Workplace Wellness and On-site Chiropractic Services: Is There a Chiropractor in the House?

Robin Kobayashi 65x57By Robin E. Kobayashi, J.D., LexisNexis Legal & Professional Operations

 

Musculoskeletal disorders (MSDs), including most commonly sprains and strains, accounted for a whopping 33 percent of all workplace injury and illness cases as well as one-third of all the days-away-from-work cases in 2013 according to the U.S. Dept. of Labor, Bureau of Labor Statistics. What’s more, workers who sustained an MSD injury needed an average of 11 days to recuperate before they could return to work compared to 8 days for all other types of injury cases. Nursing assistants, laborers, and freight, stock, and material movers had the highest rates of MSD injuries.

 

Given the high rate of MSD injuries in the workplace and the associated high costs of treatment, studies from 2011 and 2012 examined the use of on-site chiropractic services and found that these services contributed to lowered overall costs. Supporting the value of on-site chiropractic services is a 2014 study published in the Journal of Occupational and Environmental Medicine that compared the impact of on-site and off-site chiropractic care on health care utilization, specifically, radiological procedures and clinical care.

 

 

How the 2014 Study Was Set Up

 

The study focused on Cerner Corporation, a self-insured company in Kansas City, MO, specializing in health information technology and care delivery strategies. Cerner’s on-site health centers provide wellness, prevention, pharmacy services, and primary care, including chiropractic care, to all employees enrolled in Cerner’s health plan.

 

The 36-month retrospective study examined 876 employees who received chiropractic care at their place of employment (the on-site group) and 759 employees who received chiropractic care at an off-site community-based chiropractic office (the off-site group).

 

The study assessed utilization for radiological procedures (i.e., MRI, ultrasound, CT scan, and other radiograph procedures) and clinical utilization (i.e., claims for chiropractic services, physical therapy, or further medical care—inpatient, outpatient, or ER visits).

 

 

Key Findings And Facts

 

Overall the on-site group had much lower health care utilization than the off-site group.

 

For example, 55.5% of the off-site group received radiology services compared to 38.2% of the on-site group. In addition, repeat radiology services were much higher in the off-site group (20.5%) than the on-site group (10.1%). The authors of the study suggest that chiropractors who were unaffiliated with Cerner’s health plan were more likely to refer patients out of the clinic, thereby increasing costs in the system.

 

With respect to utilization of outpatient services, 47.3% of the off-site group had outpatient utilization compared to 30.2% of the on-site group. In addition, repeat outpatient services were much higher in the off-site group (29.5%) compared to the on-site group (18.5%). This pattern repeated with utilization of ER—19.0% for the off-site group compared to 13.1% for the on-site group. However, the authors of the study warned that they did not collect comorbidities or patient histories for their study, so it’s unclear whether these statistics were impacted by underlying characteristics of each group.

 

The study also found that the average number of chiropractic services and physical therapy visits per member were significantly higher with the off-site group. The authors of the study queried whether care packages advertised by community care centers might explain this big gap in utilization between the on-site and off-site groups.

 

 

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CHIROPRACTIC PERSPECTIVE: David C. Radford, D.C., M.S. urges conservative care first, based on nearly 40 years of experience treating spine cases. He worked in the Spine Center at Lutheran Hospital for several years in the Department of Neurology and Neurosurgery, where many patients had successful non-surgical care. In support of his opinion he pointed out a recent prospective population-based cohort study by B.J. Keeny et al. that was published in the journal Spine May 15, 2013. The authors found that patients who saw a chiropractic physician first for acute occupational lower back demonstrated reduced odds of spine surgery. It was reported that those injured workers whose first provider was a chiropractor had a 1.5% chance of surgery versus those who saw a surgeon first, where their odds were 42.7% for spine surgery within three years. Baseline variables associated with surgery (P < 0.05) in the multivariate model included higher Roland-Morris Disability Questionnaire scores, and greater injury severity. The area under the receiver operating characteristic curve of the multivariate model was 0.93 (95% confidence interval, 0.92-0.95), indicating an excellent ability to discriminate between workers who would versus those who would not have surgery. The authors concluded that there was a very strong association between surgery and first provider type seen for the injury even after adjustment for other important variables.

