Reducing CoMorbid Conditions with Obese Workers

An Interview with Doctor Alice Martinson
We hear a lot about the rising cost of workers compensation when injured workers suffer from co-morbid conditions. What is “comorbidity?”
Co-morbidity refers to any unrelated medical condition, which nonetheless has some bearing on the primary condition under discussion, or upon an individual’s ability to return to a functional level. An example of this would be a chronic cardiac condition delaying or preventing surgery in someone who has work-related knee osteoarthritis. Another, though somewhat graphic example, is an individual with a leg amputation who sustains an injury to two of the remaining three extremities. Given the number of returning Middle East veterans who are amputees, this is not such a far-fetched possibility.
How do you define obesity?
Obesity is defined in terms of body mass index (BMI). A BMI between 25 and 30 is considered “overweight.” A BMI over 30 is considered obesity, and a BMI over 40 is considered extreme obesity. In some written material it is called “morbid obesity.” This latter term is falling out of favor because it can carry an emotionally-charged meaning getting in the way of useful discussion. BMI is calculated as the relationship between height and weight. (WCxKit)
Rather than fooling with the math, I use a very convenient table available on the NIH website: Calculate BMI
Workers compensation will usually not cover that portion of a workplace injury related to a comorbid condition. How can the workplace injury be separated from the pre-existing condition for compensation?
For workers compensation treatment, that is not usually a hard distinction to make. A good example here would be carpal tunnel syndrome in a diabetic. Diabetes does not cause carpal tunnel syndrome, but diabetics will many times experience progression of the condition, once it occurs, at a much faster rate than non-diabetics do. Thus, surgical decisions and timing may well be affected by the diabetic state.
Where it gets harder within the workers compensation system is the question of whether a co-morbid condition interfering with the treatment of a workers compensation problem should be treated through the workers compensation system.
The most frequent instance of this I have come across is the question of whether bariatric (weight loss) surgery should be covered by workers compensation when the primary injury is knee trauma. Continued obesity in the face of a knee injury is inviting progressive osteoarthritis, so the question comes up – “Is bariatric surgery necessary to cure or relieve the effects of the work injury?” A similar example would be when a serious cardiac condition is found that interferes with necessary surgical treatment of a work injury.
Should treatment of the cardiac condition be provided under workers compensation?
There are different policies and case law in each state, so I would encourage anyone who encounters this issue to check for the rulings in their particular locale.
What pro-active steps can an employer take to communicate to employees their pre-existing conditions are not covered in the event of a workplace injury before injuries occur in a way that does not cause “uproar,” i.e., hurt feelings, cries of discrimination, threats of lawsuits?
The key word in your question is “pro-active.” Certainly, employees need to be educated about health maintenance issues and policies as general principles BEFORE a specific instance workplace injury brings up a specific question in a specific individual. Many large employers have incentive programs for smoking cessation, weight loss, and similar issues further reinforcing the importance the employer places on avoidable problems. There are enough benefits to these programs, that I encourage even small employers to adopt wellness programs as part of their employee policies.
Do you recommend pre-employment/post-offer screening for pre-existing conditions?
Except in the unusual case of extraordinarily critical or demanding work, pre-employment/post-offer screening using such things as spine X-Rays does not seem to be cost-effective. It is always appropriate to obtain a history of pre-existing conditions after an offer is made, because no one can predict the future but it is a great way to document the past. Having a starting point is very beneficial if the question of work-related progression or aggravation comes up. The best pre-employment screening I know of is not screening of the employees, but of the physical demands of the job for which an employee is sought. (WCxKit)
Can you explain what you mean by having the employer screen the physical demands of the job?
The more physically demanding the job, the greater the opportunity for something bad to happen to an individual doing it. An employer must know the physical demands of the job tasks. This is not rocket-science. A 5’2” woman weighing 130 lbs should not be hired to lift and carry cartons about a warehouse that are almost as tall as she is. You laugh! Several months ago I was doing a workers compensation exam on just such a woman doing just such a task. Or a more subtle instance — someone with knee pathology (problems) is not suitable for a job requiring constant squatting or climbing stairs and ladders. If you know those are the physical qualifications of the position, you as the employer have every right, and perhaps the responsibility, to determine if a prospective employee meets those qualifications. What is important is to determine the physical qualifications in advance, just as you do with education, temperament, ability to work without supervision, and so many of the other non-physical aspects in any job description. When you decide on an individual’s suitability for hiring into a specific position, you then have the opportunity to choose the whole package.  A physical therapy or rehabilitation firm can often do a physical demands evaluation of the jobs in your facility.
As an example – a clerk is hired into a prison office. The only problem is it takes a half-mile of walking each way from the parking lot to her job. You would never know that from her job description. Some folks cannot do that. Same thing for some work settings where the employee works on one floor and the bathroom is on another. Do not think that does not happen – the IRS office in Fresno is exactly like that.

