1. Medical Treatment Outcome and Return to Work
A Biopsychosocial Perspective

2. What’s Important to Risk Managers and WC Insurance Companies
Prevention of Work Injury
Cost Containment
Return To Work
Claim Resolution

3. What Employers May Think?
Do our job….follow policy and procedure, incident report, referral for initial medical evaluation, contact WC insurance company
WC insurance company…addresses claim through medical management, benefits, return to work, claim resolution
Bottom Line: Employee sustains injury, is provided services through WC insurance company, returns to work or does not

4. The carrier, the employer and the employer/risk manager play crucial roles in the resolution of work injury. Without ongoing consistent communication, the employer becomes the loser. Collaboration by all parties plays a key role in helping the injured worker recover and return to work as quickly as possible.
Many others play crucial roles in the resolution of work injury and there are many factors that affect medical treatment outcome. All of these players, including all of you, and factors affect return to work, potential relapse and claim resolution.

5. Researchers review of 8,000 claims reported from 2009-2014 by 130 Minnesota school districts

8. Quick Rundown
In 2012 a UC Davis researcher estimated the national annual price tag of occupational injuries and illnesses at $250 billion. This figure is $31 billion more than the direct and indirect costs of all cancer, $76 billion more than diabetes, and $187 billion more than strokes.
The majority of injured workers return to work
90% of the annual costs of work injury and illness are incurred by the 5 to15% who become chronically ill or develop a pain-related problem and fail to return to work
Estimates of 5 to 15 % remain off work three months or longer and chronic pain becomes a major factor in predicting RTW

9. 2/16/2019
“Although biomedical factors appear to instigate the initial report of pain, psychosocial and behavioral factors may exacerbate and maintain high levels of pain and disability. It is important to acknowledge that disability is not solely a function of the extent of physical pathology or reported pain severity.
Disability is a complex phenomenon that incorporates tissue pathology, the individual response to physical insult and environmental factors that can serve to maintain disability and associated pain even after physical cause has resolved.” Wilbert E. Fordyce

10. Psychosocial Factors
According to the Workers’ Compensation Benchmarking Study’s 2016 survey, the single greatest roadblock to timely work injury recovery and controlling claim costs is not overpriced care, or doubtful medical provider quality, or even litigation. It is the negative impact of personal expectations, behaviors, and predicaments that can come with the injured worker or can grow out of work injury.
These roadblocks are classified as “psychosocial” issues – issues which claims leaders now rank as the number one barrier to successful claim outcomes – and they drive up claim costs far more than catastrophic injuries, mostly due to delayed recovery.
The Hartford’s medical director stated that the “psych” part does not mean psychiatric issues, such as schizophrenia, personality disorders, or major depressive disorders. Instead, he points out, “We are talking about behavioral issues, the way we think, feel, and act. An example is the injured worker’s fear of physical movement as he or she believes that it may worsen one’s impairment or cause pain

11. Ranking of greatest obstacles to achieving desired claim outcomes [492 responses]
Source: Rising Medical Solutions’ 2016 Workers’ Compensation Benchmarking Study

12. Psychosocial Factors/ Psychiatric Comorbidity
Influence of Psychosocial Factors
Psychosocial Factors/
Psychiatric Comorbidity
Acute Pain
Sub-acute Pain
2-4 mos.
Chronic Pain
3-6 mos.
Influence/Risk

13. Predictors of Disability
Job Satisfaction
Length of Time Off Work
Relationship with Supervisor
Relationship with Co-Workers
Work History
Level of Social Support
Coping
Psychological Dysfunction
Perception of Fault
Litigation
Compensability
Injury Severity

14. Other Factors Associated with Negative Return-To-Work Outcomes
Older age
Being female
Higher pain or disability
Depression
Higher physical work demands
Previous sick leave and unemployment
Activity limitations.

15. Other Factors Associated with Positive Return-To-Work Outcomes
Higher education and socioeconomic status
Higher self-efficacy and optimistic expectations for recovery and return-to- work
Lower severity of the injury/illness
Return-to-work coordination
Multidisciplinary interventions that include the workplace and stakeholders.

16. Predictors of Surgical Outcome
Chronicity
Previous spine surgeries
Nonorganic signs
Nonspine medical utilization
Smoking
Obesity
Pending legal actions
Reinforcement of disability by family members, Stakeholders
Marital dissatisfaction
Job dissatisfaction
Physical or sexual abuse
Pre-injury psychological problems
Current psychological problems
Coping

17. Factors Affecting Pain Experience
Expectations
Beliefs
Prior History and Learning Experiences
Coping repertoire and self-management skills
Self-Efficacy
Depression
Anxiety
Fear
Reinforcement Systems

18. Expectations
Expectation is defined as believing that something is going to happen or believing that something should be a certain way
Expectations are influenced by learning history and by relationships which serve to educate and reinforce one’s perceptions and beliefs

19. Employer Family & Friends Case Manager Adjuster Treating Physicians
Physical/ Occupa Therapists
Mental Health Practitioners
Other Healthcare Providers
Attorneys
Injured Worker’s Expectations

20. Patient Expectations
Patients' expectations of treatment are a potentially important predictor of self-rated outcome after surgery. Having one's expectations fulfilled was most important for a good outcome. The results emphasize the importance of assessing patient-orientated outcome in routine practice, and the factors that might influence it, such that realistic expectations can be established for patients before surgery. Spine July 2009 
Patients’ expectations have shown to be a major psychological predictor of health outcome in cardiac surgery patients. These results confirm the importance of patients’ expectations in the prediction of postsurgical outcomes and underline the necessity to optimize these expectations in order to improve postoperative quality of life. International Journal of Behavioral Medicine February 2016,
High initial pain, external attributions of responsibility for the injury, and psychological distress were found to be significant independent predictors. In addition, poor recovery expectations was found to be a significant predictor of pain-related work disability and being injured at work a significant predictor of pain severity. Psychosocial factors strongly predict pain chronicity, severity. J Pain 2010

21. Patient Expectations
In a 2013 study, Biopsychosocial Determinants of Work Outcomes of Workers With Occupational Injuries Receiving Compensation: A Prospective Study, it was found that gender, work recovery expectations and importance of work to be predictive of work outcomes at 2 months. After 8 months, age, medical consolidation, trauma symptoms, work support and importance of work were predictive of work outcomes.
The significance of pain-related beliefs and expectations both in early and later stages of a back pain condition is pointed out. The results in this study based on a sample from the general population are in line with previous research on patient samples which support that long-term outcome in back pain is related mainly to cognitive factors such as pain-related beliefs and expectations.