 

According to Denise M. Goodman, MD, MS et al. in the April 24, 2013 Journal of the American Medical Association, “Many treatments are available for low back pain. Often exercises and physical therapy can help. Some people benefit from chiropractic therapy or acupuncture.” She also states that “sometimes medications are needed, including analgesics (painkillers) or medications that reduce inflammation. Surgery is not usually needed but may be considered if other therapies have failed.”

 

Dr. Radford pointed out that today, doctors of chiropractic medicine are very well trained to triage spine patients rapidly and accurately. When a patient has red flags indicating a serious injury or an obvious surgical case, they can help move the patient through what can sometimes be a cumbersome system. He said spine care is often a team effort; injured workers should feel confident starting care with a chiropractic physician.

 

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Study Limitations

The study did not determine whether the care received by the on-site and off-site groups improved their MSD symptoms. The authors of the study wondered whether the higher utilization seen in the off-site group may have been due to a lower quality of care in community care centers. Nor did the study examine cost savings. While the study did not analyze direct and indirect cost savings to Cerner’s health care plan, the authors believed it could be inferred that lower utilization of health care services would result in direct cost savings.

 

© Copyright 2015 LexisNexis. All rights reserved. Reprinted with permission.

 

 

 

Author Robin E. Kobayashi, J.D., Workers’ Compensation Practice Area Lead at LexisNexis. She is the site coordinator for the LexisNexis Legal Newsroom Workers’ Compensation Law. She has been a Sr. Legal Editor at LexisNexis specializing in workers’ compensation law for over 28 years. She also serves as the Editor-in-Chief of theLexisNexis Workers’ Compensation eNewsletters and the Co-Editor-in-Chief of Workers’ Compensation Emerging Issues Analysis, a 50 state survey of workers’ comp legislation and trends. Contact: Robin.E.Kobayashi@lexisnexis.com

Worksite Healthy Sleep Program: Helping Employees Sleep One Z at a Time

Robin Kobayashi 65x57By Robin E. Kobayashi, J.D., LexisNexis Legal & Professional Operations

 

The CDC reports that 30 percent of civilian employed U.S. adults, which equates to 40.6 million workers, lack sufficient sleep. These adult workers are sleeping less than 6 hours a day, when the recommended amount of sleep is 7 to 8 hours a day. The CDC survey showed a 34.1 percent rate of short sleep duration among workers in manufacturing compared with all workers combined. About 44 percent of workers who worked the night shift experienced short sleep duration compared to 28.8 percent of day shift workers. Workers with high rates of short sleep duration included 69.7 percent of night shift workers in transportation and warehousing and 52.3% of health-care and social assistance workers.

 

The lack of sleep may lead to the development of chronic diseases and conditions such as diabetes, cardiovascular disease, obesity, and depression. In addition to soaring health care costs to treat these chronic diseases and conditions among workers, businesses must also contend with safety issues and lost productivity.

 

A new study published in the Journal of Occupational and Environmental Medicine points out that chronic sleep deficits can cost up to $3,156 per employee. The problem is how to reach workers who could benefit from healthy sleep guidelines and healthcare. The study examined a novel approach to how businesses can deliver an effective healthy sleep program through a workplace wellness facility.

 

 

Cognitive-Behavioral Therapy

 

According to the study, there have been numerous studies on the effectiveness of cognitive-behavioral therapy for insomnia (CBT-1) to help people sleep better both short- and long-term. CBT-1 even carries an evidence-based medicine “stamp of approval” for treatment of chronic primary insomnia and comorbid insomnia symptoms. CBT-1 covers “sleep hygiene, stimulus control, guided imagery, self-talk (cognitive restructuring of dysfunctional thoughts about sleep), meditation, and relaxation techniques”, among other things.

 

As the study indicates, the question then becomes how to deliver CBT-1 effectively to employees?