Does the ADA come into play when dealing with employees with comorbid conditions?
The ADA requires “reasonable accommodations” for an individual who declares a disability. An employer should decide in advance how to define “reasonable” in their setting. Obviously, a bricklayer with a pre-existing back disability cannot be reasonably accommodated in another brick laying job. On the other hand, there are a great number of office jobs in which individuals with back disability can be reasonably accommodated by altering the seating or the supervisor’s expectations in regard to the need to get up and change positions periodically.
What can employers do to reduce comorbid obesity in their workers and make them less likely to suffer workplace injuries aggravated by their condition?
Peer pressure is a wonderful thing. If all workers are educated about wellness issues and buy into proactive wellness efforts, getting an obese individual working towards his or her own wellness should not be too hard. It has to be a group effort for support and encouragement. That is one of the principles behind Weight Watchers, the 12-step programs, and – for that matter – TV’s “The Biggest Loser.”
What do you think about employer-sponsored wellness programs?
I am clearly in favor of them. They have to be properly designed and incentivized in order to be effective. That means the leadership needs to be involved in them too, and there has to be public recognition and tangible benefits – even small ones – to encourage ongoing participation
Are there any “pre-canned” programs out there an employer can use rather than reinventing the wheel? Do you recommend them?
Each program has to be tailored for the specific work situation. Something is better than nothing, but whenever feasible I would suggest seeking the advice and participation of a consultant who is experienced in these issues and has a track record of success they can point to. (WCxKit)
There is a really good article in the magazine Inc. that addresses these programs. See How to Build a Wellness Program There are an abundance of commercial firms interested in getting consultant business. Read the article first.ThTTh    

Author: Alice M. Martinson, MD has practiced for 40 years as a board-certified orthopaedic surgeon, 25 of which were as a Naval Medical Officer. Relying on her extensive military experience with injury evaluation, she performs IMEs and consults on loss control issues. Contact: 870-480-7475 or To read more about "Doc Alice,” go to our Directory at:



Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

Obesity Drives the Cost of Work Injuries Sky High

If you were the producer of a Broadway show, would your hire a 300-pound ballerina? The idea seems absurd, but most employers shy away from hiring and retaining obese employees. (Obesity discrimination is illegal in Michigan, the District of Columbia, San Francisco, and Santa Cruz, CA). Obesity is not a disability that falls under the Americans with Disabilities Act (ADA) unless is has a proven physiological cause. We do not advocate obesity discrimination, but feel you should be aware that the more obese people you hire and employ, the higher the cost of your workers compensation insurance will be. This is also true in life insurance, one must fall into the appropriate body weight range to qualify for reasonably priced life insurance. Sad but true. And there may be ample justification for such increase in rates.

There are many ways to define obesity. To most people, a “fat person” is someone who weights 50 or 100 pounds more than they do.  Medically speaking, a person with a body mass index – BMI (a weight-to-height ratio, calculated by dividing one's weight in kilograms by the square of one's height in meters) of 18.5 to 24.9 is considered to be of normal weight, 25 to 29.9 is considered to be overweight, with 30 and above is considered obese. The doctor once told my husband he was obese which was very surprising because I don't view him as obese — a beer tummy maybe, but certainly not obese to my way of thinking.

