Workplace and Joint Replacement: What’s On-The-Job and What’s Just Aging?

Episode Notes

Transcript

Announcer:

Workers’ Comp Matters, the podcast dedicated to the laws, the landmark cases, and the people that make up the diverse world of workers’ compensation. Here are your hosts, Jud and Alan Pierce.

Alan Pierce:

Hello, everybody. It’s attorney Alan Pierce along with my co-host, Judson Pierce from the firm of Pierce Pierce and Napolitano in Salem, Massachusetts, bringing you another podcast on workers’ comp matters. And today we are going to be talking about an interesting study that came across our desk from the Workers’ Compensation Research Institute, WCRI. We’ve had other researchers from WCRI on in the past, and we always value and welcome the studies they provide the workers’ compensation industry on various matters involving workers’ comp, especially trends in claims, cost analysis and other such things. And today we are delighted to introduce a guest we’ve had on before is Dr. Sebastian Negrusa. Sebastian is a vice president of research for WCRI. He has a PhD in economics from Clemson University and he is the supervising researcher and is here to talk about a paper that was published by WCRI earlier this year in January of 2026, authored by Dong Chun Wang Venela Thumala and Randall Lia O from WCRI.

And the title of the paper or the study is Recent Trends in Joint Replacement Among Workers’ Compensation Claims. Both Jud and I could tell you that in our daily practice over the years, not only have we seen an increasing amount of joint replacements being recommended or performed, but we have seen a change in the frequency and the duration of post-surgical treatment and also the body parts that have been affected in our practice when I first started. I would say most of my injuries were to the back and primarily the low back followed, I suppose, by the knee and the cervical spine or neck. But over the last couple of decades at least, we’ve seen an increased amount of claims involving less so the low back and that may have to do with changes in the way people work and the preventative measures they take at work in terms of lifting as well as aids to lifting.

But we’ve seen a lot of other problems both in the knees and primarily in the shoulders or upper extremities from rotator cuff to labrum to bicep tendons, et cetera. So having said all that, we want to talk about what WCRI has been able to look at in terms of these trends in joint replacement in workers’ comp claims. So Jud, having introduced Sebastian, welcome Sebastian. And Jud, perhaps you might want to kick things off for us.

Judson Pierce:

Thank you, Alan. And hello, Sebastian. My first question for you is what prompted WCRI to undertake the study on joint replacement and workers’ compensation now?

Sebastian Negrusa:

WCRI is a public policy research institute. We have a membership structure. We provide independent research for stakeholders in the workers’ compensation space. We come up with studies on topics of interest for stakeholders in the industry. And this was a topic that always, or in the last few years, rose to the top as being one of the more interesting topics or one of the topics of higher interest.

Alan Pierce:

One of the items that, and I talked about it briefly in my introduction, is that joint replacements, first of all, are becoming more common in workers’ compensation. Is that something that you… How have you found that out? What is the data that underlies that broad statement?

Sebastian Negrusa:

That’s exactly what we found in this study. And by the way, I also want to give out a shout out to the authors of the study, Dong Chun Wang, Venelatumula and Randy Lee. They have done an incredible amount of work to come up with these trends. And what they found using claims data from workers’ compensation was that there is a clear increase in the frequency of joint replacement surgeries in workers’ compensation.

Alan Pierce:

And in terms of the body parts, have you also seen a shift in emphasis as to which areas of the workers’ bodies are being impacted most by work and how that may have changed from past years or past studies?

Sebastian Negrusa:

Yes, absolutely. We do see an increase in the frequency of shoulder joint replacement surgeries and a small decline among knee injuries and kind of a constant unchanged trend in hip surgeries as well. So definitely the increase in the frequency of joint replacement surgeries is driven by the increase in shoulder injuries.

Judson Pierce:

One of the biggest findings is the migration from inpatient hospitals to outpatient surgery centers. Is this primarily about technology or cost savings or better patient outcomes?

Sebastian Negrusa:

That’s a great question, Jud. Our study does not provide an in – depth analysis of the reasons behind this rapid shift. It’s ultimately a study providing a first look at the trends in joint replacement surgery in workers’ compensation. But some of the drivers you already mentioned in your question could be at play. We could not measure the impact of these factors in this study. Technology, this is something that everybody is in agreement, allowed for the delivery of these surgeries in a safe way to patients and all the care protocols that have been adopted as a result of technology changes allow for a faster, safer delivery of these surgeries. Cost savings, it’s another interesting potential driver. Cost savings are to a large extent achievable as a result of the new medical technologies and the care pathways that have been adopted and used already in outpatient settings. So cost savings do provide incentives for payers as well as providers to adopt the shift of having outpatient surgeries more so than in the past.

