When an employee is injured and has a workers' compensationclaim, it's crucial for employers and insurers to look beyond theemployee's physical and medical issues to address the injuredworkers' mental health needs. Failing to do so could result inlonger and more costly absences and, ultimately, return-to-work(RTW) failure.

There's a complex array of psychosocial issues that arise withemployees out on workers' compensation, points out Sherri Hickey,assistant vice president–Medical Management at Safety National, aprovider of alternative risk-funding products such as excessworkers' compensation, deductible casualty, loss portfoliotransfers, and reinsurance. These include concern over being ableto return to work, anxiety about losing their jobs, and fear ofpain, whether real or imagined. "This is sometimes referred to as'catastrophizing' — taking every pain, even if it's minor, andexaggerating it to the point where they believe their life hasended with this injury," she says.

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The more prolonged a disability becomes, the more many employeeswill ruminate on the injury, Hickey adds. "Some employees willbegin to treat the claim and the treatment associated with it as ajob in itself, making RTW all the more difficult. From apsychological perspective, the injury becomes their life," shesays. "In some cases, employees may also have a sense ofentitlement — that they are owed everything they can get!"

Insurers and third-party administrators must quickly identifyand address any psychological and social issues that may delaytreatment or postpone an employee's return to work, stressesMaureen McCarthy, manager, Workers Compensation Field Claims,Liberty Mutual. "Claims managers should look for such issuesthroughout the claims process. There are sophisticated algorithmsthat automatically analyze data to identify claims that have suchissues. Then medical professionals can become involved to confirmthe presence of these issues and help determine how best to addressthem in order to foster recovery and return to work."

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We are what we do

Losing the ability to work, even temporarily, can be a majorblow to the way people perceive themselves and the way they believesociety and family perceive them. They may have felt like theprovider; now they feel like a burden. They may start to feeluseless or become dependent on others in their sphere. An overlyrestrictive approach to injury or illness can cause people towithdraw from their normal activities (including work) and resultin isolation.

For so many people, work is a part of their personal identity,points out Mark Walls, vice president, Communications and StrategyAnalysis at Safety National. "When you meet a person, usually oneof the first questions you ask them is, 'What do you do?' Whensomeone is away from work due to a disability, they lose that partof their personal identity, which can be emotionally challenging.Add to that the financial pressures caused by disability and thesocietal stigma associated with disability."

By recognizing how the inability to work affects workersmentally and emotionally, you can be sure that caring for the wholeworker is an integral part of your RTW plan.

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Alternative approaches, such as yoga, massage and cognitivebehavioral therapy can be more successful than medications inmanaging pain. (Photo: Shutterstock)

Taking the holistic approach

The holistic approach to health care considers the whole of thepatient: body, mind, and emotional state. Going hand-in-hand withlooking at the entire person is bringing together conventional andcomplementary medicine in a coordinated way — also known as anintegrative approach.

The use of integrative approaches to health and wellness hasgrown within care settings across the United States. Researchersare exploring its potential benefits in a variety of situations,including pain management, relief of symptoms in cancer patientsand survivors, and programs to promote healthy behaviors. Programsthat reduce painrelated fear and encourage a return to activitygenerally provide a positive response.

"Many integrative therapies have evidence to support their use,"says Dr. Teresa Bartlett, SVP Medical Quality,Sedgwick Claims Management Services, Inc., a global provider oftechnology-enabled risk and benefits solutions. "We often hear fromphysicians that they would appreciate being able to useacupuncture, yoga, meditation, massage and cognitive behavioraltherapy instead of opioids to manage a complex patient."

Recent studies have supported acupuncture, yoga, stretching,walking programs, and the use of acetaminophen and ibuprofenconcurrently to address pain instead of turning to opioids, Dr.Bartlett points out. "Many employers will bypass utilization reviewto pilot targeted programs for specific conditions such as back orneck pain and then measure the program's success to determinewhether these therapies are working and beneficial for return tohealth and work."

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Complementary and alternative medicine

If a non-mainstream practice is used together with conventionalmedicine, it's considered "complementary." However, if anon-mainstream practice is used in place of conventional medicine,it's considered "alternative." Examples of complementary medicineinclude yoga, chiropractic and osteopathic manipulation,meditation, massage therapy, acupuncture, relaxation techniques(such as breathing exercises, guided imagery, and progressivemuscle relaxation), tai chi and qi gong, hypnotherapy, and movementtherapies.

Aetna, for one, considers alternative medicine interventionsmedically necessary if they are supported by adequate evidence ofsafety and effectiveness in the peer-reviewed published medicalliterature. The insurer has a comprehensive policy for alternativemedicine. The policy, availableonline, outlines the alternative medicine interventions thatAetna considers medically necessary for properly selected members,subject to applicable benefit plan limitations and exclusions.

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The opioid crisis: Can complementary approacheshelp?

