Looking Beyond the Injury: Comorbidities, Causation, and Cost Control

In our final Season 4 episode of MEC Connect Impact Stories, Peggy Ford, Senior National Catastrophic Medical Consultant at MEC, explores how disciplined medical review and a deep understanding of comorbidities can transform claim outcomes. Peggy walks us through two case studies that show how comorbidities and medication can reshape settlement planning, long-term care, and total exposure. 

First, Peggy shares details about a catastrophic electrical injury that led to severe burns, reconstruction, and an above-the-elbow amputation, followed by chronic pain and phantom limb pain managed with ongoing medications and prosthetic support. Then she zooms out to the full health picture: obesity, NASH and cirrhosis, encephalopathy, anxiety and depression, cervical disc disorder, and a prior opioid addiction. 

The second case study highlights a traumatic brain injury where structured routines and innovative care strategies support independence while reducing costs by more than $127,000 annually. This includes using journaling, schedules, mood ratings, and replacement behaviors to build stability.

These Impact Stories offer a clear example of MEC’s commitment to better outcomes—where thoughtful collaboration, clinical expertise, and proactive planning lead to smarter decisions, improved recovery, and measurable cost savings.

Transcript

Season Finale Setup And Focus

SPEAKER_00 0:01

Welcome to the final episode of this season of MEC Connect Impact Stories for Midwest Employers Casualty. I'm Sarah Hans. Throughout the season, our medical management consultants have shared impact stories, real-world cases that demonstrate how strategic decision making, oversight, and collaboration can make a meaningful difference in complex claims. To close out the season, Peggy Ford, Senior National Catastrophic Medical Consultant, joins us to discuss comorbidities, causation, and cost control. Let's dive

Pre Medicare Set Aside Strategy

SPEAKER_00 0:36

in.

SPEAKER_01 0:36

Hello. Thank you for being here today to listen to a few case studies where the factor is a claimant's comorbids and how they can impact. The first one I would like to discuss was referred to me to address what we call a pre-Medicare set-aside to fully resolve or settle this file. One of the amazing services we offer free of charge to our clients is a projection of the lifetime medical costs to determine if it is feasible to settle medically. Sometimes, in looking at the costs overall for the claimant's life expectancy, we can determine it might not be worth it at this time. Otherwise, we look at all that is needed and address any mitigation opportunities that can be completed before paying for the formal Medicare set aside. We want to be prepared and have any roadblocks removed once settlement is imminent.

Electrical Injury And Long Term Care

SPEAKER_01 1:27

Our first claimant involved a 61-year-old traffic maintenance worker who encountered what is called a quote hot ground, end quote, which is a live electrical wire that should not normally be carrying electricity, that is caused by a fault in another line. This caused 13,800 volts to run through his body on May 12, 2003, when he was 39 years old. He experienced third-degree burns on his back and left shoulder and arm. The burns were third degree, quite severe, several thicknesses deep, that did not respond to treatment the way one had hoped. After multiple reconstruction surgeries, it was determined the limb could not be saved, and a left above the elbow amputation was completed. He also lost three fingers on his right hand due to damage, but his thumb was preserved, which was most helpful in his recovery. The claimant also underwent reconstruction surgeries on his back and shoulder region that were successful. He states he continues to experience chronic pain in his neck, upper and lower back, abdomen and legs that are described as sharp and shooting pains. He also reports phantom pain in his missing left arm. This is the feeling that the limb is still there. It can include pain, tingling, prickling, numbness, feelings, or even movement that's caused by the severed nerves. These sensations can last for varying amounts of time, weeks to month to year, depending on the individual. And this claimant he's still experiencing the phantom pains regularly. After recovery, the claimant was fitted for a body-powered prosthetic, which is what it sounds like, utilizing a harness and cables within the prosthetic to operate it, as well as a myoelectric prosthetic, which has a battery assist and skin surface electrodes using the electrical and muscle signals of the arm to operate the device for his left upper extremity.

