Workers' Comp

Return to Work Program Benefits & Strategies

February 25, 2020

Developing successful return to work (RTW) plans is instrumental to efficient and effective workers’ compensation claims management. Such initiatives integrate individual considerations for all injured employees that go beyond simply treating the initial injury, including comorbidities, psychosocial issues, light-duty options and pain management protocols. With this in mind, how can you ensure your RTW program is meeting your objectives? Mitchell Chief Clinical Officer, Dr. Mitch Freeman, Genex Services Senior VP of Utilization Management, Helen Froehlich, and Genex Services Vice President of Analytics and Reporting, Jim Harris, addressed these challenges during a recent session at Mitchell’s annual mPower conference. Here are some of their key points for return to work program benefits & strategies.

What makes a successful RTW program?

A successful return to work program requires coordination of various factors, with the main emphasis on the injured employee. Developing the plan early in the claim process provides the best chance of success. This starts with the initial evaluation. The treating physician assigned to the case should understand the nuances of workers’ comp, consider the employee’s entire health record when conducting the evaluation and be familiar with the employee’s job demands. Early case management intervention often has a significant effect on return to work. In fact, according to an analysis conducted by Genex Services, more than half of the injured workers referred to nurse case management were able to return to work in three months, a rate that is much higher than those not receiving case management intervention. That same analysis also points out that delays in case management intervention can lengthen return to work and cost payers more. Return to work program managers should also consider pain management and pharmacological concerns. Leading industry practices include limiting the duration of opioids on a claim to prevent overprescribing. Payers should consider implementing physician-dispensing controls, which will provide greater visibility into the injured employee’s prescribed drug regimen.

What are some major causes of RTW delays?

Pharmaceutical issues can often be a culprit in delayed return to work, whether caused by prolonged dependence on opioids or issues with physician dispensing. However, factors not related to the injury often contribute to delays, such as lack of support from family and friends, limited access to care and employee disinterest in returning to the job. Case management can help identify and mitigate these issues early on and set a course for success. To illustrate the point, Froehlich discussed a case involving a Genex case manager assigned to an injured employee who had injured his left shoulder and had faced eight months of pain. The injured worker had not received an appropriate treatment path, and as such, was prescribed multiple narcotics, anti-inflammatories and muscle relaxants. These prescriptions provided him little pain relief, however. The injured worker told his Genex case manager that he felt “the world had given up on him”. After collaborating with orthopedic and pain management specialists, the case manager was able to provide a more aggressive treatment strategy, which involved a shoulder procedure. This required her to work closely with the surgeon, physical therapists, employer and employee to help the injured worker through rehabilitation after the surgery. Throughout the new treatment plan, the case manager helped provide a weening plan for the injured worker. After this great effort, the man returned to work fully functional. Read more about this incredible story at Genex Services. Identifying and considering comorbidities into the return to work plan is also vital. If an injured employee has a preexisting condition, such as diabetes, that is unknown to those involved in the claim, it can be more difficult to develop a proper RTW path. Medications for comorbid conditions can impact negatively with those prescribed for their workers’ compensation injury, thereby delaying recovery and the ability to return to work. Knowing the injured employee’s current medication regimen and also if he or she has a history of alcohol or substance abuse will allow providers to develop a more effective course of treatment.

What are some overlooked issues in creating effective RTW programs?

With so many factors to consider in creating and implementing a successful return to work program, some issues can be overlooked. From a pharmaceutical perspective, this can include the level to which formularies are implemented for claims. Certain states have mandated formularies, which can include injury-specific directives on prescribing and dispensing medications. These directives may be complicated to understand and implement, and certain components can be easily overlooked. This is where a PBM partner can make a difference, by managing proper and thorough formulary implementation to help payers correctly follow the guidelines, which can result in better care for their injured employees. Additionally, by using networks so the formularies are followed, leveraging direction of care and following legislative requirements, payers can promote better outcomes for their injured employees. Another significant contributor of delayed return to work and total claims cost is litigation. When an injured employee retains an attorney, the expected length of disability and claim costs can increase by as much as 200–300%. Injured employees may seek legal counsel due to breakdown in communication from various parties in the claim, dissatisfaction with direction of care, or help in navigating the complexities of the workers’ comp system. Many carriers and TPAs turn to nurse case management to provide an extra resource to both the adjuster and the claimant to help alleviate some of these issues. Harris described a large nationwide employer that has taken patient advocacy to a whole new level. By increasing the injured employee “touch” with an adjuster, a telephonic case manager and an employer representative, they have been able to reduce their litigation rates and increased their RTW rates. There is no question that a claim’s dynamic changes when an attorney is involved, so having a plan to increase communication and patient touch can go a long way in facilitating return to work and providing key benefits of a return to work program.

What are some ways to measure your return to work program?

Having the ability to track and trend your claims costs, claims durations and return to work achievements are key to developing and enhancing any RTW program. Outcome data is everywhere, but only the savviest and most successful entities can get their arms around the data to form conclusions. Harris highlighted five main objectives workers’ comp professionals should look for when creating or improving their return to work data analytics. Below is his return to work program checklist:

  • Information Exchange: Make sure vendors and partners are giving the information needed to meet your objectives. True partners will deliver transparency in the results.
  • Consistency and Data Integrity: When working with multiple partners, the information should be measured and delivered in a consistent fashion. If different companies are recording findings in different manners, that should be addressed when looking at the overall results.
  • Meaningful Analysis: Results should be company-focused to meet the needs of the program. If company metrics are measured by specific regions, locations, claims offices or job-specific classifications, the data should be lined up to deliver data results at those levels.
  • Data Integration: Data outcomes need to be combined across multiple products to deliver a complete picture of how a program is performing. This approach should include claims results as well as outcomes from bill review, case management, utilization review and other related services to identify successes and opportunities for improvement.
  • Data Visualization: The old adage of “a picture is worth a thousand words” is never truer than when one is trying to assess content from millions of rows of data. A good partner will provide dashboard tools or outcome reporting that allow quick and easy measures to spot trends.

What are some ways to improve return to work rates?

The experts recommend considering a few different factors when trying to improve return to work rates. Clinically, two areas are key to improving RTW rates: having service providers that are experienced in workers’ compensation and ensuring formularies are properly followed. In case management, return to work rates can be improved by following best practice guidelines, providing a thorough initial evaluation that offers a more accurate injury severity score and involving both the employer and family in the injured employee’s recovery plan.