Medical costs as a percentage of total claims are on the rise. Such costs rose from 46 percent in 1987 to 59 percent in 2007, according to the National Council on Compensation Insurance. Two of the top cost drivers are obesity (and associated co-morbidities) and the aging workforce.
Obesity accounts for nearly 10 percent of all medical spending and could be as high as $147 billion in 2008, according to a research paper presented by Finkelstein et al. at the CDC’s “Weight of the Nation” conference in July 2009. Naturally this impacts medical costs in workers’ compensation.
A workers’ compensation study of Duke University employees found that those who are morbidly obese filed twice as many claims and had 13 times as many lost workdays as colleagues who were at recommended weights. Their claims were 2.8 times more expensive than claims for employees of normal weight at one-year maturity, according to the “Obesity and Workers’ Compensation” study. Costs accelerated as claims aged, climbing to 4.5 times more expensive at the 36-month maturity.
Numerous factors contribute to higher medical costs. Many medications are based on an individual’s body weight. For example, the powerful antibiotic Cubicin costs approximately $2 per unit, and it takes 295 units to treat a 130-pound person for a cost of $590 per dose. Treating a 350-pound claimant is nearly three times the cost, requiring 800 units, or $1,600 per dose.
Durable medical equipment costs more, too. Crutches, walkers and power chairs made for bariatric patients cost between 35 and 45 percent more than those needed for normal-weight claimants.
However, DME is no place to cut costs. Wheelchairs that are too small put pressure on redundant tissue, which can cause costly pressure sores and wounds to develop. Equipment that cannot handle a claimant’s weight may break and lead to reinjury or secondary injuries.
In one case, inadequate crutches snapped under a 375-pound firefighter who had previously broken his leg on the job. The secondary injury caused a broken shoulder on top of his original right leg fracture and put him back on temporary total disability, increasing medical and indemnity exposure. Now he also needed a one-arm-drive wheelchair, and temporary ramping systems to give him access to his home. One minor oversight changed this claim in a split-second from a simple broken leg with minimal exposure into a costly complex claim. The Cost of Co-Morbidities
Other medical cost drivers are co-morbidities associated with obesity, such as diabetes, high cholesterol, hypertension and cardiac disease, along with peripheral vascular and arterial diseases (poor or compromised circulation). Co-morbidities create higher risks for strokes and heart attacks and can complicate and prolong recovery.
Diabetes affects more than 20 million Americans, and over 40 million Americans have pre-diabetes. Wounds tend to heal more slowly in obese, diabetic and pre-diabetic patients. A wound in the lower extremity of a normal-weight individual will usually heal nicely in a matter of weeks and the employee can return to work fairly quickly. The following case illustrates what happens when the claimant is obese and pre-diabetic. Case Study: Painful Outcomes
On December 15, 2009, a 59-year-old man’s foot was broken when a co-worker accidentally backed a vehicle over him, causing fractures to the second, third, fourth and fifth metatarsals of his right foot. The injured employee was an overweight smoker who was also an undiagnosed pre-diabetic.
Casted for several weeks, the foot developed a skin tear, skin infections, and pressure sores. The claimant needed to be hospitalized and required surgery for a diabetic pressure ulcer infection. The mid-January surgery involved a complicated, deep-tissue foot and ankle incision and created a wound roughly the size of a banana.
After nearly two weeks in the hospital, the claimant was sent home with a home health prescription for a nurse to change dressings and monitor blood sugar levels twice a day and provide diabetic and nutritional counseling and education. Now considered diabetic, he was placed on an insulin sliding scale to maintain adequate blood sugar levels, along with Metformin, at 150 mg one to two times per day.
After three months, the wounds had not yet healed. The doctor and nurse estimated it could take an additional three to four weeks for the man to return to work. Under normal conditions, the claimant would have been back on the job within six weeks, but this patient had diabetes and poor circulation. Diabetes elevates the blood sugar stored in the tissues and compromises the healing process. With poor circulation, blood does not flow to and from the wound as well as it should so the wound doesn’t receive the amount of oxygen it needs to heal.
Obesity-related co-morbidities turned a relatively simple lost-time claim into a complex and expensive claim requiring four months of intensive wound care and antibiotic therapy.
The literature on the management of fractures in patients with diabetes reveals generally poor outcomes. There is a 42 percent incidence of complications in patients with diabetes, compared to no complications in the nondiabetic group, according to a study published in the Journal of Bone and Joint Surgery.
Conservative management may be preferable to surgical treatment in view of the high risks associated with management of fractures with diabetics. Tight metabolic control for patients with diabetes who sustain fractures is essential.
Nurse case managers should take a close look at height/weight ratios and medical histories on claims and be aware of potential co-morbidities and alternative therapies for diabetic patients. Reserve extra for obese claims, roughly 2.8 percent higher in year one and up to 5.3 percent in year five. Effects of a Graying Workforce
Another big player in medical costs is the aging workforce. Between 2006 and 2016 the number of people in the workforce between the ages of 55 and 65 will grow by 36.5 percent.
The good news is that older workers are less likely to get hurt on the job than their younger colleagues. The bad news is that when they do get hurt they take longer to heal.