Comorbidities And Medication Cascade

SPEAKER_01 3:31

As the records were reviewed, it became clear that the claimant has comorbids that are impacting on his overall health. He is overweight. He has NASH, which is non-alcoholic streptohepatitis, which is also sometimes called non-alcoholic fatty liver disease, because causes fatigue, pain in the ripe upper abdomen, and jaundice. Since then, he's also been diagnosed with cirrhosis, which may or may not be related to the Nash, as after time, the scarring or fibrosis on the liver interferes with its functioning. This causes reduced hormone production, creates issues with the liver's ability to break down substances and accrete the byproducts, which is basically its job. So this is now called encephalopathy, which is a medical condition that affects the brain's function. It occurs when the brain does not receive enough oxygen or nutrients, leading to further damage. And he was hospitalized for this condition in early 2024. So these damages can all lead to causing different changes of functioning from mild confusion, loss of memory, drowsiness, default changes in personality, muscle weakness, speech-hearing difficulties, and even hallucinations. The claimant has a prior opioid addiction and was previously taking Suboxone to treat the addiction. He's also a former smoker. And finally, he's been diagnosed with anxiety and depression and cervical disc disorder. Currently, the claimant treats for medications regularly, approximately every three months with his physician. The medications for this injury include progabolin for nerve pain, ropinerol for restless leg syndrome, and this is also utilized for Parkinson disorder, but it's often taken off label for muscle spasms and stiffness, which is probably related to his amputation. Trazodone and venlofaxine are taken for depression, although, again, trazodone is often utilized off label to assist in going to sleep. He also utilizes Voltain gel to put on the stump for nerve pain and lenses for opioid-induced constipation. Physician notes state the claimant asked for opioids for better pain relief on a regular basis. However, both the physician and the psychologist in that clinic have concluded that he is not a candidate for opioid therapy related to his injury. Now there are multiple reasons as to why this could be, including his prior addiction tendencies. However, we do not have the physician's rationale to confirm their decision in the notes provided. So Linz asked what's the question mark in looking at this file. He's not prescribed any opioids from the treating physician. There does not seem to be any issue or what would be causing the opioid-induced constipation. No stomach issues, although he does have liver issues. Opioid-induced constipation is a very serious constipation problem caused by using opioids as the usage reduces the motility in the digestive tract. In other words, opioids slow down the colon's ability to move your digestive food through your system. This leads to very hard stools that are extremely difficult to expel. This in turn causes blockages and other horrible things like a perforated colon. This is not a good thing. And a very good example of the cascade of taking medication that causes side effects that necessitate taking more medication to treat that side effect, that then causes additional medication to be prescribed, and so on and so on. Anyway, back to Linsess. And the issue, it is outrageously expensive, costing about $21 per pill. Yep, that's correct. $21 for each pill taken on a daily basis, sometimes even twice a day, to poop. Over his lifetime, the cost of Lins S would total $125,000. Therefore, paying for this when there are a multitude of other options out there that would be more cost-effective should and can be considered.

Relatedness Review Saves $125,000

SPEAKER_01 7:50

Once the pre-MSA was completed, addressing all of his future care that would be needed, we discussed the lenses usage with the adjuster on the file and recommended she contact the physician to determine its necessity. When this was completed, the physician dated the medication Lins S was not needed for this injury and provided documentation that it was continued. It then came to light that the claimant was receiving opioids from another physician that was not related to our claim. So that one clarification, which is even considered small, saved the file $125,000 over a lifetime. It's always good to question and determine relatedness, and our MEC nurses can help you with this anytime.