 

 

How The Study Was Set Up

 

A voluntary 8-week worksite-based healthy sleep program was set up at the Mayo Clinic Dan Abraham Healthy Living Center to help employees gain knowledge of factors that influence sleep as well as gain skills and behavioral techniques to improve their sleep. The participants completed questionnaires about their sleep behavior, energy level, sleep problems, bed partners, use of sleep medication, daytime performance, stress level, caffeine habits, napping, etc., both before and after the completion of the sleep program.

 

Eight, one-hour live participatory sessions covering CBT-1 were held, with seven of those sessions delivered by wellness coaches. Participants were given skill-building exercises such as guided imagery, muscle relaxation, sleep hygiene, meditation, and yoga, and their assignments included, among other things, keeping a sleep log, attending classes in meditation and yoga, and identifying self-talk related to sleep.

 

The study analyzed the outcomes for 53 individuals covering the period 2010 through 2012.

 

 

Key Facts About The Participants

 

  • 2% of the participants were female
  • Median age was 56.4 years
  • 9% were married
  • 2% worked day shifts
  • Average body mass index of 26.6 kg/m
  • 6% of the participants were employees
  • 17% of the participants were spouses or domestic partners
  • 4% of the participants were students, retirees, or volunteers at the medical center

 

 

Key Findings Pre- And Post- Healthy Sleep Program

 

  • Poor quality sleep: Decrease in poor quality of sleep from 5 nights on average per week to 3.5 nights on average per week
  • Impact on job performance: Slight decrease in sleepiness impacting job performance from 2.5 days on average per week to 2 days on average per week
  • Feeling rested: Increase in average rating of 3.9 (10 = always) for feeling rested after a night’s sleep to 5 (out of 10)
  • Knowledge about sleep: Increase of average rating of 4.9 (10 = extremely knowledgeable) for knowledge about sleep to 6.9 (out of 10)
  • Trouble getting asleep: Decrease of average rating of 5.5 (10 = always) for trouble getting asleep to 3.8 (out of 10)
  • Trouble staying asleep: Decrease in average rating of 7.0 (10 = always) for trouble staying asleep to 5.8 (out of 10)
  • Ability to deal with sleep problems: Increase in average rating of 4.4 (10 = extremely confident) in ability to deal with sleep problems to 6.3 (out of 10)

 

 

Study Limitations

 

The study examined a small group of people who voluntarily participated in the healthy sleep program. The authors believe that a larger study with more diverse samples is needed.

 

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OCCUPATIONAL MEDICINE PERSPECTIVE: Leslie J. Hutchison, MD, MPH, FACOEM, of HLM Consultants notes that although the article does not indicate the cost of the program, he believes the savings cited can carry over multiple years without repeated training. “The significant positive effects of the intervention suggest that other interventions are likely to increase the impacts on job performance, further decreasing sleepiness impacting job performance,” explains Hutchison. “Follow-up study of this group might define residual problems that could be addressed in further training or other interventions.”

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Takeaways

 

The study results show the benefits of a healthy sleep program where workplace wellness coaches are used and sleep experts help design and deliver the program in a group setting. The participants reported an improved quality of life, more energy at work and at home, and a significant decrease in stress. The study also underscored the importance of participants having more confidence in their ability to deal with their sleep problems after completing the program, as this could lead to behavior change.

 

© Copyright 2015 LexisNexis. All rights reserved. Reprinted with permission.

 

 

 

Author Robin E. Kobayashi, J.D., Workers’ Compensation Practice Area Lead at LexisNexis. She is the site coordinator for the LexisNexis Legal Newsroom Workers’ Compensation Law. She has been a Sr. Legal Editor at LexisNexis specializing in workers’ compensation law for over 28 years. She also serves as the Editor-in-Chief of theLexisNexis Workers’ Compensation eNewsletters and the Co-Editor-in-Chief of Workers’ Compensation Emerging Issues Analysis, a 50 state survey of workers’ comp legislation and trends. Contact: Robin.E.Kobayashi@lexisnexis.com

Worksite Wellness Programs: Why Workers’ Comp Insurers and Small Businesses Should Team Up

Robin Kobayashi 65x57By Robin E. Kobayashi, J.D., LexisNexis Legal & Professional Operations

 

Small businesses employ 56 percent of the U.S. workforce. They get pounded each year with the high costs of doing business, and they often lack the financial resources, staffing, expertise, management buy-in, or motivation to help reduce some of those costs by implementing a worksite wellness program.

