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2013 NCSI Annual Meeting May 19-22, 2013 Rancho Bernardo Inn San Diego Presented by: Kevin Glennon, RN, BSN, CDMS, CWCP, QRP Vice President Home Health & Complex Care Services MSC Care Management-A One Call Care Management Company

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Disclosure Statement Kevin T. Glennon, RN, BSN, CDMS, CWCP, QRP works for MSC Care Management-A One Call Care Management Company as their Vice President of Home Health and Complex Care Services. A provider of Home Health, Infusion Therapy, Complex Care Coordination, Medical Equipment, Devices and Supplies and Assistive Technology Products and Services in the Workers Compensation Industry. Off label use of certain medications may be discussed during this presentation along with Nursing considerations. Discussions related to urine drug testing companies may be discussed during this presentation. Additionally no financial relationships exist with any commercial party.

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Objectives Review case studies to learn to expect the unexpected Identify the needs of the aged worker, the obese/overweight worker and the injured worker with significant co-morbidities Discuss the level of medical care and treatment needed, the increased costs associated and how co-morbidities adversely affect recovery and indemnity benefits Understand increased recovery times for better return to work planning based on injury, age and adverse factors

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The Current Trend NCCIs latest review indicates: Overall claim frequency has increased for the first time since 1997 (3%). Prior years trend -4.3% Indemnity decreased by 3% and Medical increased by 2% Workers compensation medical costs per claim average more than $6,000 and soar to nearly $25,000 for lost-time claims Prescription drug (Rx) use, a medical expense that makes up 19% of all workers compensation (WC) medical costs

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Complex Injuries and Complicating Factors Head Injuries Spinal Cord Injuries Amputations Spinal Fusion Surgeries Multiple Fractures Pelvic Fractures Crush Injuries Burns Upper & Lower Extremity Injuries Diabetes Obesity Circulatory Disorders Cardiac Conditions Hypertension Neurological Abnormalities Age Infection Home Environmentort

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OBESITY - ICD 9 278 Obese claims are 2.8 times more expensive than non-obese claims at the 12-month maturity This cost difference climbs to a factor of 4.5 at the three year maturity and to 5.3 at the five year maturity The cost difference (at the five year maturity) is less for females than for males

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Obesity Supersizing Workers Compensation Costs $78.5 Billion/1998 $147 Billion/2008 46.6% Increase 27% of increased medical costs directly related to obesity Medical 29%-117% greater than normal weight Approximately 1/3 of all Americans are obese (>72 million) $62.7 billion direct costs (medical) $56.3 billion indirect costs (includes lost work days)

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Obesity Statistics

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Obesity Related Co-Morbidities Hypertension Dyslipidemia Diabetes Coronary Heart Disease Stroke Gall bladder Disease Osteoarthritis Orthopedic Problems Impaired Mobility Peripheral Vascular Disease Kidney Failure Sleep Apnea

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Osteoarthritis is the most common joint disorder affecting Hands Hips Knees Neck Back 10 extra pounds of weight increases the force on the knee by 30-60 pounds with each step

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Body Composition

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Know Your Weight Limits

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Rising obesity will cost U.S. health care $344 billion a year If Americans continue to pack on pounds, obesity will cost the USA about $344 billion in medical-related expenses by 2018, eating up about 21% of health- care spending, says the first analysis to estimate the future medical costs of excess weight. "Obesity is going to be a leading driver in rising health-care costs," says Kenneth Thorpe, chairman of the department of health policy and management at Emory University in Atlanta Emory University

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The Aging Workforce

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The Generation Gap Traditionalists (born 1927-1945) - Typically loyal, hardworking with the best collective work ethic Baby Boomers (born 1946-1964) 73 mil- Typically competitive, political, hardworking, and entrepreneurial Generation X (born 1965-1981) 49 mil- Typically entrepreneurial, independent, looking to improve skill set Millennials (born 1982 - 2000)80 mil - they're trustworthy, loyal, helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean, and reverent

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The Aging Workforce This increase does not just reflect the aging of the baby-boom population, since none had yet reached age 65 BLS expects the growth in employment to continue During the period 2006-2016 Workers age 55-64 are expected to climb by 36.5% Workers between the ages of 65 and 74 and those aged 75 and up are predicted to soar by more than 80%

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The Risk Older workers pose an increased risk for fatal work injuries Require more time to return to work following an injury or illness And are less likely to receive training as their jobs change With many employees staying in the workforce past retirement age, there is growing concern for aging worker safety There are many challenges that face this group of people that, if not appropriately addressed, could lead to serious, long- term injury in the workplace with little or no hope of recovery to a normal life

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Managing Safety for the Aging Workforce Many employers have shifted their focus to wellness and prevention as a means to address the healthcare costs of an aging workforce, with an emphasis placed on such services as smoking cessation and weight management in addition to addressing the current physical demands of jobs Risk Management Shift to Job Modification for current employees What needs to be done to keep the aging workforce safe in the current work environment

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Managing Safety for the Aging Workforce Specific safety concerns for older workers: Shorter memory More easily distracted, e.g., by environmental noise Slower reaction time Declining vision and hearing Poorer sense of balance Denial of decreasing abilities, which can lead to employees trying to work past their new limits

