Still recovering from the impacts of the pandemic, the workers’ comp industry must seek new approaches to optimize patient care, reduce duration and increase return-to-work rates in 2022. This requires a fresh look at best practices – especially in light of new findings on the treatment of injured workers. To effectively guide the industry (and workers) towards recovery, MedRisk has analyzed important trends seen over the past year and, in response, offers changes that may be made in the years to come.
Researchers have long agreed there are significant benefits to starting physical therapy early – that is, within 14 days post-injury, according to a 2020 Workers Compensation Research Institute study. To further reap these benefits, especially given the challenges the industry is facing in light of the pandemic, practitioners are shifting focus to one very specific type: manual therapy (MT).
decrease in temporary disability with early PT vs late post-injury PT
PT is understood to be the first-line treatment for musculoskeletal injuries before considering addictive opioid prescriptions and invasive procedures. Further, the 2020 study from WCRI says that for workers with low back pain, early initiation of PT (as defined by WCRI) is associated with lower utilization, lower costs and shorter duration of temporary disability.
more likely to experience a worsening disability without MT
A 2020 systematic review of randomized controlled trials updated a 2013 review exploring the value of MT (among other interventions) over the past several years. The 2020 review concludes by strongly recommending MT be integrated as an additional therapy. This supports earlier study results, which observed that patients who received only exercise (without MT) were 8 times more likely to experience a worsening disability compared to patients receiving exercise and MT treatment.
lower average medical cost per claim with early MT
In September 2021, WCRI released an initial study on MT for LBP claims. Researchers found that the temporary disability per claim was 22 percent shorter and the average indemnity payment per claim was 28 percent lower when workers received early MT compared with those receiving it later; a positive step towards more effective WC outcomes.
We’re seeing an increased focus on early MT in the industry and we’re delivering on it in our business. MedRisk data highlights patient age, surgical status and case complexity as three key factors that impact case duration and have been traditionally difficult to tackle. Our data – which has shown consistent results over the past five years – reveals the difference with and without early MT.
PT utilization and visit duration usually increase with age – a concern for the WC industry as the workforce continues to age. The good news: the value of early MT also increases with age. MedRisk data shows that patients between the age of 51 and 60 are discharged 7 days sooner and those 61+, 9 days sooner when they’ve received early MT. As the industry navigates an aging workforce, a shift to more MT sooner will get employees back to work faster.
DAYS TO DISCHARGE
Following surgery, patients receiving MT later in their episode require more treatment over a longer period of time than those who receive MT early in the episode.
Early MT is especially valuable for complex cases involving more than one ailment. In such cases, early MT leads to fewer visits over a shorter duration.
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The mental health challenge of the pandemic persisted throughout 2021 and has continued to impact recovery time. Looking forward, we expect anxiety and depression rates to align with COVID-19 recovery as underemployment, high hospitalization rates and other negative pandemic-related stressors remain.
With uncertain times, mental health concerns and rising PT costs comes a renewed focus on structure and guidelines to lean back on.
MedRisk gathers the latest legislative and regulatory developments and challenges each quarter. Here is a full summary of significant movements in 2021 and the implications for 2022.
California and Virginia released new and comprehensive privacy statutes on the books, although the effective date for both initiatives is delayed until January 1, 2023.
The California Privacy Rights and Enforcement Act (CPRA) expands upon the current California privacy statute, the California Consumer Privacy Act (CCPA), by regulating not only the buying and selling of consumer information, but also its “sharing.” This term is narrowly defined as targeted advertising based on the consumer’s personal information.
The Virginia Consumer Data Protection Act (CDPA) takes a different approach to consumer privacy, following many of the concepts found in the European Union’s General Data Protection Regulation (GDPR), such as the use of the terms “controller” and “processor.” A “controller” is an entity that determines the purpose and means of processing personal data (such as an insurer or TPA), whereas a “processor” processes personal data on the controller’s behalf (such as MedRisk). There are a number of thresholds and exemptions that will relieve MedRisk and many of its clients and trading partners from CDPA compliance obligations.
Implications: Although neither the California CPRA nor the Virginia CDPA is likely to have much impact on the operations of MedRisk or its trading partners, a potential trend toward a patchwork of comprehensive and inconsistent privacy laws is troubling. Most companies that operate nationally may be driven toward adoption of a lowest-common-denominator set of privacy standards that comply with state laws representing the binding constraint.
Amendments to the Workers’ Compensation Board Medical Billing Disputes regulation became effective on November 1. These amendments require all objections to medical bills be filed with the Board simultaneously rather than sequentially. As amended, 12 NYCRR 325-1.25 now provides that the Board will deny any objections to payment of a health care provider’s bills that are not raised simultaneously in Form C-8.1, including objections based on legal, valuation or Medical Treatment Guideline grounds. The regulation is further amended to require payers, if the objection relates to the provider’s failure to obtain prior authorization, to provide with the filing evidence that the prior authorization request was actually denied.
