Social Determinants of Health and Workers Compensation

Rafael Gonzalez, Esq. President, Optum Settlement Solutions

Social determinants of health are the structural components and conditions in which people are born, grow, live, work and age that affect their short term and long term health. They include factors like socioeconomic status, education, transportation, living arrangements, the foods they consume, the physical environment they live and work in, the safety of such environments, employment, their exercise and physical activity, support networks, and of course access to consistent and appropriate healthcare. 

Socioeconomic Barriers to Getting Healthy

These socioeconomic factors are real, and they are a real barrier to getting healthy because they affect our access to healthcare. I recently attended a conference in which the speaker indicated that a third of us reported we had at least two chronic conditions which resulted in emotional and financial distress in the past year that was difficult to cope with alone. Like most of us, I have read studies that US adults were more likely than adults in all other countries to report that they were “always” or “usually” worried about having enough money to buy nutritious meals and to pay their rent or mortgage. All of the national think tanks have published studies and statistics indicating that an overwhelming number of US adults report having a cost-related access problem, ultimately becoming a financial barrier to health care.

Like healthcare providers, health plans tend to think that people care about the same things they do – getting and staying healthy through a range of preventive care activities including annual well visits, chronic condition management, medication adherence programs and health education. However, over the last 50 years, they have learned that the same things aren’t often on the minds of the typical healthcare consumer. For them, for all of us, healthcare is one of many competing priorities, and it is often put on the back burner when compared with the long list of things that is really on their mind- paying rent, keeping the lights on, putting food on the table, and making a car payment, just to name a few.

Now Add an Accident in the Course and Scope of Employment

Now add to this mix an accident in the course and scope of employment. The confusion, worry, and instability caused by the inability to work because of a disabling condition as a result of such an incident. The limited income and limited duration of same. The voluminous, rigorous, and sometimes burdensome requirements the employer and its carrier impose upon the injured worker and his/her family. The stress and psychological effect of this entire situation on the injured worker and his/her family. And yes, the existence of those very same social determinants of health now raging, provoking, affecting, and often times detrimentally producing less than desired medical and functional results.

Access to Food, Housing, Transportation, and Healthcare

Health plans and medical providers who are in the front lines of meeting these same needs have learned that in order to successfully treat individuals and achieve and maintain short term and long term health, such entities need to know and assess individuals' access to healthy food, safe and stable housing, reliable transportation and consistent and appropriate healthcare, as these things are influenced by income and racial disparities and are related to poor health outcomes. Have workers compensation organizations? Health plans and medical providers long ago figured out that socioeconomic factors contribute to chronic stress, which negatively impacts physical and mental health. These organizations, which insure and treat millions upon millions of us, figured out that effective care cannot be delivered when we ignore life factors that have such an enormous impact on our health. It therefore became critical for healthcare organizations to direct efforts and resources towards addressing issues of social inequities, diagnose problems, and remove barriers that negatively impact the health status and quality of life of their customers and patients. Have workers compensation payers?

Identifying Resources to Help with Social Determinants

Long, long ago, in a land, far, far away, when I first began practicing law, I represented injured workers through the Florida workers compensation administrative, legal, and appellate system. I learned early on that these social determinants of health were as important, as significant, as the medical care and treatment they were receiving for their work related injuries. So, it became clear I needed to go beyond the claim, beyond the data, beyond that which the system had identified as significant factors. I started by having a conversation with the injured worker and his family and his doctors and his rehabilitation specialists and his vocational team and his employer and carrier, with the single purpose of identifying all of the factors that were or could affect his short term and long term health. My goal was to identify these factors, figure out what available resources existed to assist with each, and agree on a blueprint for life beyond these models.

I didn’t know it then, but I was clearly developing a strategy to assess and address social determinants of health in order to promote the short term and long term health and wellness of my client. It is time that workers compensation payers engage in, promote, and incorporate such a strategy in their claims handling today. We can start doing this by having a direct and open dialogue with the injured worker, his/her family, medical providers, and others involved in the claim with the intention of better understanding individual needs and barriers to getting better so he/she can return to work and connecting him/her to available community resources. 

Identifying, Assessing, and Solving for Life Necessities

Like health plans, while assessing social determinants of health, I learned that people who report concerns about life necessities (food, shelter, safety) are significantly more likely to report having poor health, way more likely to report their health negatively impacting their work, and incredibly more likely to report high emotional stress that affects their work and family obligations. Therefore, it became important to identify, assess, and solve issues pertaining to:

• Life necessities (food, shelter, safety)
• Mental and physical health changes
• Health impact on taking care of others and employment
• Money/financial worries
• Caretaker stress
• Housing stability over time
• Access to transportation
• Perceived ability to overcome problems and seek help

Conversations with the Injured Worker

These conversations do not happen in a vacuum, nor do they happen just once. Yes, it may mean authorizing care you never intended to accept. Or it may mean bringing on a social worker to assist the injured worker get the community services help he/she needs. Or it may require your nurse case manager speaking with the authorized treating physicians as well as physicians who may be treating the injured worker for non-related conditions. It may even mean hiring an attorney to help the injured employee obtain social security benefits, Medicare, Medicaid, public assistance, food stamps, childcare, or any number of items that may help with the individual’s medical care and short term and long term health.

