interesting experience for me. So we've talked about that quite a bit. So my disclosures are as follows. I'm employed by the Barnabas Health Medical Group. My hospital system is 13 hospitals strong. Uh, so you know, lots of, um, challenges there, as you can imagine, from the workers compensation standpoint, we are self insured. We do have a T. P. A. That helps us with managing our claims, but a lot of it is internally managed. I did all the causation assessments for the long Kobe cases in particular, being the, uh, trained OEM physician. A couple of the things I'm officer of a calm, as you know, uh, and as I mentioned among the W. C. R. I. Committee for New Jersey, I will not be discussing any off label drug use. I do talk about the P word, which I'm not supposed to say. Uh, I'm sure you can guess what that is. The, uh, Norma, Norma, Trellville, return of air. Try to say that three times fast. That's our party is inhibitor, which we'll talk a little bit about. Uh, so in terms of learning objectives, so we'll look at the process for defining long Kobe it and how that final definition affected our usability in diagnostics, return to work benefits and disability decisions. So this was not the big return to work talk, right? I know yesterday my colleagues, Dr Garvey and Dr Middleman from Prudential did talk a bit about, uh, some of the return to work challenges and workability. But of course, I talked to me a little bit in this. Secondly, we'll explore a little bit about the effects of the various covid strains and revolved a bit from the wild type, the original virus type, right? Then the alpha strain and the delta strain. And I have to be honest, the workers calm data did stop at the delta strain, and we may have subsequent on the crown data. Uh, but of course, the vaccine data did touch on as far as the Omnicron. Uh, so we do have a little bit variation there. We look at prevalence of long Kobe. That's a big part of what we're going to talk about in some of the factors that are influencing the prevalence and impact on claims. So you'll see a bit of that. So we'll talk about the effects of working industry characteristics, how the state variations. I'm sure you recall some of the presumption laws that were quite variable across the states. We didn't delve into that too much because I think a lot of us know what those were. And certain states had various policy approach to Kobe. It is. I'm sure you know, we'll look at some of the symptoms, severity and hospitalizations, whether it's I see you care versus non I see you care and how that affected our claims outcomes. So, you know, why are we still talking about Kobe? Isn't Kobe over? Uh, so, you know, we definitely saw some labor market challenges as high as 18% of people with long Kobe did not return to work for more than a year. Uh, so there the percentages in the incidents and prevalence data. There were a lot of variations, as you can imagine, from study to study. But, you know, we saw that the long Kobe definitely affected our labor workforce. It affected our U. S. Economy. In the employment settings, we were still battling with return to work issues, reasonable accommodation, disability and in all honesty. So when we first the first wave, you know, we had about 90 something long Kobe claims that we were managing. And in this year, we went down to definitely single digits and managing single digits at this point. So we've definitely made some progress, but, you know, we certainly haven't resolved all of it in terms of even the Kobe claims themselves. Those have come down. And, of course, the hospitals, we definitely smartened up, right? Because now we have PPE. Now we can enforce the compliance challenges. At the beginning, a lot of us had supply chain issues with the PPE. I'm sure you all recall this s O. We've certainly gotten much better with that. And some of the data that I presented last year could literally see the peaks in our data where those specific sites, particularly the newer hospital sites that we were acquiring that wasn't on board with all our policy and our compliance mechanisms where they were definitely challenges. And those were the areas we had the most deaths associated with Kobe. And so is in on some of those OSHA discussions and so forth. So we'll do some case based discussion, which I think is perhaps helpful for folks. Eso only two cases. Eso. Our first case, we have a 47 year old ICU nurse. Eso she contracted Kobe in April 20 April 2020. The height of everything, right? So symptoms were, you know, the classic in osmia agnosia that you might think about. And she had GI distress. Her oxygen saturation was 86%. Sorry, the presbyter setting in here 84% on room air. So she had what we would consider a significant exposure, and I'm not going to review what those are. So definitely over 15 minutes. Close contact. You know, the PPE was plus or minus. Some of the discussions you were having at that point was kind of, you know, nebulous and evolving, but definitely short of breath. We're talking about a 47 year old, so 47 is young, right? Eso that's still quite young. And so she was unique. She was a single mother. She was caring for aging parents and her teenager, you know, the sandwich generation. I'm sure many of us can relate. Eso short of breath. We got the usual, you know, testing, chest X ray, cardiac echoes, stress testing. You were a little slow on the uptick, right? So it took us till January of 2021 to get her that right heart