Complications that Drive Expenses in Medically Complex Cases

Posted by Paradigm on January 24, 2012 under Medical Case Management | Be the First to Comment

Medically complex cases, including catastrophic injuries with post-acute medical needs, account for a very large portion of workers’ compensation claims costs.  However, when claims managers seek to control volatility by helping the injured worker reach the highest possible recovery, they in turn reduce the risk of complications and lower long term medical care costs.

There are several factors responsible for driving the high costs in catastrophic and complex cases.  First, there are the numerous ongoing risks that are inherent with these types of cases.  Second, there is a considerable amount of medical care involved–significantly more than in other cases.  Third, there are complications due to the increased number of settings in which care takes place and the increased number of providers and specialists that deliver care.  These factors all increase the likelihood of errors that lead to increased expenses.

One example of this is the high incidence of complications associated with a traumatic brain injury.  Figure A, below, represents the dramatic volatility that is inherent in these catastrophic injuries over time.  Some of the more frequent complications driving increased medical need and costs include skin breakdown, hydrocephalus, seizure disorder, spasticity/contracture, impulsivity, pneumonia, meningitis, chronic pain, and the inability to live independently in the long term residential setting.

Each risk is case-dependent and all can greatly increase the ultimate costs of the case.  Poor management in the acute period can lead to a host of significant and expensive long-term complications, even when the initial costs appear to decline.

The trajectories for Paradigm-managed cases are quite different when it comes to costs for all types of medically complex cases because we prevent or mitigate the medical complications commonly responsible for poor outcomes and high costs.

Figure B (below)  represents cumulative medical expenses for all types of catastrophic injuries.

Three simple actions can help claims professionals and treating medical achieve the highest possible clinical outcomes, reduce the risk for outbound volatility and control the overall claim costs:

1) Engage top tier medical specialists to consult with claims staff and treating physicians

2) Map a detailed care path to the best-case recovery

3) Closely manage the case according to the care plan

For more information on reducing volatility in complex and catastrophic cases, please read our white paper entitled, “Controlling Volatility in Medically Complex Cases,” located on our website.  To refer a case or ask us a question, please call 800-942-1725, or join our social communities.