Implications: The New York State WCB, in adopting these revisions, cited the need to expedite the resolution of medical payment disputes in the interest of administrative efficiency. The new requirements, however, appear to place the burden of improved timeliness primarily on insurers, employers and TPAs. The revisions may present challenges for payers’ claim staff in compiling and presenting all potential objections to medical bill payment within New York’s 45-day prompt payment timeline.
The Pennsylvania Commonwealth Court ruled that in 2016, the PA Department of Labor incorrectly calculated the PA fee schedule for PT evaluations and re-evaluations. The Court reasoned that CPTs 97161, 97162 and 97163 were not new codes, but rather replaced CPT 97001 with three codes that recognized varying levels of complexity. Similarly, CPT 97164 was not new but was merely a renumbering of the old CPT 97002. Thus, the fee schedule rates for the new codes should be based on the higher 1995 Medicare reimbursement rate, adjusted for inflation, rather than on then-current (and lower) 2016 Medicare rates.
The Court concluded that Pennsylvania PT providers have been shorted $20 to $21 per relevant service since January 20, 2017. The Court reversed the Secretary of Labor’s determination to the contrary and remanded the matter to the Department of Labor to “correct its 2017 Workers’ Compensation Fee Schedule,” which the Department promptly did.
Implications: The immediate practical implications of this decision are unclear. The court acknowledged that the corrected fee schedule will allow providers to submit supplemental invoices to WC payers if they choose to do so. MedRisk’s predominant provider payment methodology is based on per diem maximums rather than a percentage of fee schedule, so MedRisk has not seen an influx of requests for additional reimbursement. Longer term, however, the decision will encourage providers to negotiate for higher network reimbursements commensurate with the higher fee schedule rates for PT evaluation and re-evaluation codes.
Legislative measures as reported in the NCCI 2021 Regulatory and Legislative Trends Report have adopted and expanded presumptions that workers’ exposure to COVID-19 arises out of and in the course and scope of employment and, therefore, is a compensable injury or disease under WC. Five states that recently expanded presumptions are Alaska, Illinois, Minnesota, Vermont and Wyoming. Further, legislative measures establishing a presumption of work-relatedness are broadening employers’ WC exposure in three additional ways. First, the original list of workers subject to the presumption has been considerably broadened. Second, many bills do not have sunset dates tied to a time-limited COVID-19 emergency declaration (typical of a gubernatorial executive order), so they will not expire when the pandemic subsides. Third, some bills are not limited specifically to COVID-19, but instead have terms that apply broadly to future unspecified infectious diseases or pandemics.
Another societal trend finding its way into legislation affecting WC compensability arises from public awareness of the serious and lingering health effects of post-traumatic stress syndrome suffered by public safety personnel and armed service members. States that enacted legislation in 2021 expanding WC coverage for mental injuries included Connecticut, Idaho, Maine, Maryland, Nebraska, New Hampshire, Utah, West Virginia and Wisconsin.
On August 1, North Dakota became the first US jurisdiction to permit PTs to act as primary treating providers for WC claimants. The state’s exclusive state fund, Workforce Safety & Insurance agency, issued guidelines permitting PTs to perform stay/return to work planning, correspond with WSI regarding the injured worker’s injury, provide capability assessments every two weeks, determine maximum medical improvement to guide claim management, and refer the patient to most other health care providers without WSI prior authorization.
Implications: Allowing patients to have direct access to PTs without requiring a referral from a physician is common within group health plans, but the North Dakota statute and guidelines break new ground for WC claimants. North Dakota employers currently have the option of requiring injured workers to treat with the employer’s choice of Designated Medical Provider, however, so the immediate impact on employers may be limited. Nevertheless, this innovation bears watching as a means of delivering prompt and cost-effective health care and medical management to claimants who have experienced musculoskeletal injuries.
On May 5, Governor Doug Ducey signed into law HB 2454, which provides broad support for telehealth services in group health coverage. The measure clarifies existing law that Arizona endorsement of telehealth encounters applies to ancillary services and requires a carrier to reimburse health providers at the same level of payment for equivalent services, regardless of whether the services are provided in person or via audio-visual telehealth.
Specifically in relation to WC, the law allows medical examinations for WC claims to be conducted via telehealth with the consent of both the employee and the requesting party.
Implications: HB 2454, which was effective on its enactment, continues the broad trend toward state endorsement of telehealth when those services are medically appropriate. WC payers should incorporate telehealth into their injured worker treatment options if they haven’t done so already.
Two bills that posed significant challenges to California’s Medical Provider Network (MPN) system have been defeated, at least for now.
