Mental health and illness are getting significant attention within the workers’ compensation and disability management communities, especially in light of the twin scourges of the opioid crisis and the COVID-19 pandemic. Some companies are committing to raising awareness on mental health this year—increasing awareness and sensitivity to mental health is key to lifting the stigma that still adheres to mental illness conditions so that we can better address them. An important step in that direction is to understand the impact of mental health conditions in our own workers’ compensation and disability space.
Behavioral health or mental health claims are often thought to be qualitatively different from most physical claims. They often develop over time rather than as a result of a discrete event, diagnosis relies on more subjective symptoms than with physical conditions, treatment is typically multi-modal, and clinical training for many of the treating professionals follows a path other than traditional medical school education. In addition, these claims are also generally considered more complex by front-line analysts and believed to be more resistant to treatment.
While behavioral health claims are compensable under most group benefits short-term disability plans, workers’ compensation coverage varies by state. Most states impose significant compensability barriers to these types of claims, typically stating either that behavioral health conditions must be accompanied by significant related physical diagnoses; or that they are compensable only for certain employee groups (e.g., first responders). The most significant exception to these limitations in the U.S. is California, which is the most open to behavioral health claims in workers’ compensation.
Here, we will examine how similar or dissimilar primary behavioral health claims may be in group benefits and workers’ compensation. We will look specifically at prevalence, diagnosis, and severity, and will also look at the impact of behavioral health conditions as secondary conditions or comorbidities.
Age and Gender Distributions
We reviewed all of our group benefits short-term disability claims at The Hartford for a four-year period (2015-2018), as well as our California workers’ compensation claims over the same years, and the results are remarkably stable year over year. Behavioral health claims constitute a significant proportion of group benefits claims, but their prevalence varies with claimant age. For behavioral health claims in group benefits short-term disability:
• 32% involved claimants under 35 years of age.
• 28% involved claimants 35-44.
• 24% involved claimants 45-54.
• 14% involved claimants 55-65.
Behavioral health claims constitute a much smaller proportion of our California workers’ compensation claims, but their prevalence also varies with age:
• 37% involved claimants under 35.
• 26% involved claimants 35-44.
• 22% involved claimants 45-54.
• 13% involved claimants 55-65.
For both group benefits short-term disability and workers’ compensation, behavioral health claims appear disproportionately distributed among the younger cohorts. To examine if these age patterns are simply reflective of there being more claims among younger workers, we carried out the same age analysis for musculoskeletal claims. Within group benefits short-term disability, musculoskeletal claims increase linearly as a function of age—unlike short-term disability behavioral health claims—with 36% of such claims involving claimants 55-65 years of age and just 12% involving claimants under 35.
In contrast, workers’ compensation musculoskeletal primary diagnoses are very disproportionately represented in the young, with 43% of claims involving claimants under 35 years of age and 13% involving claimants 55-65. What this reflects—perhaps not surprisingly—is that short-term disability musculoskeletal conditions are more often progressive, hence impacting older workers; whereas workers’ compensation musculoskeletal conditions are more often traumatic, and impact younger employees who have less seniority and experience and often have the more dangerous, or “heavier,” jobs.
In terms of gender, 70.5% of primary behavioral health group benefits claims were from women, while 70.1% of workers’ compensation primary behavioral health claims were also from women, and the gender proportions were stable across age groups. This is consistent with the published literature on behavioral health and gender, and likely reflects—at least in part—the greater willingness of women to self-disclose mental health issues. Short-term disability musculoskeletal claims are also more prevalent among women, but less so—56% of short-term disability musculoskeletal claims were from women, and that proportion varied very little across the age groups. Meanwhile, workers’ compensation musculoskeletal claims were more prevalent among men (55% male, 45% female).
Behavioral Health Claim Severity
The next analysis addresses the relative severity of behavioral health claims. Unfortunately, we could not get apples-to-apples comparisons because our standard measure of severity for short-term disability is claim durations, whereas on the workers’ compensation side we track treatment days. To get a sense of the relative complexity of primary behavioral health claims, and to be able to make comparisons across type-of-claim (group benefits versus workers’ compensation), we developed a ratio based on musculoskeletal severity. Musculoskeletal claims constitute the largest proportions of both group benefits and workers’ compensation claims, and thus can serve as the standard. For short-term disability claims, mean disability days for primary behavioral health claims were divided by mean disability days for primary musculoskeletal claims for claimants within the same age cohort. A score of 1.0 would reflect that, on average, behavioral health claims last about the same as musculoskeletal claims; higher scores would reflect longer durations (and higher costs) for behavioral health. For workers’ compensation, the mean number of treatment days for each age cohort with musculoskeletal injuries served as the basis.
The numbers indicate that while the group benefits behavioral health ratios track very closely to the severity of musculoskeletal claims for claimants in the same age grouping (ratios very close to 1.0), workers’ compensation behavioral health claims are notably more severe than group benefits claims, across all age groups and particularly among the younger cohorts.