Brain Injury Case With Complex Barriers

SPEAKER_01 9:11

He also needed aortic repair, which involves surgically locating the damaged part of his aorta and placing a synthetic graft on the injured part to prevent him from bleeding out. Our claimant is deaf, utilizes American sign language and written communication, which of course hinders the ability to communicate well unless others can sign or write. He's hypothyroid at depression. Schizophrenia, diagnosed in 2004, for which he does not take medication by his choice. Further information determined that when testing prior to injury, he's considered borderline intellectual with an IQ of 75 and functions at a third grade level. However, and this is where you should not judge a person by their testing, it should be noted he had a 24-year history with the employer and was working as one of their general managers. They were short drivers that night and he filled in to deliver a pizza. It was also determined he was working two other part-time jobs and he lived alone with his cat. After recovery in the hospital, he was transferred to the brain injury rehab center. His recovery was hindered by behavioral issues, and it was not clear what was related to his prior mental health issues, his low intellect, or a new head injury. Now his only other issue post-accident is continued double vision. It is not clear if Sergio will be able to correct that issue due to the trauma of his head injury and the surgical plate that is still inside his head protecting his skull. It has been decided to try the surgery, even with the concern it may make the double vision issue worse, but the claimant is sincerely hoping he will have improvement. The current treatment plan is to address medical needs, physical, cognitive, and behavioral deficits, through medication management, and intense multidisciplinary treatment strategies. The claimant is very impulsive. He will not follow rules and acts out. Redirection is extremely difficult. He can even be violent at times, throwing chairs, slamming doors, and pushing people. He will be demeaning and confrontational with staff and other patients. He hides in his room. He won't eat with others during mealtime and refuses medications, which is a hallmark of schizophrenia. He does not complete his chores required on a regular basis and makes exorbitant demands. His access to his personal funds must be limited as he sends money to quote girlfriends, end quote, in Malaysia. It is very difficult to get the claimant on a behavioral plan and get him to stick to it, which is beyond frustrating. It's a claimant wants and deserved to be more independent, but his brain injury, his mental capacity, and his mental illness is interfering. Now it is known that this brain injury center has a more independent living apartments just over the border in another state. This would be an ideal outcome if he can adhere to the behavioral plan, as physicians have determined he may not live alone at this time. He only has a sister and they're estranged, and his friends could be transported to see him occasionally.

Rehab Behavior Plans And Planned Failure

SPEAKER_01 12:21

So some of the items that worked with him include a daily anxiety journal, and the purpose here with to provide opportunities for the claimant to purge negative, ruminating thoughts as a way to reduce his topics of perseveration, which is overly focusing on things over and over and over again. And that interferes with communication on a regular basis. Daily schedule and mood ratings, providing an opportunity to self-direct his day and become accountable for managing scheduling conflicts. The mood ratings will also be filled off by the treatment team and staff each day to gauge his stability and track frequency of maladapted behaviors that can be problematic within a less structured environment. Replacement behaviors continue to be encouraged and explained to the claimant to allow him to take place in the process. And continuing self-awareness and insight into the severity of the brain injury-related deficits and their impact on his daily functioning are reinforced frequently. A fascinating concept is the quote, planned failure, end quote, in the community with multiple errands assessments. And this requires strategic planning, categorization, prioritization, and rule following with a time pressure management component within the community setting that has all the natural distractions to challenge his sustained attention. The idea here is to provide the ability to fail within a supported environment and then engage in meaningful discussions on ways to improve.

Independent Living Placement And Savings

SPEAKER_01 13:56

So, 15 months post-injury, it was determined he was at MMI. And two months later, 17 months post-injury, gradually, through a great deal of trial and error and work on a staff and claimant's part, they were successful. He was progressing on a good program, and it was time to move the claimant to his new, more independent, assisted living facility. After seven months there, there have been a few hiccups, but overall this is a very successful placement. Future goals will be the potential for vocational evaluation to determine if a return to work in any capacity can be addressed. The claimant continues to express he would love to return to work in some capacity. It is anticipated he'll need a more structured and supportive work environment now, however. He is not currently released to drive, but potentially in the future he could undertake a driving evaluation to determine his deficits. This will depend on the outcome of the eye surgery as well. It is really important to address a person's living up to their best ability. But because every dollar counts in the insurance world, we were able to save $127,750 annually on the assisted living option. And currently, Claiman has a 33-year life expectancy. So this is a win-win for all.

Key Takeaways And Season Sign Off

SPEAKER_01 15:23

We very much appreciate your listening to examples of how MEC worked holistically to provide the best possible outcomes. These two cases show very divergent issues, but the results were both positive. Thank you very much, and MEC is available to assist you with your needs.

SPEAKER_00 15:43

Thank you for listening to MEC Connect. We hope today's impact story and the season as a whole has offered valuable insight into how thoughtful medical management can influence recovery, return to function, and long-term outcomes for injured workers. Be sure to follow MEC Connect so you don't miss what's next. And stay tuned for our next season, where we'll continue sharing how MEC's skilled people, proven processes, and innovative technology are achieving measurable results and creating lasting value. Thanks for listening.