The Workers Compensation Research Institute (WCRI) released a report examining factors associated with high-cost workers' comp claims.
High-cost claims are defined as the top 5% of medical payments within 36 months of injury. The study analyzed claims from 32 states while excluding catastrophic or minor injuries, highlighting the complexity of high-cost claims which often involve serious injuries such as disc herniations, neurological neck injuries, or burns and require multiple healthcare providers.
Key factors contributing to high costs include patient characteristics, injury-related treatment needs, and inefficient healthcare utilization.
High-cost claims represent 28% of total medical payments within 36 months, with the average medical payment per claim exceeding $100,000, more than seven times higher than other claims with more than seven days of lost time. Total costs of high-cost claims were on average more than $200,000 per claim. High-cost claims are associated with longer disability durations compared to non-high-cost claims, coming in at 64 weeks vs 18 weeks.
Injury complexity was one of the most important factors associated with the probability of a high-cost claim. When compared to carpal tunnel syndrome, WCRI found that:
- Fractures between the ankle and hip/pelvis, fractures of the spine (excluding spinal cord injuries) and severe burns make claims 8-9 times more likely to be high-cost claims
- Disc herniations/disorders, neurological neck and back conditions, and sprains, strains and non-specific spine pain made claims 4-5 times more likely to be high-cost claims
- Degenerative conditions and comorbidities increase the likelihood of a claim becoming a high-cost claim by 46% and 33% respectively
Demographic and injury-related characteristics of workers with high-cost claims include:
- 34% involve workers aged 55 or older
- 63% involve male workers
- 36% are for workers with less than two years of tenure
- A higher incidence of neurological back and neck injuries, shoulder impingement, and rotator cuff injuries is observed in high-cost claims
- 58% of high-cost claims involve at least one comorbidity
- Workers in the construction industry are most likely to have high-cost claims, followed by those in agriculture, forestry, and fishing
