MedRisk has always been dedicated to understanding and advancing best practices. Those best practices have proven to be even more critical for a nation struck by a global pandemic. By sharing the most meaningful changes we’ve seen in the wider community over the last year and the insights into where PT for workers’ comp is going next, we hope to make an even larger impact on increasing patient-focused care and improving return-to-work success for patients, providers and employers alike.
of top WC payers trust MedRisk’s managed PT
of network providers agree with MedRisk clinical recommendations
lay-offs or furloughs during COVID-19 shut down
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Injured Workers Treated
COVID-19 has had an incalculable impact on the health and wellbeing of everyone. The following broad trends within the wider healthcare industry are expected to have significant impacts on managed physical therapy in workers’ comp.
In March, the American College of Surgeons recommended suspending non-emergency and elective surgeries in the interest of patient safety and the redeployment of resources. Analysts estimate the resulting backlog of these surgeries and related medical procedures (including post-surgical physical therapy) will take nearly a year to bounce back from.
Depression, anxiety, trauma- and stressor-related disorders (TSRD), suicide ideation, and substance use all increased significantly by June 2020 due to the pandemic. Some researchers estimate depressive disorders are four times what they were for the same period in 2019.
According to the American Medical Association (AMA), more than 40 states have reported a significant increase in opioid-related deaths this year compared to 2019, highlighting the critical importance of effective alternative treatment paths such as PT and other conservative care approaches.
MedRisk data shows significant fluctuation in the volume of post-surgical PT this year that correlates closely to the postponement of non-emergency surgeries due to COVID. As the medical community attempts to catch up we expect a higher number of post-surgical PT referrals and even pre-surgical physical therapy to help deconditioned patients prepare for postponed surgery. We also expect longer duration overall due to both delayed surgical and non-surgical medical care, a prediction supported by recent research from the WCIRB in California.
MedRisk’s data suggests injured workers are being hit especially hard by the pandemic-related rise in depression and anxiety. These psychosocial factors can be significant barriers to recovery leading to longer duration of PT care and can negatively impact return-to-work. As such, the workers’ comp industry should brace itself for both an increase in PT spend due to longer duration and higher total medical and indemnity claim costs.
Moderate to High Feelings of Depression
Moderate to High Feelings of Anxiety
While the opioid crisis is experiencing a surge due to COVID pressure, MedRisk’s proactive interventions have been associated with significantly less opioid involvement in lost time claims. This mirrors recent research that shows PT can reduce the number of opioid prescriptions in LBP cases. Based on what we’re seeing, we expect managed physical medicine to play a critical role in the effort to curtail the proliferation of opioids both now and in the future.
opioid involvement in standard care cases
opioid involvement with MedRisk proactive intervention
MedRisk is now combining predictive analytics and proactive clinical interventions which have had an overwhelmingly positive impact on total claim outcomes:
The Department of Workers’ Claims has proposed Administrative Regulation 803 KAR 25:260, which adopts the ODG treatment guidelines broadly applied to non-emergency medical care. Treatment recommended in the guidelines would be presumed to be reasonable and necessary. Conversely, treatment not recommended or not addressed in the guidelines would require preauthorization, with the burden placed on the provider to justify the proposed treatment. For retrospective bills, payers would not be responsible for paying for treatment outside the guidelines unless it (a) was provided in a medical emergency, (b) was authorized by the payer, or (c) was approved via dispute resolution by an administrative law judge.
Implications: Once formally adopted, the new Administrative Regulation will add Kentucky to the list of jurisdictions that use independently developed interstate medical treatment guidelines to promote effective medical care while reducing friction within the WC system. The treatment guidelines apply to all treatment administered on and after September 1, 2020.
Senate Bill 381 adds a new section to the existing statute (NRS 616B.527) permitting payers to contract with preferred provider networks and giving payers the right to require injured workers to obtain healthcare services (including physical therapy) within the preferred provider organization. The new law imposes a qualification on employers’ and insurers’ ability to direct care: the injured worker must choose from the employer’s/insurer’s list of physicians and chiropractors only if the employer/insurer maintains a list of 12 physicians for each of the enumerated physician specialties and for 12 chiropractors.
The new law requires employers and insurers to maintain a list of physicians and chiropractors only, but not a list of PTs. If the payer doesn’t provide a list that complies with this requirement, the injured worker can select a physician or chiropractor from an approved list compiled by the WC Section of the Division of Industrial Relations. Further, the new law requires employers and insurers to file with the DIR an updated list of physicians and chiropractors by October 1 of each year.
Implications: The statute considerably restricts what has been a permissive approach to employer direction of care by imposing a “panel” requirement for physician specialties and chiropractors. Payers were required to submit their lists to the DIR by January 1, 2020, in order to maintain their ability to direct injured workers to network physicians and chiropractors.
The New York State Workers’ Compensation Board adopted several amendments to its regulations to conform them to the Expanded Provider Law taking effect on January 1, 2020. The amendments to the regulations implement the statute by detailing the billing process to be followed by newly authorized providers. The amendments clarify the regulations in three ways. First, the amendments provide that payers subject to the regulations include third party administrators as well as employers and insurers.
