The COVID-19 pandemic surprised all of us in January 2020, with its speed of viral infection transmission causing high mortality and morbidity among those afflicted in the United States. This newly formed mutant coronavirus, now known as Severe Acute Respiratory Syndrome Coronavirus 2 or SARS-CoV-2, took the world by storm and many in this country succumbed to severe acute hypoxemic respiratory failures that overwhelmed medical providers, hospitals, communities, and public health organizations in the locales most impacted by the pandemic.
People infected with COVID-19 ordinarily develop fever, cough, and fatigue that progresses quickly to shortness of breath from lung complications like pneumonias and ARDS (acute respiratory distress syndrome) causing severe hypoxia (i.e., low oxygen levels) and organ failures. Many of those stricken became severely and critically ill, necessitating prolonged hospitalizations in intensive care units (ICUs).
Unfortunately, the initial death toll was very high, up to 65.7% for those being placed on mechanical ventilators, and even higher for some who were so critical that they needed cardiopulmonary bypass or extracorporeal membrane oxygenation. Adding to the challenge was the fact that our medical community neither had any knowledge about COVID-19 nor access to any known treatments or cure; hence, our medical providers improvised and relied on their past experience with other severe respiratory infections to keep severely ill COVID-19 patients alive.
What has been learned
Since March 2020, we have become more knowledgeable about COVID-19 and the SARS-CoV-2 virus. We have also become more familiar with the underlying mechanisms for COVID-19 viral transmission, infection virulence, organ damage, and complications. Even more importantly, the medical community now knows which treatments are more effective during acute phases of the illness and how to better intervene to mitigate and prevent severe complications and death. Examples include medical providers utilizing more noninvasive ventilation techniques and avoiding invasive mechanical ventilators altogether, while proactively administering medications like steroids and anticoagulants to limit the degree of systemic complications.
We have identified some promising new therapies for hospitalized COVID-19 patients, such as Remdesivir™, and other promising new therapies, like monoclonal antibodies that can effectively treat early COVID-19 infections. Furthermore, our experience in the U.S. supports the premise that the majority of people getting COVID-19 infections will experience mild to moderate symptoms and not require hospitalization. This has been reinforced by a recent report published by Health Strategy Associates, LLC, whereby a survey of workers’ compensation payers and insurers revealed that a majority of COVID-19 claims to date were generally “not expensive,” with many incurring minimal to no expenses.
The potential impact on workers’ compensation
The United States is starting to see significant reductions in the overall mortality of critically ill patients from an earlier high of 66% to around a 30.9% COVID-19 death rate. All of this is reassuring news to the workers’ compensation industry, but it is important to keep in mind that a small percentage, up to 5%, of people infected with COVID-19 become critically ill with severe complications requiring significant acute care interventions, as well as post-infection sequela, requiring greater and prolonged medical costs due to extended recovery needs.
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In response to the initial medical devastation from COVID-19, Paradigm expanded our catastrophic and complex care solutions to include Paradigm Contagion Care℠, an outcome-based continuum of care service to facilitate injured workers’ best functional level of recovery from COVID-19 infections.
As the COVID-19 survival rate improved, our experience at Paradigm led to one important epiphany — that high numbers of COVID-19 referrals to our program had very similar characteristics and challenges extant with our traditional catastrophic injury claim referrals involving traumatic brain injuries, spinal cord injuries, multiple trauma, burn injuries, and amputations. What is clear to us about our COVID-19 referrals is the high prevalence of complex organ injuries that would typically be associated with “outlier” claims having very expensive acute medical costs, compounded by long-term medical and rehabilitation costs arising from residual damages/injuries related to lungs, heart, brain, spinal cord, kidneys, and even limbs.
Catastrophic cases and COVID-19
Both complex COVID-19 claims and catastrophic injury claims are rare in frequency but have a disproportionately high impact on medical expenditures.
The following illustrative case studies are examples of our “outlier” COVID-19 injured workers. Please note, to ensure confidentiality, our cases are summarized and depicted clinically without specific reference to employer, carrier, location, jurisdiction, and care provider names.
COVID-19 Injured Worker No. 1: Neurological complication in a young healthy male
Injured Worker No. 1 is a 31-year-old male laborer who contracted COVID-19 while at work. He had no prior chronic medical problems, no history of tobacco use, no drug use, and was a social drinker. He was not obese, with a body mass index (BMI) of 26. Injured Worker No. 1 initially complained of headaches, body aches, and fever, and over the ensuing few days, developed additional symptoms, including shortness of breath and nausea, which progressed to severe fatigue and difficulty walking. He experienced some numbness on his right side, weakness, and difficulty speaking.
