.
“The question is always, ‘Why should we pay for this?’ Well, we are already paying for this,” said David Lupinsky, Sacramento, California-based vice president of digital health and innovation for CorVel Corp. For example, he encountered a claim in which a worker with a minor but painful musculoskeletal injury, one month into treatment, began to say he would never return to work.
Stunted recoveries and often unnecessary treatment also add to costs, Mr. Lupinsky said.
“We are paying for it in (pain management) injections and surgeries,” he said. “I say, ‘Get to the core of the issue and pay for that.’”
The injured worker in the example was “catastrophizing” — thinking that the worst had happened and that he would only get worse, which is a belief that spells problems for physical recovery, Mr. Lupinsky said.
Claims professionals are starting to realize that they must consider an injured worker’s psychological hurdles, said Mariellen Blue, Wayne, Pennsylvania-based national director of case management services at Genex | Coventry, part of Mitchell International Inc.
“One of the things that is important to remember is physical injuries do have psychological types of impact,” she said. “Regardless of what is the cause of your injury … that physical injury would precipitate psychosocial responses. If the claims person is not looking beyond the (physical) this will undoubtedly increase the duration of the injury and result in long-term issues.”
Other mental health issues that can complicate a claim include perceived injustice, when a worker feels his or her employer has wronged them; kinesiophobia, the fear of movement; depression; and anxiety. Such terms are part of the comp industry’s emerging lexicon of the “biopsychosocial model,” referring to mental elements that can weigh heavily on the trajectory of a claim despite not being part of a compensable, physical injury.
Traditionally, the industry avoided psychological claims components based on the understanding that addressing them would translate into a “psych claim,” which could come with added costs and time off work, and fall under the realm of compensable mental injury, which comes with its own complications (see related story).
“We often talk about mental health and how certainly an injury can put an injured employee in a space of uncertainty, discomfort, which ultimately leads to mental health manifestation,” said Beth Burry-Jackson, Richmond, Virginia-based senior vice president of case management and clinically integrated programs at Sedgwick Claims Management Services Inc. “Just because there is anxiety and depression ... we emphasize it does not have to be a psych claim.”
Dr. Marcos Iglesias, Hartford, Connecticut-based vice president and chief medical director of Travelers Insurance Cos., said the biopsychosocial model leans on “yellow flags,” indicators that a claim warrants some intervention beyond management of the physical injury.
The mental component for insurers is “not their problem, but if you want to help the injured employee and you want to help the claim along, it might make sense to help the individual in the problems they are having,” he said.
Acceptance of mental components in comp claims is changing because insurers, using data analytics and injured worker questionnaires, can more quickly identify such issues. “They know there is a belief system you need to impact instead of something just physiological” to better manage and eventually close the claim, Mr. Lupinsky said.
Referrals represent another avenue for identifying potentially problematic claims, and providers are becoming better attuned to a person’s mental roadblocks that may be affecting recovery, according to experts.
Michelle Despres, vice president of physical therapy and national clinical leader at Jacksonville, Florida-based One Call Care Management Inc., said she noticed the mental issues prevalent with physical injuries while working with physical therapy patients several years ago.
“Before I ever heard the term biopsychosocial, I realized injured workers often came in with fears,” she said, recalling treating a veteran truck driver with an elbow injury who worried he would never again be able to provide for his family, including two daughters in college. “I remember thinking, this is a much bigger problem than the man’s tendon.”
Once a mental problem is identified, the first approach can be for claims handlers — and front-line providers — to talk to the injured worker about the psychosocial barriers.
“An individual needs to understand that a lot of these (mental) reactions, being depressed or stressed or anxious, are normal and that’s where case managers can come into play,” Ms. Blue said. “Oftentimes, being able to talk about it can go a long way in it not becoming a long-term issue.”
Solutions aren’t complex — goal setting, life coaching and even a focus on sleep management can help, Dr. Iglesias said.
For workers who may need something more, cognitive behavioral therapy, or talk therapy that aims to change a person’s way of thinking about their injury or pain, is fast becoming part of claims management solutions.
Mr. Lupinsky said such therapy sessions can take place once a week for 12 to 15 visits and can provide injured workers with “tools to reframe” their thinking. “It can be really incredible to see what they can turn around in that short period of time,” he said.
While data on the success of such techniques is hard to find, the industry is flooded with anecdotes on the effectiveness of cognitive behavioral therapy.
Stacey Caldwell, a Ridgefield, Washington-based corporate claims manager for workers compensation services provider Barrett Business Services Inc., presented several examples during a session at the Risk & Insurance Management Society Inc.’s 2021 virtual conference in April.
Among those who benefited from cognitive behavioral therapy was a 62-year-old truck driver who slipped and fell while getting fuel. The man injured his back in the incident, aggravating a previous back injury, and was later told seven years into conservative treatment that surgery may be the only cure for his chronic pain.
Flagged for biopsychosocial intervention, the man eventually got healthier and lost weight with the help of therapy, thereby avoiding surgery and enabling the closing of his claim, she said.
Another success story concerned a 50-year-old warehouse worker who fell backwards after tripping on a pallet, injuring her arm, wrist and shoulder in an overall soft-tissue claim, which are typically problematic in workers comp, Ms. Caldwell said. “We had really gone down the rabbit hole,” she said, recalling the woman saying, “I will never be able to work again.”
With cognitive behavioral therapy the worker learned “how to reduce her stress and not internalize negative comments and thinking,” Ms. Caldwell said. It helped close the woman’s claim within months when the early prognosis was an expensive four- to five-year claim, she said.
More than a dozen states have laws that make mental injuries compensable under certain conditions, and the workers compensation industry is responding with early intervention and treatment.