 

Consequently, small businesses should perk up their ears about a hot-off-the-press study in the Journal of Occupational and Environmental Medicine, in which Pinnacol Assurance, a workers’ comp insurer in Colorado, teamed up with 260 small businesses to help them implement worksite wellness programs. This study was unique because a workers’ comp insurer, and not a health insurer, helped small businesses—at no cost—set up a workplace wellness program and provided continuous guidance on design and execution of the program.

 

What does this study mean for small businesses across the nation? It could mean that an alternative model exists where a “plug-and-play” type of workplace wellness program developed by a workers’ comp insurer could succeed when targeting small businesses.

 

 

Definition of Small Business

 

For the purposes of the study in question a small business had less than 500 employees and no more than $7 million in average annual receipts.

 

 

How the Study Was Set Up

 

The study examined, for a period of five years, Pinnacol Assurance’s “health risk management” (HRM) program, which was offered for free to 55,000 policyholders, 99.6 percent of whom were located in Colorado. The Pinnacol Assurance leadership reasoned that “poor health has a negative effect on workers’ compensation costs” and that “health risk management will become as fundamental to managing risks as safety management is currently.”

 

The HRM program was voluntary. Pinnacol Assurance and insurance agents actively recruited employers to participate. Employers also self-enrolled. In the end, a total of 260 small businesses enrolled in the HRM program. These businesses came from a range of economic sectors.

 

 

Goals of the HRM (Workplace Wellness) Program

 

The goals of the program aligned with the goals of the small businesses which participated in the program:

  1. Improve employees’ healthy behaviors
  2. Reduce workers’ comp rates and costs
  3. Enhance work productivity

 

 

Key Facts and Findings

 

The study is a workplace-wellness bonanza of interesting facts and findings that illustrate “opportunities to address important modifiable health risks in the small business workforce”:

 

  1. The business size of the 260 employers studied ranged from fewer than 10 employees to more than 250 employees; the majority (53.4%) had fewer than 50 employees
  2. The vast majority (70%) were located in the urban “Front Range” of Colorado
  3. 71% remained in the HRM program after 1 year, with 82% of that number remaining in the program through the end of the second year
  4. Small businesses participating in the program definitely wanted more on-site support for implementing and maintaining the program
  5. 6,507 employees at these 260 small businesses enrolled in the HRM program and completed a baseline questionnaire.
    1. The mean age was 41.4 (plus or minus 13 years)
    2. 3% were married
    3. 6% were white
    4. 7% were male
    5. 2% were full-time employees
    6. 7% had completed a 4-year college degree
    7. 3% had some education beyond high school
    8. 9% had an annual income of less than $25,000
    9. 8% had an annual income of less than $50,000
    10. The average “overall wellness score” (OWS) was 66.7, plus or minus 13.3, falling into the “doing well” category (60 to 79 score)
    11. 9% were normal weight, 34.3% were overweight, 25.6% were obese
    12. Less than 17% smoked cigarettes
    13. No data was available for marijuana or illicit drugs
    14. 7% of females consumed 7 or fewer servings of alcohol per week
    15. More than 98% of males consumed 14 or fewer servings of alcohol per week
    16. 62% exercised at least 3 times per week
    17. 1% ate at least 3 servings of fruit or vegetables daily
    18. 7% reported 7 or more hours of sleep each day
    19. 5% reported moderate or high stress in their work, home life, or finances
    20. Common health conditions and risk factors reported by employees were overweight (37.8%), seasonal allergies (34.8%), depression (22%), chronic fatigue (20.4%), chronic sleeping problems (18.4%), headaches (17.2%), arthritis (16.3%), high cholesterol (15.7%), hypertension (15.3%)
    21. Chronic and long-term health conditions included: diabetes (3.8%); cancer (3.3%); osteoporosis (2.9%); coronary heart disease (1.7%); chronic lung disease (0.7%)

 

 

Limitations of Study

 

The study attempted to answer the question of whether it was feasible to target small businesses to offer a workplace wellness program to its employees. It was beyond the scope of the study to determine whether health risk reductions would reduce workers’ comp claims and costs.

