Imagine an injured employee who is 52 years old, an occasional smoker, and 20 pounds overweight. Normal job duties include lifting a 30-pound box to a height of 45 inches a few times a day. He is diagnosed with a lower back injury and the physician orders physical therapy.
Now, imagine a different injured employee who is 27 years old and physically fit. Normal job duties include lifting a 15-pound box to a height of 36 inches all day. He is also diagnosed with a lower back injury and the physician also orders physical therapy.
Old benchmarks say these two patients should rehabilitate in the same number of visits. But that would be illogical. Common sense concludes that they need different levels of support and treatment. However, the aforementioned “benchmarks” do not account for the uniqueness of each person. So with that said, in these examples, how would the treating physician anticipate the “right” physical therapy prescription?
The short answer is that using this old way, no one really knows how much therapy to order.
Using the old way, patients are diagnosed and prescriptions ordered based on averages, historical clinical experience, physician instinct, and/or prescribing habits. This old way often leads to either over-treatment or under-treatment.
No previous guideline has leveraged technology, data science, and clinical treatment data to effectively predict a customized expectation for therapy based on patient-specific characteristics and that individual’s unique return-to-work requirements. It’s a one-size-fits-all approach to orders and care that equates to cold porridge—lumpy, inadequate, and disappointing.
Furthermore, it’s an exponentially growing bowl of lumpy porridge to address. Workers’ compensation care, and how it’s managed, has emerged as a critical component of health and wellness for American employers. Musculoskeletal disorders (MSDs), and their costs, make up the majority of workers’ compensation care and continue to expand to critical levels of our national healthcare spend.
In a 2015 study by the United States Bone and Joint Initiative (USBJI), MSDs were found to affect more than one out of two people in the United States ages 18 and older, and nearly three out of four people ages 65 and older. These injuries/disorders outpaced other common health conditions like cancer, diabetes, respiratory, and circulatory conditions. In a 2014 study the USBJI found that direct and indirect costs of MSDs were estimated at $322 billion, and the cost of treatment and decreased wages was estimated at $980 billion annually.
According to a 2020 Occupational Health & Safety article, MSDs can negatively impact workplace injuries and are responsible for almost 30%of all workers’ compensation costs. In a 2018 study by the National Academy of Social Insurance, employers’ cost of workers’ compensation benefits were $98.6 billion, a 5% increase since 2014.
Given these statistics, it’s imperative to find a smarter way to manage and support workers’ compensation care by utilizing new technology and insights combined with clinical treatment data to drive better solutions for payers, providers, and patients. We all deserve better porridge.
Finding the “Just Right” Number
Returning to our original examples of the patients with different individual complexities and return to work requirements—what is the right number of treatment sessions? Should the physician take into account the patient’s age and current medical conditions? And after treatments are completed, how will the physician know if the injured worker is ready to return to work?
Today technology exists that allows stakeholders to take a holistic view of an injured worker’s medical condition, comorbidities, essential job demands, and the mechanism of injury, at scale. This new approach enables right-size care based on specific patients' needs and coordinates care to best-in-class therapy providers. It also allows the industry to fairly and accurately assess provider performance based on physical, functional, clinically proven metrics. This new way enables workers’ compensation stakeholders to proactively and dynamically order the right amount of treatment, at the right time, to the right provider, for each individual patient.
Instead of best guesses (cold porridge), the new way achieves meaningful industry transformation through the use of clinical treatment data combined with predictive modeling and data science (“just right” porridge). By digitizing the clinical as well as the claims data, actual, objectively defined functional outcomes for workers’ compensation patients are supported and reported, at scale.
With these new technologies and this new approach during the treatment process, the ability to enhance care in real-time is activated, while the patient is still being treated. This dynamic application of data is critical not only to achieving the best long-term outcome for patients, but it also drives value to both payers and providers. It is “just right” porridge.
Taking this approach a step further, data science can be applied to clinical treatment data, to identify the variables and combinations of variables that can impact the length, cost, and duration of a claim. As a result, predicting the likelihood of the claim becoming high-cost and high-risk at the outset of care allows claims examiners to be better able to prioritize claims to manage utilization and costs.
This new approach allows for consistently optimizing the medical management of workers’ compensation claims for every stakeholder. Physicians, therapy providers, examiners, and nurse case managers are empowered with actionable insights. This approach is the key to “just right” care, designed to achieve the best possible patient outcomes.
New Generation Guidelines
Let’s take a quick look at a practical application of this new approach:
In 2019, data scientists looked at the combination of age and the physical demands of the specific job on a subset of the patient claims they supported. They identified that, while both factors have an impact on the duration of a case; when combined, the impact multiplied. Scientists looked at these differences and determined that:
• Patients older than 50 years of age were in therapy 17% longer than those under 50 years of age.
• Patients with very heavy physical job demands were in therapy 6% longer than those with less physical job demands.
• Patients over 50 years of age with a very heavy physical job demand were in therapy 30% longer than those under 50 years of age and in a less physically demanding job.
Data scientists were then able to use this information to engage with the treating therapy providers and guide them with specific treatment plan improvements. As a result, within the first four months for one employer, the percentage of their surgical cases becoming outliers was reduced from 17% to 12%.
The Middle Ground
Going back to our beginning scenario, the application of data science in combination with a person’s unique health and job factors allows everyone to set the “just right” treatment expectations for each person and the job they are expected to perform. It allows us to change the course of care early if needed, reducing excessive or unnecessary medical utilization. It is through this modern application of new technology, tools, and data that we are able to significantly and concurrently improve the experience of payers, therapy providers, and patients.
When the industry takes a “just right” approach to care, we not only drive down cost, but we are able to right-size every other factor impacting the entire workers’ compensation process. We can impact treatment timelines, number of visits, and the end goal for end of care. When we manage toward the end of care and identify maximum medical improvement, we automatically optimize the cost of a claim and deliver a return on therapy investment for the payor.
When we utilize these new technologies and solutions to take the “just right” approach to care, we are able to remain focused on the injured worker at the center of the claim in ways never before experienced in our industry. This enables us to work collaboratively and proactively to return injured associates to their job, their family, and their life. This is the kind of transformative approach that is changing the workers’ compensation industry nationally—and assures that Goldilocks gets what she needs, when she needs it.