The injured worker was hospitalized and diagnosed with COVID-19 pneumonia, as well as a moderate-sized acute stroke involving the cerebellum due to a blood clot involving the left vertebral artery in the neck and the subclavian artery over the right upper arm. He required intubation and mechanical ventilator support for 20 days, resulting in tracheostomy and percutaneous endoscopic gastrostomy (i.e., gastric feeding tube) insertion. Following 30 days of being in the acute care hospital, he was discharged to an inpatient rehabilitation hospital to continue his rehabilitation care needs for his severe decondition, swallowing dysfunction, as well as right-sided weakness and gait instability from his stroke.
Ultimately, Injured Worker No. 1 was discharged to his home after 27 days in the acute inpatient rehab facility. Due to his neurological impairment, he required both electric and manual wheelchairs for his home and also had a ramp installed to ensure mobility. Currently, the injured worker has been home for 60 days and still requires support with his activities of daily living. He is continuing with twice-weekly home physical therapy and has ongoing speech therapy. Although there has been some incremental progress with his impairments, due to his physical limitations and isolation, he is dealing with some depressive symptoms and has been exploring his need for personal-care assistants to support his care, potentially for years to come.
COVID-19 Injured Worker No. 2: Accelerated permanent organ failure in a young female
Injured Worker No. 2 is a 27-year-old female office worker with a pre-injury medical history of Systemic Lupus Erythematosus (SLE), which is an autoimmune disease, and is also a former smoker. She had recently developed some kidney impairment from SLE and was diagnosed with Lupus Nephritis, which resulted in chronic renal insufficiency. She had been physically active and medically stable on her immunosuppressant medication regimen until she got exposed to COVID-19 at work.
Her initial COVID-19-related symptoms started with nausea, vomiting, and diarrhea, but rapidly progressed to fever, cough, and shortness of breath. She required emergent resuscitation in the hospital for respiratory failure, hypertensive crisis, and anemia with intensive care unit (ICU) hospitalization with intubation and mechanical ventilator support. After 27 days in an acute-care hospital, receiving high-intensity care for multiple issues — including acute renal injury or acute kidney failure on top of her chronic kidney disease — her medical condition stabilized enough for her to be discharged to home.
Post-COVID-19 residual symptoms for Injured Worker No. 2 included some generalized weakness and severe fatigue requiring home therapy, but her most critical sequelae involved worsening of her renal or kidney function from her COVID-19 infection. Although her renal function did improve slightly post-discharge, her kidneys did not recover to her baseline and the decision was made to start her on peritoneal dialysis to support her kidney function. It has been determined by her kidney specialist that Injured Worker Noo. 2’s COVID-19 infection accelerated the progression of renal failure, as well as her eventual need for dialysis and, potentially, a kidney transplant in the near future.
The aforementioned cases represent the uncommon, yet harsh reality of COVID-19’s potential to become a catastrophic claim. Paradigm’s current experience with care managing complex COVID-19 claims to the highest functional level confirms the varying degrees of challenges caused by COVID-19 on neurological and cardiovascular systems, where complications like ischemic brain injuries from strokes, spinal cord infarcts, Guillain-Barré syndrome like polyneuropathies, heart attacks, and even limb loss from arterial blood clots and sepsis, clearly exist. Such COVID-19-related devastations require medical care to address the prolonged and/or permanent residual physical impairments.
Although there are workers without any obvious medical risk factors for severe complications, as noted in the first case study, many of these complex COVID-19 cases involve injured workers with premorbid chronic medical conditions, including obesity, heart disease, and diabetes. For now, these types of complications are primarily seen in COVID-19 claims involving hospitalized injured workers with severe and critically ill COVID-19 conditions where published literature indicates complication rates of up to 30%.
In addition, the medical community is keeping vigilance for other costly infection-related long-term sequelae like virus-related diabetes mellitus, dysfunction of autonomic nervous system, and persistent symptoms from myalgic encephalomyelitis or chronic fatigue syndrome that is associated with other well-known viral infections such as infectious mononucleosis and enteroviruses.
As more claims data becomes available to NCCI, it will be both interesting and helpful to learn more about the medical cost impacts of COVID-19 claims on the workers’ compensation system. So, for now, despite some casual observers thinking this may be “inconsequential” in response to many asymptomatic and mild cases involving COVID-19 claims, it would be prudent to acknowledge COVID’s true outlier potential as catastrophes with long-term disabilities and high medical costs.
Dr. Michael Choo has been the chief medical officer and senior vice president for Paradigm since January 2013. This article was originally published by the National Council on Compensation Insurance (NCCI) and is republished here with consent.