 

In addition, the authors of the study were unable to determine the rate of small business adoption.

 

The study didn’t undertake to examine the factors affecting employee participation. Nor did the study know which incentives each of the small businesses used to encourage employee participation. So the study wasn’t able to pinpoint any “healthy worker bias” among the participating employees. Given the possibility of a healthy worker bias in those employees participating in the program, it raises the question of just how bad the health risks and chronic illnesses could be for the entire population of employees working for small businesses.

 

 

Still…A Big First Step

 

This initial study shows that the barriers for small businesses to implement a workplace wellness program can be overcome. As the authors of this study point out, we need further studies that show exactly how a workplace wellness program can address health risks in employees, workers’ compensation costs, and employee loss of productivity due to illness or injury.

 

© Copyright 2015 LexisNexis. All rights reserved. Reprinted with permission.

 

 

Author Robin E. Kobayashi, J.D., Workers’ Compensation Practice Area Lead at LexisNexis. She is the site coordinator for the LexisNexis Legal Newsroom Workers’ Compensation Law. She has been a Sr. Legal Editor at LexisNexis specializing in workers’ compensation law for over 28 years. She also serves as the Editor-in-Chief of theLexisNexis Workers’ Compensation eNewsletters and the Co-Editor-in-Chief of Workers’ Compensation Emerging Issues Analysis, a 50 state survey of workers’ comp legislation and trends. Contact: Robin.E.Kobayashi@lexisnexis.com

Worksite Wellness Clinics and Reduction of ER Visits: Good News for Employer Health Plan Costs

Robin Kobayashi 65x57by Robin E. Kobayashi, J.D., LexisNexis Legal & Professional Operations

 

Emergency room visits and costs are on the rise in the U.S. and expected to get worse with Obamacare according to a recent report which shows people with Medicaid (many of whom have obtained coverage under Obamacare) use ER more often than uninsured individuals. Complicating this picture are the ridiculous high costs of ER visits where one stitch can cost you $500. So you can bet that employers are itching for more concrete evidence of, not just how worksite wellness clinics can substantially reduce the number of ER visits by their employees, but also the dollar-and-cents savings to employer health plan costs. A new study published in the Journal of Occupational and Environmental Medicine shows how employers may be able to reduce their health plan costs as a result of a reduction in ER visits by employees due to a worksite wellness center.

 

 

How the Study Was Set Up

 

The study covered a period of eight years—before and after the opening of an employee wellness center at Johns Hopkins Hospital (JHH) in Baltimore. The employees at JHH made up the test group.

 

The control group consisted of the employees at nearby Johns Hopkins Bayview Medical Center (BMC), which didn’t have a worksite wellness clinic during the test period.

 

Employees at both JHH and BMC—nurses, administrators, paraprofessionals, and support staff—received similar health plan benefits under the Johns Hopkins Employer Health Programs (EHP).

 

The study examined the number of ER visits by employees at both JHH and BMC that didn’t result in a hospital admission. The study concentrated on ER visits for episodic or acute care and not for chronic conditions.

 

While some of the results of the study were expected, others were surprising.

