Psychosocial issues top the list of barriers to successful claim outcomes

According to Rising Medical Solutions’ 2016 Workers’ Compensation Benchmarking Study survey, the top barriers to achieving desired claims outcomes are psychosocial issues, followed by lack of return to work options, litigation, employer/employee relationship, late injury/claim reporting, and timely communications with stakeholders (employee, employer, providers). The survey, which documented the responses of 492 claims professionals, led to a recently released report, “How to Overcome Psychosocial Roadblocks: Claims Advocacy’s Biggest Opportunity,” examining key best practices for addressing psychosocial factors.

The report begins, “We know the single greatest roadblock to timely work injury recovery and controlling claim costs. And it’s 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.”

It’s important to note that psychosocial does not mean psychiatric issues, such as schizophrenia or depressive disorders, but represents behavioral issues, the way we think, feel, and act. A person’s fears that the treatment will fail or cause additional pain can become a self-fulfilling prophecy and impact recovery or fears about judgment of co-workers can delay a return to work. According to the report, other conditions, behaviors, and predicaments include obesity, hard feelings about coworkers, troubled home life, the lack of temporary modified work assignments, limited English proficiency, and – most commonly noted – poor coping skills. These roadblocks occur regardless of the nature of the injury.

At The Hartford, 10% of claims fall into the psychosocial bucket with at least one psychosocial comorbidity, but they consume 60% of total incurred costs. Claims adjusters are required to ask injured workers, “When do you expect to return to work?” Any answer of less than 10 days indicates the worker has good coping skills and the risk of delayed recovery is low. If the answer is longer than ten days, the adjuster explores the reasons for the response. Increasingly, insurance companies are referring certain workers to specialists who provide support, which can include enlisting cognitive behavioral therapy (CBT).

A case study of Albertson, the grocery chain, revealed that about 9% of injured store workers screened since 2013 had psychosocial issues embedded in their worker’s compensation claims. Recognizing psychosocial issues as a major driver for long-tail claims, the company offers early intervention, which is usually performed by a network of psychologists who provide health coaching consistent with CBT principles. It avoids the stigma of therapy (it’s called “coaching”), is short in duration, and focuses on active problem solving to help with self-management and self-resiliency.

Medical providers are trained to find medical diagnoses and prescribing medical solutions, so it’s up to employers and claims adjusters to identify workers who are affected by psychosocial roadblocks. Some of the risk factors include:

  • Tendency toward catastrophic thinking
  • Avoidance behavior based on fear
  • Perceived injustice stemming from treatment at workplace
  • Adverse childhood experiences
  • Weak family and social supports
  • Unrealistic expectations about recovery
  • Beliefs/fear about pain
  • Fear of re-injury
  • Lifestyle and demographic risks

The workplace is often the source of barriers that cause the most trouble for injured workers. Do they feel others blame them for the injury? Are they made to feel that they have created extra work and stress for co-workers and the supervisor? Do they blame the employer for the injury? Do they worry about being reinjured? Is the recovery at work program supportive or overwhelming?

When injured workers are fearful, distressed, or blame their employer they are less likely to return to work. Understanding the issues affecting the employee and helping to resolve them in an empathic, supportive manner is key to a successful outcome.

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