The Impact of Degenerative and Comorbid Conditions in Workers’ Compensation Claims

Comorbid and degenerative health conditions play a significant and often underrecognized role in the complexity and cost of workers’ compensation claims. These conditions not only influence the course of medical treatment and recovery but also contribute to prolonged disability durations and increased financial burdens on the system.

“These conditions are vastly underrepresented in workers’ compensation claims data, which is particularly problematic due to the true scope of their influence,” said Carol Franklin, Senior Medical Manager at Safety National. “Underestimating their impact could lead to inaccurate risk assessments, delays in treatment and recovery, unexpected costs, and challenges in return-to-work planning.”

Here are five key findings from WCRI’s report.

1. Degenerative conditions were identified in 18.7% of the claims.

Comorbidities such as hypertension, substance use, chronic pain, mental health issues, diabetes, chronic lung diseases, and cardiovascular conditions were all present. However, hypertension was the most frequently reported condition, accounting for 10.6% of claims. This was followed closely by substance use at 8.5% of claims and chronic pain at 5.7% of claims.

2. Among claims with injured workers that are age 65 or older, 25% reported degenerative conditions.

Across different age groups, older age correlated with a higher percentage of claims, especially when considering hypertension, diabetes, and cardiovascular conditions. For example, 23.2% of workers 65 or older had hypertension as a comorbidity, compared to 15.2% for ages 45-64, 5.3% for ages 25-44, and 1.5% for ages 24 or younger. While the risk for these conditions increases with age, degenerative issues like substance use, chronic pain, and obesity varied across age groups and did not show the same trend.

3. Spinal injury claims have the highest occurrence of degenerative conditions.

Spinal injuries, such as neurologic neck and back, and disc disorders, often carry increased risks. Of the claims studied, nearly 60% had one or more degenerative conditions identified, with degenerative disc disease being the most common. Chronic pain was frequently linked to these claims, with over 15% of claims reporting this condition. In contrast, only 5-7% of rotator cuff, shoulder impingement, meniscus tear, and non-specific back pain noted chronic pain. Osteoarthritis was also a prevalent degenerative condition, found in 36% of rotator cuff or shoulder impingement claims.

4. Underreporting in medical coding related to workers’ compensation reimbursement guidelines, injury complexity, and provider practices may lead to the under-identification of these conditions.

Many comorbid conditions can drastically affect the treatment and recovery of an injured worker, but since they are often not reimbursable, they are not directly addressed within workers’ compensation. Medical providers may document these conditions while providing care to an injured worker, in addition to the primary conditions of a work injury, but the information may not be submitted in medical bills for reimbursement. Additionally, providers may only record conditions relevant to their treatment practices. As work injuries can become more complex over time, the need for additional tests to identify these conditions increases the likelihood that they will be reported.

5. Claims with comorbidities have considerably higher medical payments and indemnity benefits, and longer durations of temporary disability.

Comparing claims with comorbidities to those without, the cost discrepancies are substantial. For claims without comorbid conditions, the average medical payment was $9,434, indemnity benefits were $10,967, and the duration of temporary disability was 10.5 weeks. In claims with one comorbid condition, those values more than doubled, and values increased substantially in those with multiple conditions identified.