The big concern is falling. Muscle weakness, balance issues, vision problems and side effects from medicines make falls more likely. Additionally, older individuals have less effective protective reflexes to cushion the impact of a fall. The incidence of fractures of the distal radius, proximal humerus, proximal tibia, hip, pubic ramus, and vertebrae is low until the sixth and seventh decades of life, when it increases dramatically.
Most fractures in the elderly result from low-energy trauma, often occurring indoors. Older bones are weakened by osteoporosis and thus require less mechanical force to break. To make matters worse, the elderly are more adversely affected by the secondary effects of fractures.
Patients with hip fractures are at high risk because of the combination of trauma to the lower extremity, forced immobilization for several hours or even days, and surgery. Immobilization from cast treatment causes joint stiffness, and enforced bed rest predisposes patients to pulmonary complications, thromboembolism, disorientation and musculoskeletal weakness.
In the year after a hip fracture, the mortality rate of older individuals increases by 15 percent. Pulmonary embolism (thromboembolism) is the most common fatal complication due to major hip and pelvic trauma. Of patients with a hip fracture who die, 38 percent die of pulmonary embolism.
Of patients with hip fractures who are not given anticoagulants, about 50 percent develop deep vein thrombosis; about 10 percent, pulmonary emboli; and about 2 percent, fatal pulmonary emboli. Of functionally independent patients who lived at home before the fracture, 20 percent required institutional care for more than one year, and 30 percent depend on mechanical aids or assistive personnel.
Even minor fractures of the wrist or shoulder can disable formerly independent older people, who may require personal assistance in activities of daily living for many months. Elderly persons are especially vulnerable to certain complications, including stiffness, swelling, pressure sores and functional impairment. Rehabilitation is often prolonged and recovery is often incomplete. Usually, patients require several months to a full year to regain their pre-injury capabilities. In addition to the physical injuries, fear, anxiety and depression often take a toll on the aging employee.
Important nursing and caregiver issues include preventive management of these complications. The following case illustrates how good medical management produced a positive outcome for an elderly claimant with a severe injury.Case Study: The Strength of a Treatment Plan
Lois, a 72-year-old bank teller, slipped and fell while retrieving a safe deposit box, resulting in an acute hip fracture. After undergoing hip surgery, she remained in the hospital for 10 days. At that point Lois was unable to ambulate, bathe, dress or cook for herself, but she refused to go to a nursing home. Instead, her goal was to recover at home and eventually return to work.
She lived alone, but since she had a one-story home and agreed to use a walker, the doctor sent her home with a script for 24-hour attendant care and home physical therapy three times a week. Within six months, she was able to get around without the walker. During the next two months, home care tapered off and treatment focused on her returning to her position at the bank.
One of the hardest parts of her rehab was convincing her to give up stiletto heels. Lois had never driven a car and had always walked to and from work—in high heels. An additional three weeks of home care was prescribed to ensure that she could walk—in tennis shoes—to and from work and switch to flats at the bank.
Approximately 10 months after her injury, Lois went back to work at the bank. Despite the gravity of the injury, she made a successful recovery due to several factors.
First, despite having significant osteoporosis, she was otherwise in good health before the fall— not overweight, diabetic or suffering from high blood pressure or high cholesterol. Plus, she had good circulation in her legs. Second, her care management team listened to her and developed a treatment plan that fit her goals. Lois was terrified of not regaining independence and ending up in a nursing home.
Case managers need to be aware of potential physical, emotional and mental complications facing older claimants. These patients are more apt to be confused, so practitioners should ensure these patients understand the treatment plan, take medications properly and comply with other therapy. Any fear or depression should be addressed. If Lois had been forced to go from the hospital into a nursing home, the outcome may have been drastically different. Instead, the support and encouragement from her home health care team proved key in her successful recovery and return to work. Tackling Age and Weight
What can case managers do? Flag the files of older and/or obese patients for extra attention. Understand the important role height, weight and age play into your care management strategies.
Pay even more attention than usual to medical histories. Consider how co-morbidities, such as diabetes, poor circulation and high blood pressure, will adversely affect your injured workers’ recovery time and the file’s medical and indemnity reserves.
When working with older employees, be aware of the fears they may have as well as the need for longer recovery times. Monitor their medications and reactions to drugs very carefully; remember older people face an increased risk of side effects. Drugs they may have taken for years might react poorly with a new medication prescribed for the injury. You may also need services that are not typical for normal compensation claims, such as more more attendance care for elderly employees who can only walk 10 or 20 feet with a walker and who have no caregivers living with them.
Perhaps most important, consider the costs. Obesity and old age can dramatically increase the cost of medical care. Alert adjusters and other care managers to be prepared to spend more—especially upfront in order to guard against adverse aspects and re-injury. Reserves for “obese claims” should be at least three times higher than for recommended-weight patients and increased if the claim goes on beyond a year. Remember, it takes older employees two or three times longer to recover from an injury. It follows that their reserves need to reflect two to three times the medical and indemnity costs.
Kevin Glennon, RN, BSN, CDMS, CWC, QRP, FL-W/C, is the Vice President of Clinical Services with Total Medical Solutions, a national provider of complex care products and services for workers’ compensation. (firstname.lastname@example.org)