Opioids have been the drugs that doctors and patients use tomanage pain, but the social cost has been high. Addiction toprescription painkillers is rapidly becoming an epidemic in theUnited States. Opioid prescription sales have increased 300% since1999, and drug overdoses, predominantly from opioid painkillerssuch as OxyContin and Percocet, now exceed car crashes as theleading cause of unintentional death, notes Ron Skrocki, seniorvice president for product management and development at Genex Services,a managed care services provider.

One challenge is finding pain-management practitioners who willwork with insurers and employers to ensure that alternativeapproaches are working. "It's easy to get opioid pain medicationapproved — however, it's difficult to get alternatives approved,"Walls acknowledges. "Many states have limits in their laws onchiropractic treatment and physical therapy, but not limits onopioid medications. This approach is flawed."

It's vital to look at the bigger picture. As Walls points out, apain-management program may cost $30,000, but if it allows aninjured worker to stop taking opioid pain medications costing$10,000 per year, then there is significant savings over the longterm. He recalls a case in which a worker was permanently disableddue to a back injury and was receiving high doses of opioid painmedications, which compounded his disability. "His family reportedthat he slept most of the time, and it was like he was almost deadto them," he says.

However, after Safety National sent the worker to a pain programthat taught him coping skills and the importance of exercise, hewas able to stop taking pain medications. "He is still disabledfrom work, but he has a life," Walls points out. "His family has ahusband and father back. But to reach that point, it took someonelooking beyond just the pain and opioids and being willing toconsider the whole person and alternative approaches."

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Patients need to understand all the treatment optionsavailable. (Photo: iStock)

Challenges to a holistic approach

Challenges include insurance coverage rejections, strictapplication of evidence-based medicine protocols, insufficientgood-quality peer-reviewed studies of whether complementaryapproaches are medically effective as well as cost-effective; and aneed for pain management practitioners — including physicians,psychiatrists, chiropractors, and acupuncturists — who will workwith insurers and employers to ensure that unconventionalapproaches are working.

"Conventional medical approaches such as surgery, drugs, and avariety of therapeutic techniques can often cure, or at leastalleviate, pain and disability. However, there are many times whenan injured employee's pain and physical limitations becomeresistant to traditional approaches," acknowledges David Klein,partner, The Klein Law Group, a New York-based firm thatspecializes in workers' compensation and Social Security disabilitylaw.

"Employees need to know that these alternatives are available,"Klein says. "The alternatives often work, and they don't have thepotential toxicity that medications can have. On the whole,alternative treatments are cost effective. It would be great ifmore people knew about them and availed themselves of theirbenefits."

Under certain circumstances, Klein says, an insurance carriermay agree to pay for any form of treatment. Healing treatments thathave been authorized in specific cases include massages (ifperformed by a board-authorized practitioner), as well asbiofeedback, acupuncture, chiropractic and swim therapy, heexplains.

The personal approach to RTW

The "personal approach" is key for employers to motivateemployee RTW and shorten costly claim periods. It starts withcommunication, the experts agree. "Communication is so important.Keeping the injured worker connected to the workplace can play suchan important role in preventing the anxiety associated withdisability and return to work," says Safety National's Walls.

Employees who have been away from work due to a workers'compensation claim or disability leave may question whether theiremployers even want them back, so it is critical for employers toremind employees of their desire to have them return. "Whenemployees are away from work, the employer should continue toremind them of how welcome they are to return, once medicallyappropriate," says Liberty Mutual's McCarthy.

Such employees lose the "belonging connection" with their workfamily, which is a huge component of most workers' lives prior totheir injuries, points out Bartlett. "It is imperative that theemployer find creative ways to stay connected to injured workerseither through phone calls, emails, or 'get well soon' cards. Itcan make a world of difference when a person believes they aremissed and needed in the workplace." Employers can also keepemployees in the loop by sending them company newsletters,announcements and other work communications they would be receivingif they were on the job.

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Of course, employers should also use communication to make sureworkers fully understand their benefits. Worrying about financescan be a great stressor and affect recovery. Knowing where theystand can ease uncertainty and alleviate the type of stress thatcan hamper recovery.

Understanding the family and work dynamics is also important fora holistic approach to RTW, Bartlett says. "For example, an injuredworker may be unhappy at work or in the process of beingdisciplined. It is important to know and address any conflicts inthe workplace." And don't overlook your organization's employeeassistance program: Encourage the employee and family members totake full advantage of EAP benefits.

Training for supervisors and managers is a key component ofmitigating the psychosocial repercussions of workers' compabsences. "Employers should train supervisors on the proper way tocommunicate with the individuals they manage," McCarthy says. "Astudy by Liberty Mutual Insurance found that employees who reportedto supervisors with an open, honest style of communications wereaway from work less often and for shorter periods of time.

Keep the RTW goal in mind

The bottom line: Work with the employee and the medical team todevelop a personalized RTW plan that has achievable deadlines andgoals. "A formal return-to-work program should be a key part of anyworkers' compensation claim," says McCarthy. "Employees should bereturned to light duty if possible. Employers who can't returninjured employees to temporary light duty assignments within theiroperations can still gain the benefits of RTW by having theseemployees work temporarily at local nonprofit organizations. Thisbenefits the employer, the injured worker and the community."

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