January 4, 2024

This Year’s Top Insights in Workers’ Compensation Medical Management

By Healthesystems

The past few years have been big ones for workers’ compensation managed care programs. Since 2020, we’ve experienced a pandemic, a remarkable shift in workforce dynamics, and record inflation. For 2023, workers’ comp claims organizations continued to deal with worker shortages along with many other factors, from mental health concerns to nuanced pharmacy trends.

Here are our top 5 insights from 2023 that we expect will continue to be relevant in 2024:

#1. Industry Continues to Explore Implementing AI/Advanced Analytics

Artificial intelligence (AI) capabilities are advancing rapidly, with new applications becoming available for healthcare and workers’ comp. According to the 2023 Workers’ Comp Industry Insights Survey Report, predictive/prescriptive analytics is one of the most important technological advances to workers’ comp programs in the next three to five years. The top application of enhanced data analytics and AI last year was to personalize the injured worker experience, but initial findings from the upcoming 2024 report indicate a potential shift in priority of applications. These include identifying fraud, waste, and abuse; supplementing customer service capabilities via chatbots and virtual assistants; and the summarizing and sharing of medical records.

#2. Mental Health Contributes to Claim Complexity

Mental health conditions are factors that must be considered when treating injured worker patients, as they often contribute to claim complexity. In fact, mental health conditions ranked as the top concern in terms of claim complexity in our 2023 Industry Insights Survey Report, and initial findings from our 2024 report indicate they will remain a top concern. When it comes to injured workers, studies show there is a relationship between injury and mental health. Injured workers have a higher likelihood of experiencing symptoms of depression, anxiety, and PTSD. In turn, these mental health concerns can increase claim costs and duration and result in a slower recovery and delayed return to work. Fortunately, with  machine learning technology, there is an opportunity to identify and address mental health factors that may impede recovery by gleaning information from unstructured data such as physical therapy notes, in addition to traditional, transactional claims data.

#3. Monitoring Nuanced Trends Remains a Pharmacy Program Goal

Although opioid use and abuse is still a concern, opioids are no longer the predominant factor in pharmacy prescribing or costs in workers’ compensation. Instead, the workers’ comp industry faces a growing diversity of smaller, niche trends that require more strategic formulary and clinical management across different populations and geographies – and monitoring these trends, along with containing the associated costs, remains a pharmacy program goal. We’ve seen this consistently as a top concern among workers’ compensation programs in our annual industry insights surveys. In 2023, growing contributors to pharmacy costs in workers’ comp included private-label topicals, specialty drugs, and physician dispensing.

#4. Mobile Technologies Are One Way to Keep Injured Workers Engaged

In our annual industry insights surveys, injured workers’ unfamiliarity navigating workers’ comp systems has been cited as the number one barrier to recovery for three years running. In 2023, we saw more mobile technologies come on the scene to help injured workers navigate the daunting workers’ comp system. Rather than replacing human engagement, mobile device-enabled communication can augment it by providing more touchpoints in the workers’ comp journey, allowing injured workers to engage in their care by communicating directly with claims teams. In fact, according to the 2023 Industry Insights Survey Report, mobile technologies are among the top five technological advances that are important to workers’ comp programs in the next three to five years.

#5. Worker Shortages Remain a Top Concern

In our 2023 Workers’ Comp Industry Insights Report, the healthcare provider/service shortage was the number one concern among workers’ comp stakeholders – and it continues to be, according to initial findings from the 2024 report. This lack of service providers, including home health caregivers, is significant because it poses an obstacle to facilitating care for injured workers.

Also continuing to impact workers’ comp organizations is a shortage of claims professionals – largely due to an aging workforce and a lack of new talent as well as a need to train new professionals in a period of remarkably high turnover. Therefore, many organizations are seeking solutions that help them do more with less. Both the 2023 and upcoming 2024 industry insights surveys indicate that claims process automation is the most important technology to workers’ comp medical management programs in the next few years. Workflow automation solutions can reduce the burden on capacity-strapped claims teams by supporting or reallocating tasks in the best possible way. This time-saving claims technology may include clinical logic that helps detect complexity as well as right-time decision support that helps adjusters address that complexity right within their workflows.

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