Assembly Bill 399 would have mandated that MPNs pay participating providers at California’s Official Medical Fee Schedule and would have prohibited negotiated rates below the regulatory fee. The measure would also have restricted MPNs’ ability to review provider bills for mistakes, fraud and abuse. Through intense opposition by employers and WC payers, the bill was held in the Assembly Insurance Committee without being voted on but has since been pared down to focus on the injured employee’s accessibility to MPN information. The minimum fee schedule component has been removed.
Assembly Bill 1465 would have required the Division of Workers’ Compensation to establish a state-run MPN (CAMPN) and would have permitted injured workers to select providers from this network in lieu of their employers’ MPNs. This measure is now a “study bill,” meaning that the California Commission on Health and Safety and Workers’ Compensation (CHSWC) will compare treatment delays and provider access issues between MPN and non-MPN claims and issue a report of its findings by January 1, 2023.
Implications: It is unlikely that either of these bills will be resurrected in the foreseeable future. AB 1465 met strong opposition from the business community, and the CHSWC study likely will counter the arguments of AB 1465 proponents that California injured workers lack access to high quality medical care via MPNs.
Psychological factors are known to impact the course of LBP and recovery – but how can these factors predict recovery? In this study, led by MedRisk ISAB member Steven Z. George, PT, PhD, FAPTA, researchers sought to: 1) describe LBP recovery rates at 6 months following 4 weeks of physical therapy; 2) identify psychological factors predictive of 6-month recovery status; and 3) identify psychological factors that co-occur with 6-month recovery status. Psychological risk status, depressive symptoms and pain intensity were predictive of 6-month recovery status. Elevated fear avoidance, kinesiophobia (excessive, debilitating fear of physical movement) and depressive symptoms co-occurred with non-recovery at 6 months.
Research has shown broadly that early PT can improve outcomes and reduce utilization of other medical services. WCRI’s 2020 study examines how this plays out in WC cases. In this study, WCRI examined the outcomes of five PT-timing groups (within 3 days, 4-7 days, 8-14, 15-30 and more than 30-days post injury) and defined “late PT” as more than 14 days of injury.
Patients who received early PT (within three days of injury) were:
To help fill information gaps in medical and healthcare policy research regarding MT, WCRI analyzed LBP claims in 28 states that did not have surgery and received MT. WCRI compared costs and outcomes between claims with early MT (within 14 days of the worker starting PT) and late MT, as well as claims with and without MT.
Researchers, including a member of MedRisk’s ISAB, Kathryn Mueller, MD, found that early MT was associated with lower utilization of medical services, lower medical and indemnity payments, and shorter temporary disability duration. In fact, the average medical cost per claim was 27 percent lower, the average indemnity payment was 28 percent lower and temporary disability duration was 22 percent shorter when workers received early MT compared with those receiving it later.
To lessen the public health impact of LBP – highlighted as a research priority by recent CPGs and the U.S. Federal Pain Research Strategy – it may be necessary to improve existing predictive approaches for the transition from acute to chronic LBP. A literature review published in PAIN Reports describes predictors and outcome measures from earlier studies that looked at the transition from acute to chronic LBP. Following the review, the authors – including MedRisk ISAB member Steven Z. George, PT, PhD, FAPTA – provide a standardized framework for the transition to prevent chronicity.
COVID-19, affecting a large proportion of the active working population, can have physical, psychological and cognitive consequences that result in functional disability, reducing quality of life and interfering with return to work. This is especially true for individuals who require prolonged hospitalization and intensive care. A study published in Rev Bras Med Trab analyzed the impact of COVID-19 on occupational health, specifically focusing on the value of PT in rehabilitation for patients with severe or critical illnesses. In a literature review, the authors found that patients with severe acute respiratory syndrome – caused by the novel coronavirus or not — require PT to prevent and recover from short-, medium- and long-term issues. As such, PTs must be involved in the battle against COVID-19 to help patients recover and return to work as quickly and safely as possible.
Early PT has been shown to decrease downstream healthcare use, costs and recurrence rates in some musculoskeletal conditions. A study published in 2021 in BMC Health Services Research sought to take a first look at early versus delayed PT around patellofemoral (knee) pain. By reviewing research in the military health care system, the authors found higher costs and symptom recurrence for patients who had delayed PT (31-90 days after diagnosis). Authors believe the findings could help health systems move toward “more efficient pathways for appropriate care.” This observational study reinforces the value of early PT and Direct to PT (without seeing a physician first) and extends applicability to knees.
A recent update to a clinical practice guideline (CPG) published in JOSPT provides evidence-informed recommendations for interventions to help manage LBP that are delivered by PTs or in care settings that include PT providers. This update emphasizes nonpharmacologic interventions to improve patient outcomes. The authors, including MedRisk ISAB member Steven Z. George, PT, PhD, FAPTA, reviewed 5 high-quality CPGs for LBP to produce recommendations for screening, assessment and treatment approaches. These recommendations were then reviewed by other industry professionals, including MedRisk ISAB member Paul Beattie, PT, PhD, FAPTA.