22. Patient Expectations
In a 2017 study of predictors of RTW after two years among MVA survivors Univariate predictors of NRTW included being the driver or passenger, having a prior psychiatric diagnosis, high disability level, low mental or physical quality of life, predicted non-recovery, high pain, low function, high expectations of pain persistency, low expectations about RTW, having a psychiatric diagnosis, elevated depression or anxiety. The final multivariable logistic regression model included only two variables: disability level and expectations about RTW. Seventy-five percent of individuals who will not RTW by 2 years can be identified accurately at an early stage, using only these two predictors.
Another study found that recovery expectation and fear avoidance beliefs/behaviors are the psychosocial constructs of most value in guiding early intervention to prevent work disability due to NSLBP.

23. Expectations – Catastrophic Thinking – Misinformation
Recovery Expectations (e.g. nothing will help, inadequate medical care, only surgery will help, physical therapy makes it worse, can’t do anything, can’t work with pain, pain means something’s wrong, I’m going to be disabled
Fear of being fired
Fear that claim will be denied
Fear of reinjury (Fear/Avoidance)
Settlement Expectations (e.g. they owe me a lot, it was their fault, what if I get better)

24. Why Injured Workers Hire Attorneys
According to the Workers Compensation Research Institute (WCRI), the main reasons for attorney representation in workers compensation claims is related to Workplace Trust – fear of claim denial and injury severity.
Workers were 34% more likely to retain attorney if they thought their claim would be denied either because of a denial notice, a delay in payment or perceived through communication with the claims manager vs 5% where there was no perceived denial.
In a recent study, the WCRI reviewed 7000 claims in 11 states, it was found that in Florida workers are much more likely to hire attorneys if they fear being fired – workers were twice as likely to retain an attorney
Twenty percent of injured Texas workers were more likely to be represented by an attorney if they felt their supervisor did not believe their claim
A worker is more likely to hire attorney if he or she feels threatened – some threats may come from the character of the employment relationship

25. Other Factors that Increase Attorney Involvement
High school graduates vs college graduates
Workers with language barrier
Workers with less than one year on the job
Low back conditions compared to fractures

26. Attorney’s Perspective
One of the most difficult aspects of representing individual clients is explaining to them that their case is simply not as valuable as the client may perceive it to be.
In some instances, claimants believe their settlement amounts should be much larger than they actually are, whether based on pre-conceived notions about the lawsuit or settlement process or out of the frustration, pain, suffering, and other issues a given injury has caused them.

27. Barriers to RTW - Attorney
Lack of communication with client
Lack of involvement with client until MMI or release to return to work
Failure to provide clear information about WC system and settlement process to client from beginning of case
Delays in advocating for client with insurance company
Reinforcement of faulty beliefs and perception of disability

28. Barriers to RTW - Physician
Role as patient advocate vs “company doctor”
Treatment goals focused on feeling better rather than getting better
Failure to include transitional work in the treatment plan
Lack of information re physical demands of the job

30. Barriers to RTW - The Employer
Fear of liability for re-injury or aggravation
Failure to appreciate transitional work as therapy
Use of benefits system (WC, STD, LTD) to manage personnel problems
Lack of information re: the economic benefits of transitional work

31. Barriers to RTW - The Claims Adjuster/ Case Manager
Focus on benefit delivery rather than rehabilitation
Poor communication with providers, employers and injured workers
Delays in treatment authorization
Caseloads too high given administrative complexity of WC system

32. Case Manager/ Adjuster Healthcare Practitioners
Injured Worker
Healthcare Practitioners
Litigators
Employer

33. Case Management - Easier Said than Done!
Facilitate communication and coordination of treatment among healthcare providers – make sure everyone is on the same page, with the same goals, etc.
Encourage employers to establish meaningful accident prevention, wellness and return to work policies
Facilitate referrals and approval for appropriate and quality rehabilitation services in a timely manner

34. Positive Outcomes
The injured worker should be viewed as the most important member of the rehabilitation team BY EVERYONE
The injured worker should have a good understanding of their diagnoses and recommended treatments HEALTHCARE PROVIDER
The injured worker should have some concept of the WC system and how it works ATTORNEY CASE MANAGER EMPLOYER
The injured worker should understand the importance of assuming self-care responsibilities, being an active participant in their recovery process, and complying with treatment recommendations BY EVERYONE
BOTTOM LINE: The injured worker should: Be Informed, Have Realistic Expectations, and Be an Active Participant in Recovery and Return to Work

35. Corvel: Recommended Reading
8 Simple Ways to Create A Mentally Healthier Workplace
Mental Health in Workers’ Comp
Injured Workers- Anxious Workers
Opioids Effect on Return to Work
Watch Out for Stressed Out Workers
Advocacy: The Impact of Continuous Triage
Back to Work, Back to Savings
Exercise and Education: Essentials for Resolving Lower Back Pain
Red Herrings

36. Thank You…..