At one time or another as an employer you are going to experience work comp injuries. Some of these injuries are minor in nature, while some can be severe and life-changing.
Joint Replacement More Common – Very Difficult Claims
The nature of joint replacement can rear its ugly head from time to time. In the past, joint replacement surgery was only thought to have occurred in older employees, with a lifetime of cumulative injury to the specific joint, be it the knee, hip, shoulder, or ankle. But now Carriers are starting to see knee and shoulder replacement surgeries in younger to middle-aged employees. This type of injury and subsequent surgery can lead to very difficult claims in the field of workers compensation. [Wcx]
In the past, Carriers were quick to deny surgeries such as these on the basis of the need for the surgery not being totally occupational in nature. Once this replacement surgery is performed, it is seldom a “one-time” procedure. The life span of prosthetic joints was said to be short, with it being a positive outcome if the prosthesis would last 3-5-7 years.
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Advances Made in Surgery, Much Homework Still Needs to be Done
Recently over the course of the last handful of years several advancements have been made in the field of joint replacements, and several surgeons are getting quicker to recommend joint replacement surgery as a way to resolve ongoing pain and the need for opiate medication on a long-term basis. Joint replacement has led to a better quality of life, and an increase in overall functionality in the right candidate. But in the world of work comp, carriers are still very slow to accept these procedures without a lot of homework done beforehand. Let’s look at some of the pros and cons of these types of procedures:
PROS – Less Pain Meds, Decreased Long-Term Treatment
The first positive for getting joint replacement surgery is the decreased need for ongoing pain medication. Expensive, and often addictive in nature, surgeons will point out that the prosthesis can lead to be a functional way of life without the need of strong pain-relievers, automatically positively impacting the overall expense of the work comp claim. Decreased needs for physical therapy, diagnostic testing such as MRIs and EMGs, and decreased loss of work time after rehabilitation are all positive indicators that can mean less wasted claim dollars.
The technology involved in the actual lifespan of the prosthesis has improved as well over the last 10-20 years. In the past, prosthetics were often drowned out in negativity, with insurers quick to point out that the lifespan is really an unknown. In certain cases, the replacement could last 15 years whereas in others it could fail right out of the starting gate. The price tag on these surgeries can hover well over $100,000 after all of the surgeries, diagnostics, physical therapy, medications, and so on, and that doesn’t include lost wages away from work and decreased productivity once the employee returns to gainful employment. However, all of these are past stereotypes and research has shown more positive outcomes. It varies from patient to patient, but, most injured workers have decreased pain levels, which can be the most important factor.
Need Proper Evaluation to Determine if Surgery is Correct Answer
There may be no model for the perfect joint replacement candidate because everyone’s body varies. Age, arthritis, functionality,pain tolerance, patience, activity level, job tasks, employer flexibility, job experience, and other pre-existing conditions need to be taken into careful account before a procedure like this is even considered. I have seen some cases where the doctor will start off with a rotator cuff tear repair, only to end up recommending a total or partial shoulder replacement within 2-3 months post-surgery. This may be quick to jump the gun considering the extent of the injury, however, the adjuster has to consider if the injured worker will fail a number of surgeries before finally considering joint replacement.
CONS – Fear of the Unknown, Will the Surgery Work?
I believe that the strongest con involved in these procedures is the factor of the unknown. Carriers like to know facts, and have statistically-guaranteed outcomes. Unfortunately with joint replacement procedures there is not a guarantee. You can send the claimant for a few IMEs with different surgeons and get a feel for what they think will happen, but until that patient goes under the knife all bets are off. These claims and injuries have to be evaluated on a case-by-case basis. Your risk drivers will help to determine if authorizing these procedures will lead to a best outcome.
The biggest unknown of them all is the actual claimant. Psychologically, surgeries are not a magic bullet. There can be months of pain and rehab ahead, and your injured worker may not be the most patient person in the world. In my experience dealing with these procedures post-op, the most common complaint is they want to know when they will be better and able to function like they did prior to the injury. The truth is, some people will never be the same. They may never be able to pick up their kids or grandkids and toss them in the air as they did before. They may not be able to lift 30lbs over chest level or they may never be able to squat down and garden in their front yard pain-free as they once did. And this fear of the unknown can stop many people from even wanting to go through with a procedure with such unknown results.
Carriers Often Settle Early to Ensure End to Claim
The reality is that with these invasive surgeries is nobody knows the outcome. This can scare off adjusters from authorization and steer the claim into litigation for settlement, which could be just as costly. Carriers calculate if the claim were to settle, they know the outcome and the associated costs. If a claim such as this were to settle for $250,000 at least the Carrier can pay that, and be done with it. Whereas if the carrier sinks $100,000+ into this procedure, who knows if this person will need another surgery in 5 or 7 years, and maybe that surgery is the one that will fail even worse than the first one.
Carriers fear unknown future costs, and fear even more the potential for a claim to have to be re-opened with a higher expense in the future. Settlement leads to the end of the claim and guarantees that it is over. Your claimant receives a check, and you close the file knowing it cannot be reopen years down the road. Carriers have to hedge risk which can cost them greatly upfront in Court, but they get comfort knowing the claim is over. This isn’t to say that the carrier doesn’t care; after all, the claimant has to be on board with settlement for it to go forward. This maybe the best way for all parties to move forward with each satisfied with the outcome. Of course, each case will vary greatly from one to another, which is the hardest part involving claim of this nature. [Wcx]
If a claimant has a recommendation for joint replacement surgery, your carrier has to do their homework. Whether is it involving the knee, shoulder, hip, or ankle, I would be surprised if any carrier or adjuster accepted the need for a joint replacement surgery without taking the time to gather years’ worth of past medical records, get a few IMEs, and evaluate the case very carefully. These procedures affect the claimant in one way or another, either positively or negatively. It is only after the procedure that all parties know if it is worth it in the end or not.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: email@example.com.
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