 

 

Key Facts and Findings

 

  1. The worksite wellness clinic at JHH provided free services to its employees from 7 a.m. to 4 p.m., Monday to Friday; however, the JHH employees must pay for laboratory, x-ray film, and pharmaceutical costs.
  2. The JHH worksite wellness clinic assessed and treated 2,600 patient visits on average per year, with the majority of cases involving low to medium medical complexity.
  3. The most common medical conditions treated by the JHH worksite wellness clinic were ear, nose and throat, respiratory, ophthalmologic, skin, and urinary tract.
  4. Only 1.5 percent of the individuals treated at the JHH worksite wellness clinic were referred to ER for further assessment and treatment; however, whether or not the JHH clinic users would have actually gone to ER if a clinic didn’t exist remains an open question and wasn’t studied.
  5. The highest users of the JHH worksite wellness clinic were maintenance, dietary, transport personnel (primarily hourly workers); treatment of episodic medical conditions at the worksite wellness clinic had a greater effect on the lowest paid members of the workforce.
  6. Women outstripped men in utilizing the JHH worksite wellness center, 87 percent to 13 percent; employers need to take more steps to encourage men to utilize a worksite wellness clinic.
  7. The median age of employees using the JHH worksite wellness center was 40.2 years.

 

 

JHH Employees With Worksite Wellness Clinic

 

JHH employees overall: The number of ER visits during a month decreased from 2.5 percent (preclinic period) to 2.1 percent (postclinic period)—a 16.3 percent relative reduction.

 

JHH employees in the high user clinic group (maintenance, dietary, transport personnel): The number of ER visits during a month decreased from 5.1 percent (preclinic period) to 4 percent (postclinic period)—a dramatic 21.8 percent relative reduction.

 

 

BMC Employees With No Worksite Wellness Clinic During the Same Time Period

 

BMC employees overall: The number of ER visits during a month decreased from 2.0 percent to 1.9 percent—a 7.2 percent relative reduction.

 

BMC employees belonging to maintenance, dietary, transport personnel group: The number of ER visits during a month decreased from 3.3 percent to 3.1 percent—a 7.7 percent relative reduction.

 

 

Adjustments Made to Study

 

The authors made several, careful adjustments to their study. For example, adjustments were made such that the reduction in ER visit rates could not be attributed to health insurance co-payment changes in the EHP health care plan. As the authors of the study observed, increasing co-payments for ER visits as well as establishing high-deductible health plans have both been shown to decrease ER visits overall.

 

Another adjustment to the study involved the fact that women made up 77.1 percent of the workforce at JHH and 81.4 percent of the workforce at BMC. This variable was controlled when determining that women were the predominant users of the worksite wellness clinic in question.

 

The authors, however, didn’t control for the use of other urgent care centers and facilities near JHH or BMC which could treat for episodic medical conditions. But since JHH (the test group) and BMC (the control group) were within a 2.6 mile radius of each other, the authors reasoned that employees at both JHH and BMC could have used these other primary care centers.

 

 

Estimated Cost Savings for Employer’s Health Plan

 

The study sought to determine the financial effect on an employer’s health care plan as a result of a reduction in ER visits due to a worksite wellness center. It estimated the cost savings related to the JHH worksite wellness clinic at approximately $40 per member per year and more than $210 per member for the high user clinic group.

 

The authors of the study explained that when the JHH worksite wellness clinic was established, the costs of assessment and treatment at the clinic were expected to offset the employer’s health plan’s expenses for diagnostic and treatment costs of a visit to an outpatient, urgent care facility or physician’s office for patients involving low to moderate medical complexity. The study found that reimbursement by the employer’s health plan was approximately 10 percent of the amount it would have to pay for an ER visit, thereby suggesting that the worksite wellness clinic had a “greater effect on medical costs than previously anticipated.”

 

© Copyright 2015 LexisNexis. All rights reserved. Reprinted with permission.

 

 

Author Robin E. Kobayashi, J.D., Workers’ Compensation Practice Area Lead at LexisNexis. She is the site coordinator for the LexisNexis Legal Newsroom Workers’ Compensation Law. She has been a Sr. Legal Editor at LexisNexis specializing in workers’ compensation law for over 28 years. She also serves as the Editor-in-Chief of theLexisNexis Workers’ Compensation eNewsletters and the Co-Editor-in-Chief of Workers’ Compensation Emerging Issues Analysis, a 50 state survey of workers’ comp legislation and trends. Contact: Robin.E.Kobayashi@lexisnexis.com

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