catheterization. And through all this, you know, as the we're now the case managers, you know, we're communicating with the specialists, and obviously people are getting into the specialist to get the care that they need. Otherwise, it was a lot of symptom management at the onset, right? Eso she finally got a right heart cath. She was diagnosed with pulmonary hypertension, and I'm sure most of you can relate. You know, our workers compensation case managers, they're only used to musculoskeletal claims, right? So now they get pulmonary hypertension. Everybody panics. Eso, you know, hopeless internist here. So, um, so, you know, the consultants, you know, what's the causation? Is this related to Kobe? And, you know, the proximity was a little suspicious, you have to admit, you know, but our pulmonologist, you know, they were thorough. They did the work up that we're looking for, you know, other potential, you know, on the differential, you know, chronic from from embolism and the like, you know, BQ scans were okay. You know, so here we have a very young person who was functional, working, taking care of her family. And now we're, you know, we're symptomatic with pulmonary hypertension on DSO. She's on light duty. Actually, she's still on light duty. The last time I saw her was January of this year. She's definitely due back in because we have to start making, you know, permanency decisions about this case, right? Eso she's very optimistic. She somehow thinks she's gonna get back to full duty. I'm not as optimistic. But, you know, in our system and the state laws are certainly on on the employee side. You know, if you're injured on the job, you get first priority in terms of, you know, job placement. If alternative duties and alternative jobs become available. So quite a cocktail. We're on a dempest, tripostanil. And of course, you know, our case managers are panicking a little bit. We're gonna be responsible for pretty much the medications for the rest of her life. However long that would be. Eso she had some hypothyroidism. Hypertension. Hypertension was pre existing. So that was not attributable to the covid at this time. Eso, you know, hopeless internist here. So she had two right heart catheterizations. The second one. And we're trying to condense your four years of data because I'm still, you know, seeing her. But there we had elevated mean P. A. Pressure at rest of normal. A wave elevated right ventricular diastolic pressure at baseline and exercise pulmonary testing that's performed. Eso, you know, they asked us about a causation. So proximity was way too suspicious, you know, and the next question was, you know, curative or palliative. And I think many of us in the room, it's kind of obvious to us, but we wanted they wanted that to be clarified. Eso that involved our engagement with our specialists and then, of course, the work status. So the second case we'll talk about is our 55 year old nurse, also very young. Eso she presented with fatigue, distant irregular heart rate. I think you kind of know where this is going. Also exposure, close contact with COVID patients, new onset atrial fibrillation. And, you know, this somebody who goes off to the cardiologist right to get cardioverted. And she did cardiovert and stable on fleconide and metoprolol. Of course, we get the same question. What's the causes causation? So we were able to get her old records. And it turns out in 2018, interestingly enough, she had some non specific cardiac complaints. And an EKG at that time was normal sinus rhythm. Eso we do it. We had a baseline for her, which helped a lot for her particular case. And at that point at the workup, she had T. T. E. She had normal exercise, stress testing, and she had known hyperthyroidism. But that was, you know, stable. She was medicated. Not that that entirely, you know, precluded that it's a potential ideology. But we didn't think it was related to the hyperthyroidism necessarily because of the proximity with the COVID infection. Eso fast forward a little bit. You were getting your follow up studies. Her T. T. E. Did show an EF of 60 to 65%, which in and of itself, you know, is very functional. But, you know, we're talking about a 55 year old here. So definitely less than what we would have anticipated, right? But no diastolic dysfunction, none of the other stuff that would get us suspicious for pulmonary hypertension. And she had a six minute walk test. At that time, I was had the capacity to do that in my clinic as well. She had cardiopulmonary exercise, stress testing through the cardiologist and pulmonologist and what have you. And for her, her function was tremendously affected and she couldn't do Zumba anymore. And I can certainly relate. That was important to her life. So this case sort of took an interesting turn. Eso fast forward a little bit 2023. And yes, I said that right in 2023 in January, H. R. Center into me for fitness for duty. There were performance issues. She was forgetting to administer medications, I. V. Fluids on patients. And so, you know, when you have these types of cognitive referrals, we have to take them very seriously. So, you know, I'm having a conversation with her. And by this point, we developed a quite a rapport because, you know, she's seeing me for a few years. And you know, we're the occ health docs. Sometimes it's the only doctor that they see for quite some time, right? So she starts telling me, Oh, yeah, by the way, in January of the prior year, I had