And one other factor that may be of importance here is that the Center for Medicaid and Medicare and Medicaid services also had a program in the aftermath of the ACA adoption, the Affordable Care Act called CJR, Comprehensive Joint Replacement, that created incentives for a reduction in the length of stay to avoid unnecessary inpatient hospitalizations, to improve discharge planning, to reduce complications, to reduce readmissions. And that also might have played a role in the adoption of joint replacement surgeries being performed in outpatient settings more so than in the past.

Alan Pierce:

Yeah. And an observation that I’ve made both in terms of our practice as well as my personal life, I’m at that age where I’ve been lucky enough to avoid any joint replacement surgeries myself, fortunately. But it’s been around me, friends, family members, et cetera. And I’m amazed when somebody I’m close to says, “Well, I’m going in and having my knee done. And how long are you going to be in the hospital? Are you going to go to rehab?” No, I’m coming home the same day. And the same thing with the shoulder or hip. And you’re right. I think they have found that by bringing in some early at home visits, it’s much less costly and you’re not really giving up much in terms of medical care. The other point, Sebastian, that I wanted to bring up was the experience of the early or maybe not even so early days of COVID where the goal was that people that had to be hospitalized or have surgery needed to be discharged from the hospital sooner than normal because of the risk of COVID, the risk of other types of infections, the staffing issues, et cetera.

What if any role were there lessons learned, let’s put it this way, from the COVID experience of discharging folks sooner during the pandemic that may have led to a more universal acceptance of outpatient or very limited inpatient stays following joint replacement surgery?

Sebastian Negrusa:

That’s a great point, Alan. Actually, we do review literature pointing to this shift and the way this shift was accelerated by the pandemic and the need of patients to be sent home or sent to outpatient facilities in those days of early COVID. That definitely another factor that was likely at play contributing to this very rapid shift away from inpatient settings to outpatient settings for these kind of surgeries.

Alan Pierce:

And in fact, I noticed that your statistics of the types of bodies parts that are being replaced, you were using the injury year of around 2021 or so, which is kind of a year after COVID. So the joint replacements probably were a year or more after that. So we really are talking about a change that we could see right in real time.That’s a great point.

Sebastian Negrusa:

With what we’re

Alan Pierce:

Discussing. Yeah. So we’re going to take a quick break. When we come back, we’re going to talk about some of the other issues that we as attorneys are seeing in joint replacement issues and that is causation, medical and more importantly, legal causation. So we’ll be right back with Dr. Sebastian Nagrusa from WCRI.

Judson Pierce:

And we’re back. Sebastian, I know that insurers often argue that surgery is occurring too late after an injury. Part of this study actually addressed that as a player or role player in this. What did the study talk about in terms of surgery delay or how long after an injury a surgery is occurring?

Sebastian Negrusa:

So we do have statistics at a more descriptive level on the timing when joint replacement surgeries are performed. And for instance, in the case of knee surgeries, we do see that the timing is longer in the case of knee surgeries than it is for other body parts like hip and shoulder. It was outside the scope of this study to analyze whether this was optimal or not, or whether this was done at the right time or not. And we do find evidence coming from other studies that we cite in the report according to which there is a higher probability of having knee surgeries later in the worker’s recovery if there are meniscus tear surgeries or surgeries trying to address meniscus tears earlier on. But this is an important venue for future research. Absolutely.

Judson Pierce:

Oftentimes we as plaintiff’s attorneys representing injured workers who have suffered some traumatic event at the workplace, we find it a little bit easier to prove a causation, the causation element. But when someone has worked at a job for decades and has done perhaps some damage to their joint, we also see the argument from the other side that, well, it’s the person’s age or the person would’ve come up with this need for a surgery anyway because he or she has osteoarthritis. That diagnosis, Sebastian, plays a major role in a lot of these cases. How does this study separate or does it the normal aging process from work-related aggravation in workers’ compensation systems?

