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By: Denise Johnson

Reductions in emergency room visits and total claim costs prompted employers, a small business insurance specialist, to expand its Injured Employee Hotline nationwide. The service, which began as a test in Florida in 2014, gives injured workers the option to receive a professional nurse consultation by phone for no additional cost to their employers via a centralized call center that’s staffed 24/7.

During the hotline pilot, Barry J. Vogt, senior vice president and chief claims officer, said the insurer learned several things.

“One of the things was a decrease in emergency room visits. In fact, for the pilot in Florida, we saw emergency room visits actually decrease by 50 percent when a call came in through the injured employee hotline,” Vogt said. “Not all claims came in through the hotline. This hotline, it’s a nurse triage process. If the injured worker has already treated, the opportunity to do that triage and channel to appropriate medical care is already gone. For those injured workers, or employers that contacted us prior to that treatment taking place, we did see that roughly 50 percent reduction in ER visits.”

In addition, the use of the hotline seemed to eliminate almost all of the 911 calls.

“Sometimes, something may seem like it’s urgent to the point that you may need to call 911, but when those calls came in through the nurse triage line, we did not find much need to call 911,” explained Vogt. ”

There were a few instances, but for the most part, calling 911 was not necessary when they came in through the nurse triage line.”

Another benefit noted as a result of the hotline was the increase in self-care claims.

“For those claims that came in through this hotline, we found that we increase pretty significantly the number of claims where self-treatment was appropriate,” said Vogt. “We insure a lot of restaurants in our book, for example…we get burns around a stove or a fryer. To be able to explain the burn to a nurse and have them perform some triage and indicate for example, they don’t need to see a doctor, ice it and keep it away from heat. The nurse follows up with them the next day to make sure that any time that self-care is recommended, that it was appropriate.”

By reducing unnecessary and costly emergency room visits or treatments by out-of-network medical providers, the insurer said the service has shown it can reduce total claim costs by an average of 35 percent while ensuring injured employees receive the care they need.

According to Vogt, the nurses recommend the appropriate level of care and direct employees to the most effective, in-network medical providers.

“We did see an improvement of 10 percentage points in penetration into our outcome-based network in Florida during the pilot,” said Vogt.

The response from employers has been overwhelmingly positive, he said.

“We haven’t had it long enough to really get some good metrics around it yet, but one of the big benefits to the employer is speeding up return to work,” explained Vogt. “By channeling these injured workers to appropriate, outcome-based, occupational medicine type of treatment, we believe… that we’ll see earlier return to work. When they get their injured workers back quicker, of course, that benefits the employer.”

Another benefit to employers, Vogt said, is that over the long-term there is increased employee satisfaction.

“There’s somebody who’s advocating for them. They see their employer as more looking out for them, as being an advocate for them, making sure they get the appropriate medical care upfront,” explained Vogt. “That seems to drive some improved employee satisfaction based on some of the comments and feedback that we have received.”

In addition to the benefits for injured workers, there are also tangible benefits for small business owners. Calls to the Injured Employee Hotline automatically trigger the opening of a workers’ compensation claim with less paperwork needed by the employer. Because injured employees can get the appropriate care they need more quickly, there is less likelihood a claim will result in a legal dispute, Vogt said. Also, since employees are referred to in-network medical providers, the total cost of a claim is lower, which can help business owners control the future costs of their workers’ compensation policies.

“This process not only performs medical triage, but it also integrates with our first reporting of claims. Once the triage process is done, the nurse has also taken all of the pertinent loss information that feeds into our claims system and ultimately reports a claim to us. As an adjuster, they’re getting more than just the typical who, what, when, where. When the claim gets reported to them, they’re also getting a lot of good information about the injury and treatment, and maybe some co-morbidities if we got some of that information upfront” Vogt said. “The adjuster is much better prepared to begin the handling of that claim, because they have much better information.”

Getting the information early can aid in predictive modeling, Vogt said, to allow an insurer to gain better insight into certain claims that may benefit from additional resources.

He said there hasn’t been much change in the insurer’s book of business relating to changes in workers compensation injury trends. The insurer still sees knee, back and elbow claims. Because restaurants make up a large part of EMPLOYERS’ book of business, the company also sees a lot of lacerations.

“Our book of business is low to moderate risk hazard and primarily small businesses. Given the kinds of businesses we write, I really haven’t seen much of a change in that trend,” Vogt said.

The insurer has seen a change in case mix, he explained, resulting in more incident only and medical only claims.

Pharmaceutical Management

Like the rest of the industry, the insurer is dealing with the opioid abuse issue and pharmaceutical spend, in general.

“We have a Pharmacy Benefit Management (PBM) program, that uses a number of triggers to pick out claims that look like they may be problematic. We look at things like the MED, the morphine equivalent dose, multiple prescribers on a claim, how long the drug has been prescribed, co-morbidities, claimants’ age and occupation,” Vogt said.

The insurer reviews claims that appear to have more prescribing going on than what would be expected, he said. When a claim is flagged, the insurer may have a nurse discuss the pharmaceuticals prescribed with a doctor.

“We may have a peer-to-peer review with a doctor, or even in some extreme cases, a face-to-face meeting or discussion with a doctor if it appears that we’ve got some extreme problems with prescribing opioids,” Vogt explained.

Vogt said that monthly meetings with its claims and medical management teams help them stay on top of problematic cases.

“We try to help the physician to understand what’s happening medically, maybe in some areas that they’re not even aware of, and to talk to them about trying to taper and wean them off of these medications. We’ve had a fair amount of success with this. We’ve been doing this now for a few years, and it’s something we do nationally across our entire book of business,” Vogt said.

The department reviews pharmaceutical spending trends on a monthly, quarterly and annual basis.

“For me, I’m looking at it more nationally across our book, but when you get it down to…We’ve got a medical director that works at our company. He’s looking at this every month and looking down at the case level,” Vogt said.

The claims team will examine why certain cases linger.

“There’s cost savings for us, obviously, if we can wean them [injured workers] off these medications, but it’s beyond that,” Vogt said. “It’s about what happens long term and what’s best for that injured worker, for that employer, and getting them well, and getting them back to work. That’s really what we’re trying to do here. It’s not just about the spend, it’s certainly not healthy for somebody to be on these opioid medications for a great length of time, which is occurring today in this industry.”

The early use of opioids is monitored very closely, he said.

“When one of these claims comes in new and we see that the doctor’s prescribing opioids pretty rapidly, that’s a warning sign. One of the things that we see with our outcome-based network is that we tend to see less of that,” said Vogt. “We tend to see better management of those doses and the medication being issued, which is why, tying this back to that nurse pre-claim triage, to have them channel an injured worker into our network in those states we’re allowed to do that, which is most of them, it really also has a preventative impact on the downstream prescribing. They’re getting doctors who tend to be very focused on the recovery and the return to work and don’t tend to prescribe that so much. “

 

Photo: http://www.bcbsm.com/index/members/health-wellness/nurse-line.html

 

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