A Biopsychosocial Approach to Claims Management

By Laurie Barkhorn
 
For risk managers of large companies, managing the cost of workers' compensation is a top priority. Industry best practices help injured workers recover from their injuries and facilitate their return to work while reducing the overall cost of claims. But forward-thinking insurance companies and risk managers don't take their current best practices for granted; they continually seek new ways to improve outcomes. The Hartford is an industry leader in this regard and is experimenting with innovative ways to manage claim costs while providing best-in-class support to injured employees.
 
This article is part of a series in which we share some of The Hartford's initiatives that are designed to drive better outcomes for our customers.
 
Dr. Marcos Iglesias, vice president and medical director at The Hartford, is leading the company in new directions with medical case management. I met with Dr. Iglesias to discuss the major programs he's working on and why they matter to large, loss-sensitive companies.
 
LB: Tell us what you do at The Hartford.
 
MI: I lead a forward-thinking group of medical strategists at The Hartford. Our mission as a team is to create innovative medical management strategies that deliver the best possible outcomes for workers' compensation and group benefits claims. For policyholders, this means managing claim costs and keeping valuable employees productive and on the job. For claimants, our goal is to help ill and injured workers regain function so they can return to their normal lives as soon as possible.
 
We're currently focusing on a biopsychosocial approach (BPS) that is helping us accomplish this goal and take medical claim management to a new level.
 
LB: What is the biopsychosocial (BPS) approach?
 
MI: The BPS approach considers the whole person – the biological, psychological (or behavioral) and social factors that contribute to health and one's ability to recover from injury and illness. The BPS model was introduced in the 1970s by the late psychiatrist George Engel who believed it isn't enough to attend only to the physical symptoms of disease and disability, as had been the tradition for hundreds of years. Rather, clinicians need to take into account a patient's beliefs, behaviors, feelings, social environments and culture in order to provide effective care.
 
The BPS model has led to a shift in the focus in healthcare, and that shift has also begun to take hold within the insurance industry and its approach to medical claims management. This is important and necessary, because we now know that recovery is rarely just a biological issue. If we look more closely at a patient's life, we often find non-physical barriers that cause delays in recovery. The Hartford's BPS program addresses those barriers.
 
LB: What prompted your interest in this new and different approach?
 
MI: In the early years of my medical career, many of the patients I treated were injured workers. One of my frustrations was that two similarly injured workers would come into my office and yet go down entirely different recovery paths with drastically different outcomes. One would meet medical expectations and be back to work within a reasonable period of time. The other would have a delayed recovery plagued by all sorts of complications. I couldn't put my finger on why the outcomes were so different, and that was my problem to solve.
 
My research and work with patients led me to the BPS model, which subsequently brought me into the insurance world and laid the foundation for the work I'm doing today.
 
LB: What are some of the risk factors that delay recovery?
 
MI: Most people equate recovery times with the seriousness of the injury of illness, but medical and research literature shows that social and behavioral factors can pose equal if not greater barriers to recovery. Employment issues such as poor job satisfaction or repetitive, heavy work during unsociable hours can contribute to longer recoveries.
 
Other risk factors may be psychological, such as depression or anxiety. More often, however, they are due to poor coping skills, fear that pain and activity will be harmful or catastrophic thinking that projects a worst-case scenario, the lack of family or social support or an overprotective family.
 
Through our internal data analytics, we've found that the presence of psychosocial risk factors can account for a two- to four-fold increase in the disability duration of work-related injuries. We're continuously refining our assessment tools in order to identify these risk factors early on in the life of a claim.
 
LB: What techniques are you using to identify risks?
 
MI: First, we're using a technology known as predictive modeling for early identification of high-risk claims. Predictive modeling allows us to monitor the various characteristics of a claim and target those with a high risk for delayed recovery before they become volatile. Our models alert a dedicated team of experts who can intervene in a proactive and effective way.
 
Our claim handlers have also been trained on questions to ask when talking with patients and the signs to look for in their responses that may point to psychosocial barriers.
 
LB: What techniques are you using to help the patient restore function?
 
MI: We've developed a continuum of solutions for the claims handlers to use based on the risks they identify. Behavioral intervention can help ease catastrophic thinking or fear of activity. Patients who lack coping skills may benefit from assistance in scheduling, goal setting or responding to stress more effectively. We've also developed a voluntary coaching program known as iRECOVER® that targets claimants with an elevated risk for prolonged disability.
 
Our goal is to help patients return to a productive life and work with greater confidence and more life skills than they had before the illness or injury.
 
LB: Tell us more about your coaching program, iRECOVER.SM
 
MI: iRECOVERSM is our new, patent-pending lifestyle coaching intervention program for claimants who have been identified to be at high risk for delayed recovery. Participants meet with a coach over the phone for one hour per week for up to 10 weeks, and receive education and guidance tailored to their unique risk factors. They also receive a workbook and homework to complete in between meetings with their coaches.
 
We're still in the early stages of implementing the program, but results so far have shown participants are experiencing an earlier return to function and to work than non-participants.
 
LB: What feedback are you getting from those involved in this program?
 
MI: We have received many positive emails and letters. Some participants have said that they've acquired skills they can use in other aspects of life, and that they're surprised that an insurance carrier would offer a free program like this that is so helpful in their recovery and their lives.
 
Of course, the ultimate test of its effectiveness will be in our claim outcomes.
 
LB: Any best practices or advice you can provide to risk managers?
 
MI: The partners you work with contribute to your claim outcomes, so be sure to choose your partners wisely. Look for best-in-class claims management services that take advantage of the latest technologies and approaches, and make sure you're continuously learning and looking for ways to improve, too. Your professional network is one of the best resources for staying abreast of new and innovative approaches.
 
 
The information provided in these materials is intended to be general and advisory in nature. It shall not be considered legal advice. The Hartford does not warrant that the implementation of any view or recommendation contained herein will: (i) result in the elimination of any unsafe conditions at your business locations or with respect to your business operations; or (ii) will be an appropriate legal or business practice. The Hartford assumes no responsibility for the control or correction of hazards or legal compliance with respect to your business practices, and the views and recommendations contained herein shall not constitute our undertaking, on your behalf or for the benefit of others, to determine or warrant that your business premises, locations or operations are safe or healthful, or are in compliance with any law, rule or regulation. Readers seeking to resolve specific safety, legal or business issues or concerns related to the information provided in these materials should consult their safety consultant, attorney or business advisors.
 
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including Hartford Fire Insurance Company. Its headquarters is in Hartford, CT.
 
1 National Accounts In Force as of August 2016.