Special Considerations in Caring for the Workers’ Compensation Patient

Felise S. Zollman

BACKGROUND

The need for a no-fault workers’ compensation (WC) system came into being in the context of the emergence of modern industrial society. In the United States, the first state-specific WC legislation was enacted in Maryland in 1902 [1], followed by Congress’ 1906 Employers’ Liability Act [2]. This legislation shifted the traditional view that employees accepted the risk associated with the work they did, and could only sue if they could prove gross negligence on the part of the employer, to the notion that employers bore responsibility for providing a safe work environment. The first federal WC system in the United States was enacted in 1908 in the form of the Federal Employer Liability Act, which covered railway workers. The first state WC system was established in Wisconsin in 1911. The last state to put such a system in place was Mississippi, in 1948 [1,2].

The core concept of WC is that it is a no-fault compensation system in which the employee is entitled to collect a percentage of lost wages and have medical and rehabilitation care paid for by the employer or the employers’ agent or insurer. In return, the employee may not sue the employer because of the injury.

WORKERS’ COMPENSATION AND TRAUMATIC BRAIN INJURY

Much of the available data on the incidence, prevalence, and costs associated with traumatic brain injury (TBI) in the context of the WC system comes from a few select states such as Washington, because these states have created a single large State Fund, which covers the vast majority of workers in the state, and therefore have access to a large centralized database containing injury and claim-related information. A handful of large employers may opt out and serve as their own insurers, and these workers are not reflected in published data. Federal employees covered under federal WC programs are also not included.

Epidemiology

Studies have reported that work-related TBIs (wrTBIs) account for between 5% and 14% of all TBIs [3]. The average annual incidence of wrTBI is approximately 10 per 100,000 full-time equivalent employees [4]. The top three causes of wrTBI are falls, motor vehicle accidents, and being struck by objects [4]. The gender differential for occupational injuries is greater than it is in the civilian sector in general: various studies have suggested a ratio of men to women affected by wrTBI ranging from 2:1 to 10:1 [4–6]. One Canadian mild TBI (MTBI) study, however, did find a higher prevalence of MTBI claims among female employees versus males (although the incidence was 2:1 male:female). The authors postulated that the reversal in gender ratio for prevalence of MTBI might be due to an observed longer duration of claims remaining open for female workers with MTBI [6]. The highest incidence of wrTBI for women was in education and healthcare, and for men, manufacturing, transportation, and construction [7]. The annual case fatality rate for wrTBI is reported by various authors to be between 6.7% and 8% [5,8].

Costs

A study from Washington State published in 2006 reported an annual claim cost per TBI of $25,400. Medical costs were $12,600, time lost was $3,200, and disabled pension benefits were $4,000. Median claim cost was $61,000. The highest risk/most costly industries included logging, construction, janitorial services, and roofing [5].

MANAGEMENT OF wrTBI

Personnel

• In addition to the usual clinical care personnel, injured workers are usually followed by a medical case manager (MCM), typically an RN by training. The role of this individual is to direct and move the case forward through the medical or rehabilitation care process and see the case to closure. MCMs are guided by the Code of Professional Conduct for Case Managers (see section Additional Reading).

• WC carriers will typically identify a primary treating physician (PTP) for an injured worker. This physician is the individual who is primarily responsible for managing the treatment of the injured worker. Some states set forth detailed guidelines for PTPs, including case coordination and reporting duties (see, for example: http://content.statefundca.com//pdf/TreatingMDGuide.pdf).

• WC carriers will also typically assign an adjustor to each case, whose responsibility it is to manage the financial aspect of a claim. The adjustor will typically work in conjunction with the MCM on behalf of the insurance company in monitoring claims-related costs.

Management Approach

Typical injury cases would be expected to progress through a sequence of stages, from acute care to medical rehabilitation to vocational rehabilitation (VR). A study by Wrona revealed, however, that only 48% of TBI survivors seen for acute medical management (identified based on hospital discharge records) progressed to medical rehabilitation; 46% were referred for VR. Sixty-five percent of those referred for VR did ultimately return to the work force. The author hypothesized that the reason a minority of cases were referred for medical rehabilitation was because “most cases do not occur in the area served by clinical model treatment programs and do not follow the clinical trajectory of short intensive initial inpatient care, followed closely by intensive rehabilitation and referral for return to work” [9].

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