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The MedMetrics blog provides comments and insights regarding the world of Workers’ Compensation, principally, issues that are medically-related. The blog offers viewpoints regarding issues affecting the industry written by persons who have long experience in the industry. Our intent is to offer additional fabric, perspective, and hopefully, inspiration to our readers.

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Tuesday, December 13, 2016

Power-down WC Medical Costs by Identifying Comorbidities Early and Often

by Karen Wolfe

It just makes sense. When an injured worker has an underlying medical condition, recovery is compromised in one way or another. The case will be more complex and it is likely to have a longer duration, higher severity scores, and cost more. A recent article published by Denise Johnson in Claims Journal describes how identifying comorbidities early can help control Workers' Comp claim costs.[1]

Common comorbidities
Johnson identifies common comorbidities to watch for including obesity, diabetes, hypertension, and depression. Certainly these are the most common conditions that impact claims, yet there are many more.

For instance, a pregnant injured worker will require careful medical management. Pregnancy should be considered a comorbidity and managed closely. Other examples include HIV, hepatitis C, cardiac disease, and chronic pulmonary disease. The important thing is to identify the comorbid conditions in claims so they are monitored carefully and referred to nurse case management early. Nevertheless, discovering underlying comorbidities can be hit or miss.

Diagnoses in the data
Comorbid diagnoses can be found in the data--usually. Treating doctors can include the comorbid diagnosis in the list of diagnoses on the bill, but sometimes they do not. They might consider a general health problem irrelevant to a Workers' Comp claim, yet it might be critical.

Timing in the data
Reviewing diagnoses in a claim by the date they were added can be revealing. A diagnosis such as diabetes or obesity can appear weeks after the injury occurred and well into the treatment process. Moreover, when in the course of treatment a diagnosis appears can be enlightening and deserves attention.

Some comorbid conditions appear late in the data because they are newly discovered or the treating doctor becomes aware of them during the course of treatment. An example is discovering a diagnosis for a mental disorder in the data long after the actual injury.

A diagnosis of a mental disorder might result from delayed or unsuccessful recovery and the patient acts out in frustration. Or the late diagnosis might imply previously unrecognized psycho-social factors. Nevertheless, the data should be monitored continually to tag any diagnosis that creeps into the claim picture at any point.

Pre-emptive information
When comorbid, or any apparently unrelated diagnosis appears later in a claim, it could be a pre-emptive signal of poor response to treatment or even impending litigation. Monitoring the data continually to uncover new diagnoses is essential to avoid missing subtle issues.

Smart data
Data can be made smarter by the format and mechanism in which it is presented to those managing the claim. The manner in which diagnostic data is portrayed for claims reps and medical managers can be not only informative, but actionable. An example is portraying all diagnoses by the date they were added to the claim in bills. Such views can disclose subtleties about what is occurring in the treatment process and inform those managing the claim of ensuing problems.

Early intervention
Identifying comorbidities and other troublesome conditions in claims using predictive analytics and continuous data monitoring leads to early intervention and best results. For additional perspectives on this topic, please see, "Analytics-informed Early Intervention Drives Best Outcomes". [2]
Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation, analytics-informed medical management and technical services company. MedMetrics offers online apps and alerts that link analytics to operations, thereby making them actionable and measureable. We don’t do medical management. We make your medical management more powerful. karenwolfe@medmetrics.org

[1] Johnson, D. Experts Say Identify Comorbidities Early to Control Workers’ Comp Claims Costs. Claims Journal. 09-14-2016. http://www.claimsjournal.com/news/national/2016/09/14/273487.htm?_lrsc=bc8326a7-6188-4d5c-a372-994cffa2ecd5
[2] Wolfe, K. Analytics-informed Early Intervention Drives Best Outcomes. http://medmetrics.blogspot.com/2016/11/analytics-informed-early-intervention.html