Nearly every payer in the workers’ compensation system has a batch of claimants who have been managed for a long time with seemingly little-to-no progress toward a return to health and productivity. Also known as legacy cases, complex claims in workers’ compensation tend to be more than 10 years old, combine two or more co-morbidities, and maintain an open reserve of more than $500,000. These claims take longer to process and are more likely to be denied due to their intricate nature.
It can be easy for plan managers, employers and payers to think these claims are a permanent part of the portfolio and accept them as a necessary cost of doing business. Many emerging claims are written off as too difficult or complex to manage and put on a path to remaining on the books for years, or even decades.
The good news for anyone encountering this status quo, especially for the injured worker, is that healthy can still happen. Today’s health care landscape has more options, innovation and flexibility than ever before. Adopting a proactive strategy based on a multidisciplinary care plan and holistic, patient-centered therapies can make a real difference. Thanks to advancements in pharmacological options physical care intervention and behavioral health insight, we are poised to positively impact recovery and return injured workers to a higher level of health and capability.
A new approach to complex claims management
Complex claims are bad for everyone involved. These cases represent the largest population of opioid utilization, the highest morphine equivalent dosage (MED) per patient and are a source of cascading, multipronged prescription spend due to the need to treat side effects and emerging health issues.
While some long-term claims are unavoidable, many high dollar cases lasting more than 10 years are related to preventable, lifestyle-related comorbidities. Our parent company Evernorth has discussed how the trio of cardiovascular disease, diabetes and obesity, or cardiodiabesity increases treatment costs and health risks for patients in group health. These disease states also negatively impact work-related injury cases (stay tuned for a future MyMatrixx article on this topic). For now, there are other specific comorbidities present in maintenance claims that can benefit from analysis.
At MyMatrixx by Evernorth, our clinical and data teams have identified three factors in complex claims that could be dubbed “pharma-physio-psych”:
- “Pharma”: Pharmaceutical dependency and high rates of medication use that lead to more difficult claims management.
- “Physio”: This refers to physical diagnoses—untreated or undertreated health conditions, such as chronic pain or musculoskeletal disorders.
- “Psych”: Behavioral health concerns, such as unaddressed mental health issues, are also a significant factor in prolonged recovery times.
By analyzing complex workers’ comp claims and truly understanding and addressing how these and other factors are connected to recovery delays, we believe it is possible to achieve meaningful progress.
Taking the road less traveled
Injured workers in complex cases are in pain and often dealing with mental and behavioral health issues. These are people who typically want to return to work and would be eager for an effective pathway back to recovery and normal function — unfortunately, they’re too often on a maintenance treadmill that gets them nowhere. No two cases are the same, but the best place to start should be a holistic, 360-degree care plan with the primary goal of improving overall health. In workers’ compensation, this is too often the road less traveled.
3 ways to holistically manage complex claims in workers’ comp
Many options to manage complex claims are low-cost, high impact alternatives to previously attempted therapies. From physical therapy to cognitive behavioral therapy to reassessing drug therapy, these are the building blocks of a strategy built to overcome the pharma-physio-psych triad:
- Physical therapy: Physical therapy sessions can help identify and address the underlying causes of pain and improve function for patients. Even if physical therapy was attempted earlier in a claim, it could be worthwhile to try again. Like other disciplines, physical medicine has seen significant advancements in the last decade, particularly in telehealth and wearables. Designing a physical therapy program that matches injured workers with high quality providers to restore movement and function has proven to be a positive, fundamental step toward getting them back to health.
- The behavioral health component: Many payers are reluctant to take on behavioral and mental health due to the possibility of long-term costs. But if a mental health issue such as depression, anxiety or a sleep disorder is present, the cost of avoiding treatment can be higher. For example, a study published in the Journal of the American Medical Association shows a strong link between mental health disorders and prescription opioid misuse. For many of these cases, non-pharmacological interventions including cognitive behavioral therapy, education on good sleep hygiene and other low impact approaches can pay long-term dividends.
- Rethinking pharmacological interventions: There are a wide range of options for re-examining drug therapy programs for maintenance claims, including exploring lower MED alternatives or weaning programs. Drug therapy isn’t always a liability for maintenance claims either. In certain cases, the right pharmacological approach can enable completion of physical therapy that might not have been possible due to pain. For clients with concerns around long-term underwriting and desire for more predictability around claim spend, a possible solution could be a guaranteed spend option. This would provide security and predictability for future pharmacy or claim costs thanks to a fixed rate.
Making a difference, one patient at a time
MyMatrixx is dedicated to a pharmacy management platform that integrates analytics with clinical oversight to support claims with evidence-based, people-focused, whole health recommendations. Our pharmacists, nurses, data analysts and operations experts work closely with clients to provide individualized solutions for each case, including long-term workers' compensation complex claims. Through proactive partnerships, we’re willing to take the road less traveled to reduce costs, while enabling help that gets injured workers off the maintenance treadmill and back to meaningful, productive activity.
For additional information on any of these topics please click here to be connected to a MyMatrixx resource.