The percentage of claim costs attributed to medical benefits has progressively increased in recent years. Many of the same health risk factors that adversely affect healthcare in general proportionately affect an organization’s workers’ compensation claims cost.
One medical issue that poses a higher risk for a workers’ compensation claim to occur is obesity. It can also dramatically affect the outcome of the claim.
A recent data brief by The National Center for Health Statistics stated that the prevalence of obesity among U.S. adults was 39.8%. The report also identified a continued rise in obesity rates year over year. The overall obesity rate for adults aged 40-59 was 42.8%, which was higher than adults aged 20-39 at 35.7%. Adults aged 60 and over had an obesity rate of 41.0%.1
Since the group with the highest obesity rate – those aged 40-59 – represents a sizable portion of the working population, it is important to understand how this diagnosis may affect claim frequency and severity.
The obese injured person is also likely to incur higher claim costs. An NCCI research brief noted that medical costs of obese claims continue to grow at a faster pace than the non-obese. At 36 months, they were four times costlier, and by 60 months, the difference was more than five times greater. The study also noted it is not uncommon for an obese injured person’s claim to be 30 to 60 times more expensive than its non-obese counterpart since the latter's claims are often less severe and resolved in a shorter timeframe.2
There are additional diseases and health complications correlated with being overweight. These include diabetes (Type II), high blood pressure, vascular disease, increased risk of stroke with poor circulation, joint and bone inflammation, some cancers, high cholesterol, gallbladder disease and respiratory capacity decline with potential sleep apnea.
Data analytics – which is key to understanding factors that will lead to the most efficient and effective medical outcomes – have identified the primary cost drivers of the obesity claims. They are physical therapy, complex surgery, and prescription drugs.
Medical management teams should have a therapy provider partnership that consists of mutually agreed upon, evidence-based guidelines for services. Partnerships create efficiencies with:
These all allow for timely maximum medical improvement and return to work or claim resolution, while simultaneously receiving claim cost savings with volume discounts.
Medical management teams should ensure optimal medical outcomes by partnering with quality providers. Cost savings are possible by negotiating the deepest discounts possible with surgical facilities. The benefit to the provider is that they receive timely payments at the agreed-upon rates.
Prescription drug medical management should include:
While all the above steps are important, determining a pre-existing diagnosis is a key component in predicting work injury outcomes. Management of pre-existing conditions such as obesity when an injury occurs will improve health outcomes and opportunities to decrease disability days and early return to work. When an employee has an injury on the job, it is beneficial for the claims management team to be aware of these pre-existing conditions and for medical management to minimize the additional complications resulting from these pre-existing conditions.
When an injury does occur, all parties involved should implement a proactive and holistic approach to the unique claim at hand. The employers' insurer's medical management needs to communicate with claims personnel about the added risk associated with a diagnosis of obesity and other related health issues. Providers, the injured person, and their significant other should receive education on disease management and how it may affect the work injury. Including the injured person in plans helps them to understand expectations and buy into goals, which is beneficial to claim outcomes.
There must be adequate investment in managing the medical component of the claim to achieve an optimal outcome. An effective medical management strategy focuses both on the root cause of why medical spending is increasing, as well as on developing solutions to ensure injured workers receive a high quality of care that is still cost-effective.
When an employer and their claims team implement innovative medical management practices like the ones described in this article, it is a win-win experience for all parties.
1 Hales, C. M., M.D., Carroll, M. D., M.S.P.H., Fryar, C. D., M.S.P.H., & Ogden, C. L., Ph.D. (2017, October). Prevalence of Obesity Among Adults and Youth: United States, 2015–2016 (Issue brief No. 288). Retrieved from https://www.cdc.gov/nchs/products/databriefs/db288.htm
2 NCCI Holdings, Inc., Shuford, H., & Restrepo, T. (2010, December). How Obesity Increases the Risk of Disabling Workplace Injuries. Retrieved from https://www.ncci.com/Articles/Documents/II_obesity_research_brief.pdf