COVID. But, you know, really, she had COVID, did her isolation period, went back to work. Really no complaints of brain fog. But now she's saying, Oh, by the way, I think I have brain fog. So this was interesting. You know, was it related to the COVID from the private COVID infection from the prior year? I was pretty suspicious because, you know, it would be unlikely that she had COVID resolved and then, uh, didn't have any brain fog symptoms. And suddenly, a year later, she had brain fog. So, uh, but because of the nature of the referral, as we said, their, uh, safety issues with patient care. So we had to move forward with the evaluation. She was actually removed from work at this time. Uh, so in a couple things, she clearly needed to have, you know, care from her personal doctor. So we're trying to juggle the two, as we do often in occupational medicine rights. And, you know, they, you know, they trust us, or in this case, this particular patient, you know, is very trusting. Uh, so we had a neuropsychology evaluation, a Ph. D. evaluation. And, uh, and we had a very close relationship because of the referrals. Uh, and she did have some mild cognitive impairment. I'm sure most of you, that's a, you know, you hate that term. It's, you know, not always very useful, but it did qualify cerebrovascular type. And she did have some adjustment disorder secondary to that also. So I'm having a conversation with her. I told her she needed some work up. I was very suspicious of small vessel ischemic, uh, disease at that point. And I totally probably did an MRI of the brain. But because of my capacity, would not have been able to order that test, right? Because that's not my responsibility. But we told her she need to have her thyroid, you know, checked. And she too had hyperthyroidism. And that was, um, pretty much under control. But I told her she'd have to get a battery of tests. She needed an MRI. And she literally wrote them down, called me, called me a week later to say, Dr Taylor, what were those tests that I needed? Of course, her doctor has to, you know, make those determinations and judgment. But I was happy to communicate with her, communicate with her doctor, which we did to facilitate. Uh, so as you might imagine, this is not somebody who was able to get back to work because of, uh, those the cognitive challenges in her capacity. Uh, not necessarily due to the brain fog. In this particular instance, however, we had a couple cases of brain fog. Uh, the neurologist hated those cases. Uh, we were fortunate. All of our brain fog cases resolved. Uh, we had a lot of pots cases, and those were kind of ongoing. And of course, the pulmonary hypertension. So mixed bag. Absolutely. Uh, so causation. We talked about the work status. She didn't go back to work, but not necessarily because of covid because of the other issue. After her a fib was stabilized, she'd gone back to work for those years. And then, you know, she kind of re emerged. Uh, so we'll talk a bit about the conditions associated with long covid. And one of the frustration is you were dealing with a lot of symptom management, right? So we had a long covid clinic set up, and, uh, you know, we were caring not only for employees, of course, but the community as well. And as the case manager, I'm getting all the reports and you're seeing, you know, line by line symptoms being managed. So, you know, they have girl, they're on their P. P. I. If they had respiratory complaints, they got their inhalers and so on and so forth. So just a reminder of some of the symptoms and conditions associated with long covid. I will not read them all to you. Uh, our very first person that we put out of work actually was anxiety and PTSD. We worked with a psychiatrist, but that's another individual who never came back to work. One of those who was close to retirement age enough where they it was just not worth it for them to come back. Uh, lots of autonomic dysfunction, such as the pots and, you know, they were on their salt tablets. Uh, and if they're there by orthostatic vital stabilized, you know, we were able to get them back to work, certainly in some capacity over those periods, and those were managed with cardiologists alongside us. So I won't talk about all the long covid symptoms, but pretty much all the organ systems were hit, right? And I won't read those all to you. But that touched on all those organ systems and just a little bit of, uh, like a refresher on causation analysis, because in occupational environmental medicine, this is one of the unique areas to the field and our responsibilities. It includes establishing the diagnosis, defining our workplace exposure, looking at frequency and duration of exposure, uh, access to training on PPE and so forth. And industry type is some of the things that we would think about, right? Uh, consider exposures outside of the workplace. One of the cases that I had to manage initially was a physician who said he was exposed at the hospital. Turns out he took a trip to Maryland to meet with family and friends. So it's a little bit of detective work, a little bit of slower thing and a lot of digging through the records. He was originally treated up in Boston and, you know, came back to us and said that he contracted covid with us. So that case in particular was denied, uh, provide supporting evidence and then assign medical probability. And in terms of risk of work exposure and disappoint pointingly, some of the data that I present from workers