In a often-cited Duke University study based on 100 full-time employees with a body mass index of 40, the impact of obesity on the cost of workers compensation is tremendous. Statistics show the impact on workers compensation cost of obese employees who are injured on the job including:
1.  Claims: Obese employees have twice as many workers compensation claims (11.65 claims vs. 5.8 claims for non-obese employees.)
2. Lost days from work: Obese employees lose 13 times more work days for their injury (183.63 days vs 14.19 days).
3. Medical cost: Obese employees medical cost is seven times higher ($51,901 vs. $7,503).
4. Indemnity Cost: Obese employees indemnity cost is 11 times higher ($59,178 vs. $5,396).
Another study by researchers at John Hopkins found similar results with a direct correlation between the number of injuries and the amount of obesity, with the odds of injury at work increasing with the waistline. The more obese the employee, the greater the odds the employee would be hurt on the job.
With nearly two-thirds of all American adults either overweight or obese, obesity is now being divided into subgroups with their own definitions including:
1.      Overweight – 1 to 29 pounds above normal
2.      Obese – 30 to 59 pounds overweight
3.      Severely obese – 60 to 99 pounds overweight
4.      Morbidly obese – at least 100 pounds overweight
5.      Super obese – 200 or more pounds overweight
Per the Center for Disease Control and Prevention, in 2007 about one-fourth (26 percent) of all employees were in the obese or a higher category. It is projected that by the year 2020, 40 percent of men and 43 percent of women will be classified as obese or higher. When you include the overweight people with the obese, by 2020 it is predicted that 70 percent of all employees will be overweight, with the number of overweight people continuing to grow (no pun intended).
What does this mean for workers compensation? Well, any one who has been involved with or who has handled their share of workers compensation claims know the injuries most common to obese employees involve their back, lower extremities (knees and ankles primarily), wrist (carpal tunnel claims and women with obesity “go hand-in-hand”) and hands. Obese employees generally hurt their back when trying to lift heavy weights or lift any weight improperly, and the obese employees hurt their backs, knees and ankles more severely when they slip and fall. Due to their obesity, obese employees have a significantly higher percentage of musculoskeletal injuries than non-obese employees.
The additional strain placed on the employee's musculoskeletal system by the additional weight is only one factor that delays the employee's recovery from an injury. Obese employee's often have other comorbidity problems besides their weight that delays their recovery from injury. Other medical issues among obese employee's interfering with their recovery include hypertension, heart disease and diabetes. open-ended According to the National Counsel on Compensation Insurance, these comorbidity issues can increase the cost of a work comp claim by an astounding 30 times.
As an employer, there are some steps you can take to reduce the cost of workers compensation related to obesity. The following are some approaches employers have taken to deal with this issue:
1.      Health insurance premium discounts for employees with a BMI of 18 to 25.
2.      A weight-reduction program offered through your human resources department.
3.      Encourage physical activity at work whether it is taking the steps instead of the elevator or parking at the far end of the parking lot.
4.      Use weight loss seminars from Weight Watchers or Jenny Craig.
5.      On-site or off site fitness centers with free membership or reduced price membership.
6.      A fitness program that includes healthy eating, health improvement seminars, exercise classes, and company sponsored athletic teams.
7.      Use of the company intranet to post weight loss guides, cooking light suggestions, and any topic on good health.
8.      A recognition program for employees who meet a weight-loss goal.
Encouraging your employees to be healthy pays off in lower workers compensation cost and provides for a healthier, happier work force.  Insurance companies – yes – the very same ones selling life insurance and workers compensation need to get in line to promote wellness, health and fitness just as much as any other employer. My daughter worked for an insurance company and the supervisor had a candy dish on her desks, ice-cream sundae Wednesday, birthday cakes often and pot luck Friday once a month. Ice Cream Sundae Wednesday? Ya think everyone was bringing in Frozen Yogurt?

Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website 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. See for more information. .

