Adverse Childhood Experiences and the Sisterhood of Traveling Body Part Claims

Introduction

Throughout my career in risk management and workers’ compensation, I witnessed a puzzling phenomenon: some workers with seemingly “minor” injuries never returned to work. In contrast, others with severe injuries returned remarkably quickly. My medical team and our medical director explained that a significant factor behind many of the high-cost cases was Adverse Childhood Experiences (ACEs). These early traumas contributed to disproportionate claim costs because the affected workers often lacked the coping skills needed to manage both the physical and emotional trauma caused by the work-related injury, as well as the stress of the claims adjudication process.

Discovery of a Deeper Cause: The “Sisterhood of the Traveling Body Part Claims”

The term “Sisterhood of the Traveling Body Parts” encapsulates a specific type of claim in which a worker’s injury seems to migrate from one part of the body to another, becoming more complex and costly over time. Milliaman calls these “Jumper Claims.”

While serving as Group Vice President of Risk at Safeway, my medical team revealed that nearly all our high-cost claims involved workers with a history of ACEs. These claims weren’t driven solely by severe physical injuries or by body parts but were often exacerbated by underlying psychological trauma. Dr. Belsky, Safeway’s medical director, helped me understand that those who had experienced ACEs were much more likely to have their claims escalate if they ended up with certain doctors or attorneys. In response, Safeway launched an early intervention program to identify and support at-risk employees—those with a history of ACEs—within two weeks of their injury.

Our pilot program focused on severe back strain claims, screening patients for their “risk of delayed recovery” using the Orebro questionnaire. 82 injured workers were identified as “at-risk”. The 82 were about 30% of all the back injuries treated in the clinic during the year.  For those identified as “at-risk for delayed recovery,” we provided counseling and targeted support. The results were remarkable: only two workers required surgery, all 82 returned to work, and none of these claims were litigated. This outcome contrasted sharply with typical claims results in California. These results demonstrated the importance of early identification and intervention with psychological support to those who were in need of such support. When the program was expanded company-wide, we experienced a 40% reduction in costs associated with our complex cases. However, the success of the program hinged on early intervention—once a worker retained an attorney, the chances of preventing a claim from spiraling diminished significantly.

Understanding Adverse Childhood Experiences (ACEs)

The Centers for Disease Control and Prevention (CDC) has conducted extensive research on Adverse Childhood Experiences (ACEs), which are defined as traumatic events occurring in childhood (ages 0-17). These experiences include witnessing violence, enduring abuse or neglect, having a family member attempt suicide, or growing up in a household with substance abuse or mental health issues. ACEs are more common than many realize, with 64% of adults in the United States reporting at least one type of ACE, and 17.3% having experienced four or more.

ACEs can have profound, long-term impacts on health, behavior, and socioeconomic outcomes in adulthood. Adults with a history of ACEs are more likely to suffer from chronic diseases, mental health issues, and substance abuse, and are more likely to experience instability in both their personal and professional lives. Many of these problems are considered “co-morbidities,” which drive up claims costs.  These challenges often extend into the workplace, increasing the likelihood of involvement in the workers’ compensation system.

The Impact of ACEs on Workers’ Compensation

The link between ACEs and workers’ compensation outcomes is both significant and under-recognized. Workers with a history of ACEs are more likely to experience chronic pain, mental health disorders, and delayed recovery, which can transform a relatively minor injury into a high-cost, complex claim. This issue is compounded when these workers encounter doctors or attorneys who attempt to drive up disability in an effort to increase their revenue and fees.

Understanding this connection is crucial for companies looking to reduce workers’ compensation costs. By identifying at-risk workers early in the claim process and providing psychological support, employers can help prevent minor injuries from escalating into costly, prolonged claims. Early intervention, as demonstrated in Safeway’s pilot program, can lead to significantly better outcomes for both the injured workers and the organization.

Top Workers’ Compensation Cost Drivers Compared With Top Reasons Injured Workers Litigate

To further contextualize the role of the at-risk employee in workers’ compensation, it is helpful to examine the broader cost drivers in the system. Among the cost drivers in workers’ compensation are litigation, injuries to multiple body parts, a delay in reporting the claim, a lack of management engagement in creating and driving a safety culture, misplaced financial incentives, and hospitalizations. The “at-risk” employee stands out as one of the top two biggest cost drivers.

Moreover, when comparing these cost drivers with the top reasons injured workers litigate their claims, there is substantial overlap. Many reasons for litigation—such as poor employer-employee relationships, inadequate safety measures, and lack of modified duties—are preventable through better engagement and support for at-risk employees.

Conclusion

The “Sisterhood of the Traveling Body Parts” phenomenon underscores the importance of recognizing Adverse Childhood Experiences as a critical factor in workers’ compensation outcomes. Employers and workers’ compensation professionals must take proactive steps to identify and support at-risk employees early in the process. By providing psychological support and tailored care, we can not only reduce litigation and costs but also foster better outcomes for injured workers. Adopting early intervention programs will create a more equitable, efficient system that benefits workers and employers alike.