Buyers of TPA services should understand the value nurses bringto managing workers compensation claims – and how to maximize thatimpact – in order to better measure how well a claims managementvendor effectively controls total workers compensationcosts.

This is so important today because workers compensation medicalcosts are growing. In fact, medical costs will likely accountfor two-thirds of total workers compensation claim costs by 2019,up from about 60 percent today, according to the InsuranceInformation Institute.

This growth will be driven by increasing rates of diabetes,obesity and other co-morbid conditions; medical inflation outpacingthe Consumer Price Index; and cost shifting to the workerscompensation system as a result of group medical's higherdeductibles and reduced reimbursements.

A recent study by Helmsman Management Services, a memberof Liberty Mutual Insurance, quantified the value of nurses inmanaging workers comp claims and highlighted the most importantskills nurses need to maximize that impact.

The findings will help TPA buyers evaluate the effectiveness oftheir vendors and improve the performance of theirprograms.

The Value of Nurses

The study reviewed medical billing and claims data from 42,000workers compensation cases. It factored in such issues as aclaimant's injury severity, behavioral or psycho-socialcharacteristics, and attitudes toward work andrehabilitation. This enabled a side-by-side comparison of thecost of claims that included a nurse to similar cases that didnot.

Claims involving a nurse had:

• 18 percent lower future medical costs
• 26 percent lower overall claim costs
• 15 percent faster claim resolution

But the key to effectively using nurses to better control totalworkers compensation claim costs is to apply them to the rightclaims, rather than all claims.

There are many times when a nurse will not improve an injuredemployee's treatment or return to work, and will only increaseclaim costs. Take the example of an injured employee who has noco-morbid conditions and a positive relationship with the employer,is receiving appropriate medical care and is working intransitional duty. Adding a nurse to this claim would notsignificantly impact its outcome but would increase its cost.

Why not add a nurse to every workers compensationclaim?

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Helmsman Management Services leveraged its research to develop atool that automatically identifies those claims most likely tobenefit from the involvement of a nurse. The tool reviewsmore than 20 key variables – from the part of the body that wasinjured to the presence of co-morbid medical conditions orpsycho-social issues – and automatically alerts adjusters of thoseclaims where a nurse will have the greatest impact.

How does HMS spot the claims where nurses can add themost value?

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The Importance of Soft Skills

Once a nurse becomes involved in a workers compensation claim,the way he or she positively impacts that case depends on itsspecifics. Here are a few scenarios:

• In talking with a claimant, a nurse identifies a co-morbidcondition, and gets the injured employee into a program to bettercontrol the condition so that the workplace injury can be moreeffectively treated
• A nurse questions a proposed treatment plan – including thetiming or quantity of powerful prescriptions – reviews his or herconcerns with one of Helmsman Management Service's medicaldirectors, and arranges for a medical director to speak with thetreating physician about those concerns and the latestevidence-based treatment options
• A nurse informs the treating physician of the temporary partialduty options available to the injured employee based on pastconversations with the employer and claimant, enabling theindividual to return to work

And while a nurse's medical and technical skills drive theimpact they can have on a claim, there is mounting evidence of thecritical role soft skills play in successfully managing workerscompensation cases.

The most important soft skills nurses must have to positivelyimpact a workers compensation claim are educating, listening andcommunicating. Other key soft skills include collaborating,coordinating, influencing, empathizing and problemsolving.

What are the critical skills nurses need to impactclaims?

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The value of soft skills can be seen in the experience of a51-year-old who sustained a work-related injury that ultimatelyrequired spinal fusion surgery, which is often unsuccessful whenthe patient is an active smoker.

Because the nurse had built a relationship of trust, respect andopen communication with both the claimant and treating physician,the nurse was able to:

• Effectively remind the treating surgeon of the negative impactsmoking had on the proposed surgery, and have the physician delaytreatment until the claimant stopped or significantly reducedsmoking
• Explain this challenge to the claimant, enroll the individualin a smoking cessation program, arrange for the claimant to returnto work on light duty
• Eliminate or reduce the co-morbid condition, greatly improvingthe surgery's results, claimant's quality of life and final claimoutcome

Truly managing total workers compensation claim costs requires aclose partnership between risk manager, broker and TPA. Italso requires a TPA to focus nurses on those claims where they canhave the most impact, and to hire and develop nurses with criticalsoft skills. Understanding the value nurses bring to managingclaims – and the importance of soft skills – enables TPA buyers tobetter judge the effectiveness of their claims management providerand improve the performance of their workers compensation program.

About the Author:

Mary O'Donoghue is vice president, Medical Services, forHelmsman Management Services, a member of Liberty MutualInsurance. Mary leads a team of 450 professionals involved inmedical and disability case management, vocational rehabilitationand utilization management. She can be reached at mary.o'[email protected].

Additional information:

Why is managing workers compensation costs soimportant?

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Talk about your study on the value nurses add to workerscompensation claims.

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