If the injured worker is represented by counsel, developing a relationship with him or her is crucial to this process. If counsel won’t cooperate, won’t assist, or won’t help, go to the workers compensation judge. Make it clear of what your intent is, document what you are trying to do, let all parties involved in the case know what issues you are trying to affect, what problems you are trying to solve, and the steps you would like to take to identify, assess, and solve such social determinants of health. In order to get the most out of this effort, I recommend following these general guidelines:

• Speak and communicate with the injured worker, his/her family, treating physicians, social workers, and others involved in the case often and on an ongoing basis
• Use each of these opportunities to collect social determinants of health responses from everyone involved
• Monitor changes in responses over time and decide whether such changes are the desired results
• Offer immediate assistance to those individuals reporting issues for which the workers compensation payer has legal obligation for and has the resources to address
• Analyze health improvements in light of the responses and don’t be afraid to change or amend plan based on team’s assessment of individual’s progress

Connecting the Claimant to Community Resources

Over the last 35 years, I have worked with thousands of injured workers who have also become eligible for Medicaid and/or Medicare. I have studied this population with a keen eye for socioeconomic barriers to care. Like health plans, I learned that once barriers were identified, best results are attained if such individuals were connected with a care manager who was able to provide support and help with community resources, especially for those concerned with life necessities, as it makes sense that those who are low income and older and/or disabled are most likely to experience socioeconomic barriers to health.

Like health plans, I also found that those who report high concerns about life necessities are less likely to close clinical gaps than those who were neutral or had no concerns about food, shelter or safety. In other words, if the injured worker is worried about feeding his family, or keeping a roof over his head, or the safety of the neighborhood he lives in, or how he is going to get to his next medical appointment, there is a likelihood that his disabling condition will last longer, that his disability status will also last longer, that he will stay out of work longer, that his impairment will permanently keep him from performing other substantial gainful activity in the future. 

How Are You Addressing Social Determinants of Health?

It isn’t rocket science is it? It makes sense that those with concerns for life necessities are more likely to report that physical and emotional health problems affect their productivity, or their ability to do a good job at work, at home, or when caring for others. Concerns for life necessities translate into financial difficulty, not enough income to cover basic needs. As a result, this population base is not only dependent upon Medicare for medical care unrelated to the work accident, but more and more, especially in states that have adopted the Affordable Care Act, also dependent upon Medicaid for such care. Not surprisingly, Medicaid recipients are more affected than Medicare beneficiaries, as age and disability and lack of income, assets, and resources play a large role in everyone’s ability to be productive and healthy.

How are you addressing social determinants of health, especially for your low-income populations? Are you confident in your ability to catch and stay on top of those who don’t have access to life’s necessities? How can you leverage technology to identify and address social determinants of health? And as a payer, what can you do about it?

Social Determinants of Health in Work Comp Claims at the NWCD Conference

On Wednesday, November 6, 2019, from 2:30 pm to 3:45 pm, Marcos Iglesias, MD, VP, Chief Medical Director at Travelers, David Vittoria, PhD, Sr VP, Clinical Services at Carisk Partners, and I will present Social Determinants of Health in Workers Compensation Claims at the National Workers Compensation and Disability Conference at the Mandalay Bay in Las Vegas, NV. We will review the differences between group health plans and workers’ comp plans when dealing with Social Determinants of Health, help attendees understand how factors such as age and housing, finances and transportation, the physical demands of employment and access to appropriate healthcare can affect an injured worker's recovery and potential return to work, and discuss the reasons why resources are needed to address issues of social inequities, diagnose problems, and remove barriers that negatively impact the health status and quality of life of their customers and patients.

About Rafael Gonzalez, Esq.

Rafael Gonzalez, Esq. is President of UnitedHealth Group/Optum’s Workers Compensation and Auto No-Fault Settlement Solutions. With over 35 years of social insurance experience, he oversees the organization’s mandatory reporting, conditional payments, and set aside allocation process and services. He blogs on liability, no-fault, workers’ compensation, social security, and Medicare/Medicaid issues at www.MedicareInsights.com. He speaks throughout the country on these substantive issues and is engaged in the workers’ compensation, social security, and Medicare/Medicaid legislative process at both the state and federal levels. Rafael is active on social media, including LinkedIn, Twitter, Facebook, Instagram, and YouTube. Rafael is based at 175 Kelsey Lane in Tampa, FL 33619. He can be reached at [email protected] or at 813.967.7598.