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Managing Safety for the Aging Workforce These physical limitations lead to the following injury types for older workers: Falls caused by poor balance, slowed reaction time, visual problems, or distractions Sprains and strains from loss of strength, endurance, and flexibility Cardiopulmonary overexertion in heat or cold, at heights, using respirators, or in confined spaces Health- or disease-related illnesses, such as diabetes, cancer, osteoporosis, coronary artery disease, or hypertension Accumulation injuries from years of doing the same task, e.g., truck drivers who experience loss of hearing in left ear from road noise with cab window open

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Challenges Equipment needs change Potential for additional surgery Medications may be contraindicated or no longer effective Liver and Kidney issues Loss of family caregiver/support Are all these changes related Is anyone monitoring who is prescribing what medications

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Mitigating Risk With varying perspectives on what constitutes an older worker, there is no set definition. The Age Discrimination in Employment Act of 1967 (ADEA) applies to individuals aged 40 and over The majority of workers in their 50s work full-time regardless of health status. 3 These workers are often affected by health conditions that can limit their ability to work. For example, more than one-third (35%) of workers in their 50s who report being in fair to poor health indicated that a health condition limits the type or amount of work they can do

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Proportion of workers age 51-59 with work limitations, by health status

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Managing Safety for the Aging Workforce Look for these signs that older workers may need accommodations: Physical signs, such as fatigue, tripping Psychological or emotional signs, such as loss of patience, irritability Feedback from supervisors or co-workers on declining performance Numbers and patterns of sick day History of minor injuries or near misses

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Antibiotic Resistant Infections

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Increased Risk Infectious diseases continue to be a leading cause of death worldwide It is the third leading cause of death in the United States Emergence of new infectious diseases Re-emergence of old infectious diseases Persistence of intractable infectious diseases

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Increased Risk The Institute of Medicine estimates that the annual cost of treating antibiotic resistant infections in the United States may be as high as $90 billion Doctors currently prescribe antibiotics for outpatients approximately 150 million times a year CDC estimates that approximately 50% of all antibiotic prescriptions are unnecessary

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A Classic Example The literature on the management of ankle fractures in patients with diabetes has shown outcomes to be generally poor 42.3 % incidence of complications in patients with diabetes compared to people without (McCormick and Leith) Conservative management may be preferable to surgical treatment 32 % higher infection rate found in people with diabetes ( Flynn, et. al.) Those patients with diabetes who were treated conservatively had a greater tendency to become infected over those who treat with open reduction internal fixation (ORIF) People with diabetes who are poorly controlled and had evidence of neuropathy were shown to be very difficult to manage

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Prolonged Recovery 04-29-199706-30-1997

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A Cost Comparison Claimant A 130 lbs with post-op infection Needs cubic in 5mg/Kg/Q24 59Kg @ 5mg/Kg = 295 mg/day Cost @ $1.19/mg x 295mg = $351.64/day Claimant B 330 lbs with post-op infection Needs cubic in 5mg/Kg/Q24 150Kg @ 5mg/Kg = 750 mg/day Cost @ $1.19/mg x 750mg = $892.50/day

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NCCI Reports Pharmacy costs are 19% of total medical spending in Workers Compensation

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Drug Deaths now outnumber Traffic Fatalities in US Approximately 38,000 deaths annually 1 death every 14 minutes Death toll has doubled over the last decade Prescription Drugs now cause more deaths than Heroin & Cocaine Combined OxyContin Habit can run twice as much as a Heroin Addiction Most commonly abused Drugs OxyContin Fentanyl Actique Vicodin Xanax Soma

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TOP 50 DRUGS OXYCONTIN LIDODERM HYDROCODONE-ACETAMINOPHEN LYRICA CELEBREX GABAPENTIN SKELAXIN CYMBALTA MELOXICAM CYCLOBENZAPRINE HCL TRAMADOL HCL OMEPRAZOLE FENTANYL FLECTOR OXYCODONE HCL ULTRAM ER OXYCODONE HCL-ACETAMINOPHEN CARISOPRODOL NAPROXEN KADIAN ZOLPIDEM TARTRATE OPANA ER AMRIX TIZANIDINE HCL AMBIEN CR PERCOCET IBUPROFEN NAPROXEN SODIUM OXYCODONE-ACETAMINOPHEN ACTIQ ENDOCET AVINZA LUNESTA DURAGESIC NEXIUM LOVENOX FENTANYL CITRATE MORPHINE SULFATE EFFEXOR XR DENDRACIN, NEURODENDRAXIN TOPIRAMATE TOPAMAX DICLOFENAC SODIUM PROPOXYPHENE NAP-ACETAMINOPHEN ETODOLAC NABUMETONE PROVIGIL LEXAPRO ZANAFLEX SEROQUEL

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Adherence/Efficacy All individuals are different: Slow Metabolizers Fast Metabolizers NON Metabolizers

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Based on adherence studies Less than 30% of claimants take their medications as prescribed More than 30% fill their medications but do not take them More than 30% take additional medications and/or substances that can reduce or eliminate the efficacy of the prescribed medications

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Economic Impact For every dollar Medicare spends on medications, it costs $1.33 to manage the complications of those medications Medication-related problems account for $88.2 billion/annually Infectious Disease is the third leading cause of death in the United States The Institute of Medicine estimates that the annual cost of treating antibiotic resistant infections in the United States may be as high as $90 billion Doctors currently prescribe antibiotics for outpatients approximately 150 million times a year CDC estimates that approximately 50% of all antibiotic prescriptions are unnecessary

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Learn to Expect the Unexpected