Sebastian Negrusa:

The study with its descriptive goals does not get much into this discussion. We do point out that joint replacement surgeries are surgeries that are intended to restore function and relieve pain by removing the damaged or diseased part of the joint and replacing it with an artificial implant. And this happens in a lot of instances when the worker has post-traumatic arthritis, which is a degenerative condition after fractures or major joint injuries or post-traumatic or degenerative osteoarthritis as you’re pointing out, Jud, due to cartilage loss causing pain and disability. We do have some statistics provided in the report by whether the workers had these conditions and whether they were old versus young, whether they were prime aged workers or not. But we cannot provide as part of this study a definitive answer to this highly important question.

Alan Pierce:

And to further expand on that, I am assuming, and correct me if I’m wrong, the data that you’re getting from the insurance companies are data on claims that they have accepted and have agreed to that the joint replacement surgeries were compensable under their particular workers’ compensation statute.

Sebastian Negrusa:

Correct.

Alan Pierce:

From our standpoint, I’m sure you can recognize that we deal with a lot of claims where it isn’t quite so clear. We have an older worker, let’s say somebody over 55 who has a meniscus tear. And when the doctor does the MRI or even with other types of diagnostic tools, sees that not only does there a meniscus tear, but because of that person’s age, she or he has degenerative arthritis and a meniscal repair really wouldn’t be the appropriate medical treatment, you really need a knee replacement. That is where we have our issues drawn as to where is workers’ comp here? Are they responsible for the damage that had preexisted the traumatic injury or not? Probably a great many cases where knee replacements or joint replacements did take place following an industrial injury probably went through an alternative payer simply because the joint replacement was the knee is bone on bone.

That didn’t happen by tripping. So you’re looking at data of cases that were already accepted as work related. There’s a whole universe of cases that weren’t or were settled in a compromised fashion. So I think for our audience point, we need to draw that distinction. And I know it wouldn’t be the purpose of a study to sort of get into the legal causations, but for our listeners out there, it would be essential to see in your jurisdiction whether your workers’ compensation system allows for recovery for either medical payments or disability or both if an injury merely aggravates an underlying condition like degenerative osteoarthritis. Or if you are in a jurisdiction such as Massachusetts and many others where there is an enhanced burden of proof that not only do you have to show there’s a connection between the injury at work and the medical condition, but the injury has to be a major or the major cause as opposed to the underlying condition.

So to our listeners, a jurisdiction that allows a simple aggravation, it could be easier to get the joint replacement covered than a jurisdiction that requires that you prove that the injury is more important than the underlying osteoarthritis.

Judson Pierce:

Yeah. While we’re on that topic, Alan, I thought it interesting that the report looked at a lot of different states and there were a lot of different applications to the laws there and the utilization review and medical practices. Your study, it reviewed 32 states, correct?

Sebastian Negrusa:

Correct.

Judson Pierce:

And what, if anything, did those differences say to you or give us a little bit of a background on how those were looked at.

Sebastian Negrusa:

We actually ended up the study on a note of, well, there’s a lot of more work that needs to be done. There is a bit of a puzzle here when we look at a map, a heat map with the frequency of joint replacement surgeries in the claims data that we had access to for this study. And then we say there’s quite a bit of variation. And we started hypothesizing what might be driving these differences. It could be underlying health of the workforce across states. It could be utilization review regulation. It could be state system features. It could be a lot of things that shape the delivery of these medical procedures to injured workers. So this is definitely one of the topics we would like to return to in the future.

Alan Pierce:

We’re going to take another break when we come back and conclude our discussion with Dr. Sebastian Nagruso. And we’re going to talk a little bit about the costs and some of the statistics that emphasize the points that we’ve been making thus far. So stay with us. We’ll be back in just a moment. Let’s kind of wrap up our conversation by talking about some of the data that you’ve actually reported. First of all, when you talked about the tremendous amount of research that your three colleagues have done, I’m looking at the references and I’m looking at one, two, three, almost four pages of single space references. There’s not a number here. There’s got to be probably two or three dozen of other studies that have been referenced. So this is a quite broad researched topic. One of the things that stuck out at me is that the number of claims with joint replacement surgeries over the period between, I think you’re looking at between 2015 and 2022 for dates of injury.

