4 Factors Leading to High-Cost Claims Involving Back and Shoulder Injuries

Back and shoulder injuries are not only among the most frequent workplace injuries, but are also some of the most expensive to manage. While many cases resolve with appropriate treatment and rehabilitation, some escalate into high-cost claims that increase expenses for employers, insurance carriers, and the workers’ compensation system overall. These cases often involve delayed recovery, chronic conditions, and extensive medical interventions.

“High-cost claims do not just happen by chance; they develop over time through a combination of factors, like medical complexity and delayed recovery,” said Lisa Haug, Assistant Vice President of Medical Management at Safety National. “The earlier we recognize these patterns, the better positioned we are to control costs and improve injured worker outcomes.”

The Workers Compensation Research Institute (WCRI)’s most recent study, Patterns and Trends of High-Cost Claims Involving Back and Shoulder Injuries, sheds light on this issue.

1. Neurologic Back Pain and Rotator Cuff Disorders

These two categories represented the largest share of claims studied, with 26% involving neurologic back pain and 28% involving rotator cuff disorders. Together they accounted for 19% of the high-cost claims identified. These injuries often require costly procedures such as spinal fusions, disc replacements, shoulder replacements, and injections.

2. Late Resource-Intensive Care

Across all injury categories, late resource-intensive care was the most significant factor contributing to high-cost claims. For example, in neurologic back pain cases, 54% of high-cost claims involved late resource-intensive care, compared to just 5% of non-high-cost claims. This type of care, typically delivered a year or more after the initial injury and treatment, may include extended physical therapy, pain management programs, spinal surgeries or joint replacements, specialty medication use, durable medical equipment (DME), and even home health care or inpatient rehab.

3. Medical Services and Continuation of Care

The involvement of multiple medical providers or healthcare organizations early in treatment can increase the likelihood of a claim becoming high cost. Using unique tax identification numbers (IDs), WCRI found that 65% of high-cost rotator cuff disorder claims involved four or more provider tax IDs within the first three months of care, compared to 53% for non-high-cost claims of the same injury type.

Frequent use of major medical services across multiple providers also proved to predict high-cost claims. Surgical services, in particular, were a strong indicator. Back injury claims involving surgery cost eight to nine times higher than those without surgical intervention.

4. Degenerative Conditions and Comorbidities

Degenerative back conditions were the most costly of all injury types, with an average medical payment of $67,103 and an average total claim cost of $150,455. By comparison, the average total costs for other injury types ranged from $35,847 to $84,830.

Comorbidities such as hypertension, obesity, preexisting pain, mental health conditions, and sleep disorders also played a major role in driving higher claim costs. For instance, 90% of high-cost neurologic back pain claims involved degenerative comorbid conditions like degenerative disc disease or spinal stenosis. While less pronounced in other injury types, comorbidities still had a significant impact, appearing in about 58% of high-cost claims. Osteoarthritis was also commonly cited in shoulder injury claims.