DANA POINT, Calif. — Social factors such as poverty, housing insecurity and lack of education can significantly affect the outcome of a workers’ compensation claim, as such factors — known as the “social determinants of health” — are often barriers to recovery.
As much as 80% of the outcome of an individual’s health is linked to factors linked to an unhealthy environment, and a work injury can start a chain of events that can prevent return to work, according to panelist Rafael Gonzalez, partner at Charlotte, North Carolina-based Cattie & Gonzalez PLLC and a panelist speaking at the Workers’ Compensation & Risk Conference on Wednesday.
When you have an injury, “all hell breaks loose”; in an unhealthy environment, he said. “We see that in our claims. Can they pay the rent now? Because if they’re not, they’re not paying attention to their claim. They’re just focused on, ‘I just lost the roof over my head.’
Panelist Chad Beinschroth, Winchester, Calif.-based claims manager at construction company ABM Industries Inc., said the loss of income that comes with an injury is often the biggest concern among injured workers; that loss of income and ability to work sets off the “chain reaction” that affects housing and financial security.
And the workers’ comp industry has caught up, said panelist Debra Livingston, Tampa, Fla.-based CEO of ReEmployability Inc., which provides return-to-work services for injured workers.
“In comp, we’ve learned that whole-person recovery leads to shorter injury duration,” she said, adding that the pandemic helped drive the conversation about so-called SDOH even further.
In the pandemic, “we found that those at greater risk of mortality and health problems had problems with access to care, and many of these SDOH categories,” such as education, housing and income, she said.
“These are the conditions in which people live, learn, work and play that affect their daily lives; which affects their health and their quality of life,” she added. In workers comp, that can translate to missed forms or missed appointments, she said. “Asking why” can be the first step to understanding what’s going on in an injured worker’s life outside of the injury, she added.
Ask “why they didn’t show up for a doctor’s appointment, why they didn’t cooperate with return to work. Why don’t they take that medicine? Ask them why, she said. “There could be a multitude of reasons.
She recalled the story of a friend who needed to schedule surgery, which she had put off for three months due to required work travel and childcare issues. “What if it was an injured worker who couldn’t schedule the surgery when they were told they had to have it? They would be threatened with cutting off their benefits, right? And it’s so unfair. It kind of goes back to the whole the person,” Livingston said.
Claims adjusters who know more about an injured worker’s life and life challenges can help make community resources available to the injured worker, who may not realize he or she may be eligible for government benefits such as disability or Social Security, the panelists explained.
But identifying social issues at the time of a claim is a shortcoming in the comp industry, according to Gonzalez, who proposed a solution.
The federal Medicare and Medicaid programs now require billing codes — known as “Z codes” — to document SDOH problems, such as homelessness, divorce, death in the family or relationship problems. Workers’ comp insurance companies may begin requiring such medical codes in claims as a way for claims adjusters and employers to get a complete picture of the injured worker, he said.
“This is clearly a big shift in our world for workers… But we know it’s in another area,” he said. “Can we go learn about it and borrow some of these components and bring them over here?”