Joint replacement surgeries doesn’t seem like a great increase went from 7.0 to 8.3 per those claims. So it’s a relatively small percentage, but I suppose a jump of 1.3 percentage points starting with seven is not insignificant. But what I found was the number of inpatient procedures during the same time dropped from 5.3 claims with inpatient following the surgery to 1.9. So that was a very substantial drop. That was about a 60% or more drop, if I can do some quick math in my head. And outpatient procedures where you’re in and out the same day went from 1.6 per thousand to 6.4 per thousand. I mean, that’s a 600% increase as I look at it. So I think that alone speaks volumes.

Judson Pierce:

One of the things that jumped out at me was the average loss time claim was $35,669. When you bring about a joint replacement claim, that jumps almost $100,000. Is there any further information that you could provide our listeners on the reasoning behind? Is it just the surgery itself or I mean, shoulder replacement goes up to 129, hip replacement’s 122, knee replacement’s 116 over the average life of the claim and the duration of disability jumps too.

Sebastian Negrusa:

What we found in this study as well as in previous studies was that… So these are total medical costs per claim at a certain time since the injury. In this case, exactly 36 months since the time of injury. The comparison between claims with and without joint replacement surgeries is a start in the direction of assessing the actual cost of these joint replacement surgeries. It’s not necessarily the definitive answer, but it does point to on one hand the higher cost of these procedures, but also based on previous study conducted by WCRI by it so happens some of these co-authors as well, comorbidities play an important role in driving medical costs. And there is an exponential increase in medical costs if one other comorbidity than the source of injury that is treated in workers’ compensation is present. The medical costs go up much more when two comorbidities are present and so goes for three, four comorbidities.

So it’s very likely that the presence of comorbidities in addition to a relatively high cost for these procedures are driving these much higher costs per claim.

Alan Pierce:

And as we conclude to our listeners, we’re discussing a rather detailed, very detailed, thoroughly detailed report of about 40 pages. And the limitations of a podcast such as this are such that we really cannot do justice to all of the facts and figures and findings. And I’m going to ask for information on how any of you out there might want to get a copy of this report. But if you do, I think what we’re just focusing on appears in chapter four, which is entitled Characteristics of Claims with Joint Replacement Surgeries. And the very first table talks about the average cost and temporary disability duration for joint replacement claims, medical payments per claim, indemnity payments per claim, other costs per claim, and the duration of disability. And those are all really telling figures that we really can’t do justice to in a discussion such as this.

So Sebastian, if somebody wanted to actually take a deeper dive into your research and your study, how could they obtain a copy?

Sebastian Negrusa:

Our study is available on our website. It’s available for free to our members and it’s available for a fee for non-members as well.

Judson Pierce:

Jumping on what Alan said, I just wanted to acknowledge the amount of research that went into it. The study examined more than two million lost time workers’ compensation claims from 32 states involving injuries from 2015 through 2022 and arguably identifying trends in hip, knee, and shoulder joint replacement surgeries mostly. So it was a very extensive study.

Alan Pierce:

All right. Well, Dr. Nagrusa, again, it’s been a joy to have you here every time we talk with you or anybody from WCRI or read the reports that you write if we can get through the data because my brain doesn’t work that way as much as others. I always learn something of value to me and hopefully we can pass that on to our listeners. Anything you’d like to conclude with as a major takeaway or something you’d like to leave our audience with in terms of either this study or the value of an organization like WCRI undertaking studies such as this?

Sebastian Negrusa:

Alan, the pleasure is all mine and I always enjoy having these conversations. One point that I would like to make is that this study is providing a first look at these trends and ultimately it does highlight the importance of health promotion as well as musculoskeletal wellness programs since workers age and there will likely be a higher prevalence of workers with preexisting osteoarthritis. We also draw the attention to the importance of state policies as well as care settings in patient versus outpatient that do play a role, an important role in shaping these trends. Medical technology will likely continue to advance and it will continue to inform and direct surgical approaches and ultimately the costs associated with these procedures. So this is definitely a topic. In addition to all the discussion points we had and that offered platforms for future research, this is definitely a topic that will likely remain relevant in the future.

Alan Pierce:

Well, I’m sure once you publish the next study, we will be right with you and look forward to any others that obviously WCRI or other organizations tend to present for us. So thank you, Jud. Any concluding remarks before we sign off?

Judson Pierce:

No, just very, very apreciative of your time today and I hope all our listeners do check out the website WCRI. Looking forward to our next discussion.

Alan Pierce:

All right everybody, thanks for listening and go out and have a day that matters. Bye-bye.

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