Social factors weigh heavily among comp claimants

DANA POINT, California — Societal factors such as poverty, housing insecurity and lack of education can significantly affect the outcome of a workers compensation claim, as such factors — known as the “social determinants of health” — are often barriers to recovery.

As much as 80% of the outcome of an individual’s health is connected to factors connected to an unhealthy environment, and a work injury can launch a chain of events that can hinder return to work, according to panelist Rafael Gonzalez, a partner at Charlotte, North Carolina-based Cattie & Gonzalez PLLC and a panelist speaking at the Workers’ Compensation & Risk Conference on Wednesday.

When you have an injury, “all hell breaks loose” in an unhealthy environment, he said. “We see that in our claims. Are they able to pay rent now? Because if they are not, then they are not paying attention to their claim. They are solely focused on, ‘I just lost the roof over my head.’”

Panelist Chad Beinschroth, Winchester, California-based claims manager at facilities management company ABM Industries Inc., said the loss of income that comes with an injury is often the No. 1 concern among injured workers; that loss of income and ability to work sets off the “chain reaction” that affects housing and financial security.

And the workers comp industry is catching on, said panelist Debra Livingston, Tampa, Florida-based CEO at ReEmployability Inc., which provides return-to-work services for injured workers.

“In comp, we’ve learned that whole person recovery leads to shorter claim duration,” she said, adding that the pandemic helped push the conversation on so-called SDOH further.

In the pandemic, “we found that those at greater risk for mortality and health issues had issues with access to care, and a lot of those SDOH categories,” such as education, housing and income, she said. 

“These are the conditions where people live learn, work and play that affect their daily lives; that affects their health and their quality of life,” she added. In workers comp, that can translate into missed forms or missed appointments, she said. “Asking why” can be the first step in understanding what is going on in an injured worker’s life outside of the injury, she added.

Ask “why they didn't show up to a doctor's appointment, why they didn't cooperate with return to work. Why are they not taking that medication? Ask them why,” she said. “There could be a plethora of reasons.

She recalled the story of a friend who needed to schedule surgery, which she had postponed for three months because of required work travel and childcare issues. “What if that was an injured worker who couldn’t schedule the surgery when they were told they had to have it? They would be threatened to cut off their benefits, right? And that’s so unfair. It kind of goes back to that whole person,” Ms. Livingston said.

Claims handlers who know more about an injured worker’s life and life challenges can help make available community resources for the injured worker, who may not realize that he or she could be eligible for government benefits such as disability or social security, the panelists explained.

Yet, identifying social issues at the onset of a claim is a shortcoming in the comp industry, according to Mr. Gonzalez, who proposed a solution.

The federal programs Medicare and Medicaid now require billing codes — known as “Z codes” – to document SDOH issues, such as homelessness, divorce, death in the family, or relationship problems. Workers comp insurers can begin requiring such medical codes in claims as a way for the claims managers and employers to gather a complete picture of the injured worker, he said.

“This is clearly a big shift in our workers comp world… But we know that it exists in another area,” he said. “Can we go learn about that, and borrow some of those components and bring them here?”