Second, the amendments add as new provider types protected by the regulation any authorized medical provider of Medical Care (defined broadly in the underlying statute to include physical and occupational therapists and acupuncturists, among others). Third, the amendments simplify the billing dispute process to eliminate the “continuous course of treatment” concept and to extend time to submit bills from 90 days to 120 days from the date of service. The amendments have an effective date of January 1, 2020.
Implications: The proposed amendments primarily conform the current regulations to the new statute and bolster the WCB’s enforcement powers over all payers, including TPAs. Lengthening the permitted provider bill submission timeline from 90 to 120 days after date of service, however, may necessitate changes to payers’ late-bill denial processes. The amendments retain their status as proposed rather than final, but payers may be well-served to comply with the proposed amendments sooner rather than later.
Legislative activity in 2020 has been focused primarily on the COVID-19 pandemic. The NCCI has identified 89 separate bills or executive orders nationwide that expand the compensability of WC to employees contracting the coronovirus, 83 of which have either been enacted, issued or are in committee. While many of the executive orders will expire or have limited scope, COVID-19 pandemic and compensability will have a significant impact on WC payer claim operations.
During the pandemic and in the absence of federal legislation clarifying CMS rulemaking authority over telehealth services for physical medicine, state workers’ compensation agencies who had previously prohibited telerehab or restricted access have issued month-to-month emergency rules extending authorization. Increased access will most likely continue through 2021. Even after the pandemic subsides, MedRisk anticipates the industry to continue to embrace the use of telemedicine services, including telerehabilitation.
The NCCI predicts that the deferral of hospital treatments and physical therapy due to COVID-19 will mean longer claim duration, which can equate to higher indemnity payments and likely more overall medical expenditure. This, combined with the fact that claimants cannot return to work after medical treatment if work is furloughed, may lead to higher severity for active workers’ comp claims.
In addition, a break or delay in treatment can add complexities to treatment. Claims representatives can expect to receive prescriptions for pre-operative conditioning, and providers and claims professionals may see a rise in psychosocial barriers to recovery as injured workers finally begin treatment.
Chronic pain is one of the most common reasons for seeking medical care and has been linked to anxiety and depression, poor health and reduced quality of life and, as seen in the news, a dependence on opioid prescriptions. However, this is the first time in recent history that those managing pain are doing so through a pandemic.
As mounting research points to the effectiveness of conservative care, physical therapy has asserted a central role in both preventing and managing long-term musculoskeletal pain. How can physical therapists best support patients during a time when postponed treatment puts musculoskeletal patients at a higher risk of delayed recovery and chronic pain?
The pandemic’s strain on the healthcare system has prompted many patients to be discharged directly to their homes, without the usual supports and with a high risk of readmission. This can present new hurdles for workers, who already struggle to resume daily function and return to work following serious illness. Brian Peers, DPT, MedRisk’s Vice President of Clinical Services and Provider Management, published an article in WorkCompWire about the lasting effects of post-intensive care syndrome (PICS) on COVID-19 survivors. PICS, which refers to new or worsening physical, cognitive or mental impairments that continue after hospitalization for acute critical illness, is an after-effect for about half of patients who survive ICU treatment.
Many employers are extending remote work into 2021, while others are making it permanent. For those newly working from home, hunched over laptops on makeshift desks, the risk of injury can be even greater than at the office. Biomechanics are showing particular promise during the coronavirus pandemic when it comes to these types of remote workplace injuries. MedRisk’s Phil McClure PT, PhD, FAPTA, vice president of MedRisk’s International Scientific Advisory Board, discusses strategies derived from biomechanics that can help prevent injuries but and treat already injured workers.
We know patient education can reduce fear and anxiety and improve satisfaction, making better, faster outcomes much more likely but does it matter how the information is delivered? This 2020 study found patients with low back pain were more likely to remember what therapists said when they were included in the initial decision making; when they were given fewer, simpler exercises; and when they had their expectations and concerns addressed directly. The research suggests proactive interactions between patient and physical therapist could be key to information retention and help improve outcomes.
Dry needling to ease muscle pain has been growing in popularity as the conservative care movement gains momentum. Recent research, however, suggests dry needling does not have a significant impact on chronic neck pain when combined with physical therapy, nor did it have any effect on disability. Keeping apprised of research such as this is critical to ensuring evidence-based guidelines include the latest medical intelligence.
WCIRB recently released research on how medical care disruptions and delays due to the COVID-19 pandemic and shelter-in-place orders have likely effected claims in California's workers' compensation system. The study focused specifically on the long-term cost impacts of delayed care and was based on an evaluation of historical claim information.
For soft tissue injury claims, delays in first PT had longer duration of care as well as 40% higher medical costs and 50% higher indemnity costs. And that higher costs trend persisted years after the injury. Researchers posit the difference may be related to the lower opioid use for cases where early PT is achieved.
Based on the substantial delays the nation has experienced in 2020, the research "underscores the cost savings associated with early PT for soft tissue claims and the positive impact on work-related disability duration."