This CPG is novel because it concentrates on treatment recommendations for LBP and contains information related to interventions that were not covered in the 2012 CPG, dry needling, cognitive functional therapy and pain neuroscience education. Consistent with previous CPGs, thrust and non-thrust joint mobilizations – MT techniques – remain the best care options for acute and chronic LBP; exercise and education are also effective for chronic LBP.
Up to 84% of the general population will report at least one episode of LBP at some point in their life. This high rate of LBP treatment also has high downstream costs. An article published in PLOS One systematically reviews a collection of peer reviewed studies to evaluate the influence of PT guideline adherence on healthcare utilization and costs for LBP patients. With some exceptions, the review showed that those participating in an adherent PT treatment program experience lower healthcare utilization. This includes fewer and shorter PT visits, fewer medications, fewer visits to the physicians or emergency department and less use of advanced imaging, surgical and injection procedures.
In research published in the British Journal of Sports Medicine, O’Keeffe et al investigated how psychosocial factors do not always indicate mental health disorders and are not distinct from biological factors in low back pain. Reductions in pain and disability after treatment are, to some degree, facilitated by changes in non-physical factors, like self-efficacy. For example, exposure to a specific movement that the patient fears paired with an empowering narrative from the provider can reduce the associated fear or anxiety.
The study also argued that psychosocial factors do not only appear in persistent pain presentations. In fact, the authors, who included Steven Z. George, PT, PhD, FAPTA, a member of MedRisk’s ISAB, said that psychosocial factors are an expected and normal part of LBP experiences, acute or chronic.
There is a growing recognition among HCPs that injured worker treatment must go beyond biomechanical therapies in order to help the patient achieve optimal outcomes. Patient education and communication can be important components of minimizing time loss after injury. The authors of an article published in Medical Care analyzed linked survey and administrative claims data from WC recipients to assess whether HCP communication could predict time off work and whether this impact could be hampered by a stressful HCP experience. The report found that sharing a likely RTW date with patients reduced the odds of future time loss, regardless of the stress of their HCP experience. In addition, HCPs may be able to reduce the length of future time loss by reaching out to stakeholders in the return-to-work process and possibly through prevention discussions, but only in low-stress encounters.
In a recent article published in the Journal of Orthopaedic and Sports Physical Therapy, Hutting et al contend that self-management strategies are integral to managing chronic musculoskeletal disorders and discuss how PTs can provide self-management support throughout the course of treatment. The authors recommend an individualized, holistic approach to self-management that addresses biomechanical, psychosocial and individual characteristics. Research has shown that while passive self-management approaches (e.g., hot packs) increase the likelihood of pain behavior and disability, active strategies (e.g., exercise) can decrease the probability of these experiences.
A study published in the Mayo Clinic Proceedings: Innovations, Quality & Outcomes journal aimed to determine the connection between the type of provider initially consulted and 1-year, downstream healthcare utilization to inform future care recommendations for patients with neck pain.
The study found that the practitioner consulted at the index visit for neck pain can have an impact on downstream healthcare utilization. More importantly, the researchers found that, when compared to an initial neck pain consultation with a primary care physician, an initial consultation with a nonpharmacological provider (Doctor of Chiropractic or PT) is associated with a decrease in opioid use 30 days and 1 year after initial consultation.
In an article published in the American Journal of Physical Medicine & Rehabilitation, Tenforde et al reviewed findings from a survey of 211 study participants who received a telehealth visit for lower limb injuries, pediatric neurology or primary impairments in sports during the COVID-19 pandemic. More than half (53%) of the visits examined were with a PT, and the overall findings showed that over 90% of participants selected “excellent” or “good” when rating having their concerns addressed, communication with their therapist, treatment plan development and execution, convenience and overall satisfaction. About 87 of respondents replied with “excellent” or “good” when asked about the perceived value of having a future telehealth visit.
The multiple benefits of early PT have been documented in many studies, but this article published in the Journal of Occupational and Environmental Medicine also recognizes the vital role of the care manager – the adjuster, case manager and other claims representatives. Phillips et. al analyzed the WC claims of employees of a large, integrated healthcare system located in the Midwest for the study.
Researchers conducted a retrospective chart review of claims from 2009 that were not managed and did not receive early access to PT. Their outcomes were compared to those of workers whose claims from 2012 and 2013 were managed through a care pathway, included early access to PT and included a high level of communication with all stakeholders. The managed claims lasting longer than 90 days had lower indemnity costs, fewer therapy visits and lower total costs of claims than the ones that did not go through the care pathway.