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

Comorbidity Run Amuck – Medical Conditions Make Work Comp Injuries More Costly

Comorbidity is the presence of two or more medical conditions in a person at the same time. When an employee with a prior medical problem has an on-the job injury, the cost of the medical care and the length of time the employee will be off work is normally extended. This does not mean that workers compensation will pay for an employee's pre-existing medical problems, but it does mean that the pre-existing medical problems can complicate the medical care for the workers compensation injury.
When an employer takes an active interest in the medical status of its employees, it has a far reaching positive impact. Take for example the trucking company that did not have an overall wellness program for its employees. It was not only paying more for the cost of health insurance, it was paying more for the cost of workers compensation insurance. And then the inevitable happened: a truck driver with several — not one or two health issues — but several health issues got hurt on the job.(WCxKit)
The truck driver, who was driving a tanker truck, decided to check the level of the liquid in the tanker. The driver, 51, climbed up on the catwalk. To hold on, he took hold of a handle for that purpose, but lost his balance and started to fall. By holding on to the handle, he was able to prevent the fall, until all of his 297 pounds was on his arm and shoulder. Rip went the rotator cuff in his shoulder, pop went the handle as it was there for balancing, not to hold 297 pounds, and the trucker fell to the ground.
The doctor's immediate assessment was probable torn rotator cuff. The MRI confirmed a large rotator cuff tear in this very large guy. Normally, the doctor would schedule surgery, repair the rotator cuff, and send the employee to physical therapy for six to eight weeks, returning the employee to light duty in four weeks and returning the employee back to work full duty in eight to 10 weeks.
The obesity alone would not have been much of a factor for rotator cuff repair, but the issue that caused the obesity was. The trucker liked beer. A lot of beer, which is how he got to 297 pounds. But the alcohol also brought on other comorbidity factors including hepatitis C and cirrhosis of the liver. The orthopedic doctor did what any other doctor would do, he delayed the surgery until the claimant could get surgical clearance from the gastroenterologist. The gastroenterologist could not see the claimant immediately and four weeks of temporary indemnity benefits were paid while the claimant waited the appointment with the gastroenterologist.
The gastroenterologist agreed to take the claimant off antiviral medications. The claimant's body needed at least three months to adjust to not having the antiviral medications and for his platelet count to recover adequately for the rotator cuff surgery. Another three months of indemnity benefits.
The rotator cuff surgery was completed, but then diabetes came into play (I should have mentioned earlier that the trucker was also a diabetic). Three weeks post surgery, the area around the surgical wound began to turn red. Due to hyperglycemia, brought on by the diabetes, cellulitis (infection) of the wound and surgical area developed. The driver went back to the hospital for another surgery to surgically remove the infection. Of course when the wound was opened, the rotator cuff had not healed due to cellulitis and had to be repaired again. The second rotator cuff surgery caused by the comorbidity of diabetes adds both additional medical cost and another three weeks of indemnity benefits, as all the recovery time between the first surgery and the second surgery is loss.
When you are immobile due to obesity and recovering from two surgeries, have hepatitis C, cirrhosis and diabetes, it is nothing unusual to develop edema (where the body retains excessive levels of fluid). When you are severely bloated, it is difficult to actively participate in physical therapy. With drugs for the edema, physical therapy was only delayed two weeks, but this was two extra weeks of indemnity benefits in addition to the medical cost of the doctor's visit and the pharmacy.
For brevity of this article, we will not discuss the hypertension and basilic vein clot/thrombosis and how they delayed the medical recovery that further extended the time the employee was drawing indemnity benefits. Also, for brevity we will not discuss the employee's anxiety, depression, panic attacks, insomnia, abdominal pain, jaundice, and weight loss issues as these conditions individually did not prolong the worker compensation claim, but collectively added to the medical cost as the primary doctor had to address the issues or refer the medical issues to other doctors.(WCxKit)
While few workers compensation claims have this many medical complications, the non-work related medical issues of your employees will interfere with the recovery from the on-the-job injury. You can reduce the cost of both health insurance and workers compensation insurance by encouraging your employees to individually maintain good health and by providing a wellness program.

Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website 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. See for more information. Contact:
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

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