Waltham, MA, Aug. 8, 2024―Many studies have shown that health care costs are concentrated among a small percentage of individuals with diverse needs. A new study from the Workers Compensation Research Institute (WCRI) identifies the factors linked to high-cost claims in workers’ compensation.

“Our findings highlight the importance of monitoring claims with late occurring resource-intensive care to keep treatment on track as planned and prevent unnecessary delays in recovery,” said Ramona Tanabe, WCRI president and CEO. “Early identification of complex claims with comorbidities and degenerative conditions can also help better address workers’ needs; and a higher level of care coordination likely helps to reduce the probability of a claim becoming a high-cost claim.”

The study, Factors Associated with High-Cost Claims, defines high-cost claims as claims in the top 5 percent of medical payments at 36 months of injury, and identifies key factors that likely contribute to a higher or lower probability of claims becoming high-cost claims. The study explores the following questions:

• What is the impact of high-cost claims on costs and disability duration?
• What are the characteristics of high-cost claims?
• What are the key factors associated with an increased or decreased likelihood of high costs?
• What modifiable factors can improve care management and reduce costs?

The data for this study come from the WCRI Detailed Benchmark/Evaluation (DBE) database. The study analyzed more than 720,000 open and closed claims with more than seven days of lost time from 32 states. These claims had injuries from October 1, 2015, to March 31, 2019, with 36 months of experience observed from the date of injury, up to March 31, 2022. The DBE database covers approximately 38–77 percent of all workers' compensation claims, varying by state, and the 32 states represent over 80 percent of the workers' compensation benefits in the United States during the study period.

To learn more about this study or to purchase a copy, visit https://www.wcrinet.org/reports/factors-associated-with-high-cost-claims. The authors of this study are Dongchun Wang, Kathryn L. Mueller, and Randall D. Lea.

About WCRI

The Workers Compensation Research Institute (WCRI) is an independent, not-for-profit research organization based in Waltham, MA. Organized in late 1983, the Institute does not take positions on the issues it researches; rather, it provides information obtained through studies and data collection efforts, which conform to recognized scientific methods. Objectivity is further ensured through rigorous, unbiased peer review procedures. WCRI's diverse membership includes employers; insurers; governmental entities; managed care companies; health care providers; insurance regulators; state labor organizations; and state administrative agencies in the U.S., Canada, Australia, and New Zealand.

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