Overall, workers’ compensation behavioral health claims are 20% to 25% more “severe” than group benefits behavioral health claims in terms of our relative outcome measures (claim duration and disability days, respectively). This may relate to the differences in diagnosis, or it may be that directly associating the behavioral health condition to the work situation (as with workers’ compensation) makes it less likely that the employee will return to that triggering work situation.
Mental Health Conditions as Comorbidities
The impact of behavioral health extends well beyond primary behavioral health claims themselves to the interactions between behavioral health and other medical conditions. There is much research on the impact of behavioral health comorbidities on medical diagnoses, but there is very little research of an objective nature on the impact of behavioral health comorbidities specifically on group benefits or workers’ compensation claims. Because musculoskeletal claims constitute the largest proportions of both group benefits and workers’ compensation claims, we will focus on the impact of secondary or comorbid behavioral health conditions on musculoskeletal claims.
Disability—To set a baseline, it is useful to look at the impact of a secondary physical diagnosis on a primary physical diagnosis as a point of comparison for the impact of a secondary behavioral diagnosis. According to our research, adding a secondary musculoskeletal diagnosis to the primary musculoskeletal diagnosis increases disability durations across age groupings by about 40% overall.
Having a secondary behavioral health condition also increases claim durations for primary musculoskeletal claims. The increase in durations is about 30% on average, with the impact decreasing slightly as a function of age. While we can speculate that the impact of a secondary physical condition to a primary physical condition would typically involve some mechanical intervening variable (recovering from a knee injury may be expected to take longer if one also has to factor in an exercise-limiting back condition, for example), a mechanism linking behavioral health and physical conditions would normally require different types of explanations (e.g., depression leading to reduced energy and motivation impacting engagement in treatment).
Workers’ Compensation—When it comes to evaluating the impact of a secondary behavioral health condition in workers’ compensation, the analysis becomes more challenging because most states set very high bars for recognizing behavioral health conditions in workers’ compensation, which impacts the reporting of these conditions for workers’ compensation claims when the primary diagnosis is a physical condition.
Consequently, we not only looked at behavioral health in terms of cases with a formal secondary behavioral health diagnosis, but also we analyzed the data using a less stringent definition (labeled “inclusive”) of what constitutes a behavioral health comorbid condition. For the purpose of our analysis, where information in the claim suggested that the client (a) may have had psychological issues, or (b) was prescribed psychoactive medication, or (c) where the claim referenced words related to behavioral health (e.g., “fear,” “stress,” “anxiety,” “depression”), the claim was flagged as having a behavioral health comorbid per this “inclusive” definition. These behavioral health “inclusive” claims constituted 16.2% of the California musculoskeletal claims.
For our analysis, we again level set by comparing the impact of a secondary behavioral health condition to the impact of a secondary musculoskeletal diagnosis on a primary musculoskeletal diagnosis, for the years 2015-2018. (With respect to workers’ compensation durations, we are looking at treatment days; not days on disability.)
As with the group benefits data, adding a secondary or comorbid physical condition to a musculoskeletal primary diagnosis increases treatment durations significantly. As with adding a secondary physical diagnosis, adding secondary behavioral health comorbidities increases treatment durations. Moreover, for workers’ compensation musculoskeletal claims, adding behavioral health comorbidities increases treatment durations considerably more than adding a secondary physical diagnosis. The increases in treatment duration are further exacerbated if the secondary behavioral health condition is officially diagnosed, as opposed to simply being inferred from other information in the file.
Behavioral health as primary diagnoses are disproportionately represented in younger age groups and in women, for both The Hartford’s group benefits short-term disability and workers’ compensation claims. While group benefits behavioral health claims cover a range of diagnoses, the majority relate to depression diagnoses. In contrast, most workers’ compensation behavioral health claims relate to anxiety/stress. Average durations for group benefits behavioral health claims are on par with musculoskeletal claims, which is the biggest driver of claim volume. In contrast, workers’ compensation primary behavioral health claims are associated with treatment periods that last 20% to 25% longer than musculoskeletal claims.
When behavioral health conditions constitute secondary or comorbid conditions to group benefits claims based on primary musculoskeletal diagnoses, claim durations increase by about 30%—roughly the same impact as having a secondary musculoskeletal diagnosis superimposed on a primary musculoskeletal diagnosis. When behavioral health conditions constitute secondary or comorbid conditions to workers’ compensation claims based on primary musculoskeletal diagnoses, their impact is much greater than other comorbidities: about two to three times the impact of a secondary musculoskeletal diagnosis.
This relationship is evident even in the absence of a formal behavioral health diagnosis (when the influence of behavioral health factors is inferred from other information in the file) but is greater still when the secondary behavioral health condition has received a formal diagnosis.