compensation, they didn't drill down in all instances to the specific job titles. Uh, so we mostly had categories of like, you know, the nature of their work. Uh, but we looked at, for example, uh, known exposures at work in terms of documenting non work exposure like or travel history, which I think a lot of us probably forgot how to take a good travel history, right? But we were certainly reminded of that. And then, of course, our social exposures and so on PPE was evolving challenges with that funny story. So literally last week I had a bit of a turnover in my safety directors. So I have a brand new safety director. So I literally got an email last week to say, well, what is the compliance rate for, you know, for the PPE? Is it majority 51%? I kid you not. So we all had a little bit of a chuckle over that. So we sent him the OSHA respirator standard because, of course, you can be cited for pretty much any employee out of compliance. And we've gotten much better at this. We're using a new platform called Zebra, where our compliance data is uploaded, just like our vaccine data into our scanners. And that data is populated electronically to the, um, to our intranet. And so all the managers all throughout the system can get that data at their fingertips. And if they get, you know, joint commission or, um, you know, a CMS, uh, um, you know, on site that they can get that at their fingertips. Otherwise, you know, we're scrambling to get all that data to them in a timely fashion, which we have done because we do have it in our MR system as well. But that's a nice evolution that we've had that keeps it in compliance. So in terms of this is the Amy guides. I'm sure many of you may recognize this, of course, without the work related exposure or accident. Is it medically probable that the patient would have the current diagnosis and require treatment, right? That's where we are. So I don't know if any of you saw this. So we got quite excited. You know, we're trying to struggle through all of these cases. Uh, you know, how can we decide if they're MMI? And we saw this newsletter from Amy guides, which addressed that issue. I just highlighted here the definition of MMI. But, you know, pretty much, they said, if after a year had gone by, uh, that, you know, with long COVID cases that you could establish an MMI status with those cases. So we ran with that for a while. Didn't quite work out for all of our cases. And, you know, we're internally, we manage our cases internally. So we were responsible for the ultimate outcome regardless. Um, but we got a little excited when we saw that. Uh, so in terms of occupational disease determination, of course, typically the burden of proof was on the employee to prove that the illness or injury rose out of in the course of employment. But we saw all the presumption laws that sort of, uh, blossomed across the country from California leading the way all the way across. And, you know, New Jersey kind of followed suit with that. And so those high risk, uh, areas like health care workers, you know, your firefighters, your EMTs, they were, you know, fell under presumption laws, presumably. Uh, so, of course, the rebuttable presumption shifts the burden of proof to the party against which the presumption applies. And then your irrebuttable presumptions say that three times fast, uh, that is established a legal conclusion regardless of the evidence presented against the work relatedness. And I'll just highlight a couple here. So, uh, the diagnosis of COVID was important, of course. Uh, and some of the data, though, if you were presumed to have had, you know, long COVID, some of the COVID testing was absent. So, uh, but the majority of those had COVID tests. And, in fact, we're using for the workers comp data, uh, billing records. Uh, so the employer was, uh, you know, treating and accepting that as a claim. And generally, physicians are incentivized to accept, uh, you know, workers compensation claim because generally, workers compensation is, uh, reimbursed at a higher level. So some of those were discussed. In addition to presumption laws across state, there were policies, like some states, you know, had preferences in how they manage some of these claims, as did employers, right? So some employers, uh, they just, for the convenience, they may have wanted the workers, the COVID claim, sorry, to be handled under, you know, short term disability or group health insurance, or the employer may have had a pot of money to sort of, um, to move those cases through so that they got their employees back to work. So there were various ways in which this was handled, certainly, as you may have recalled. So this is to help me to transition a little bit. So one of the other things I was pretty excited to have gotten involved in was, uh, the process of defining long COVID, which, by the way, I'm understanding is still ongoing. Uh, but, uh, you know, how we came up with that definition and how it affected our usability in, you know, diagnostics, return to work, benefits, and disability decisions. And honestly, a lot of the webinars I've been on, uh, there's some talk about disability and return to work. I didn't see a lot on workers' compensation. So hopefully you find this as interesting as I did. Uh, so, you know, we saw a lot of different names, right? Long COVID, mostly patient derived. Of course, CDC gave us the post acute sequelae of SARS-CoV-2. Uh, so lots of names flying around there. And, uh, the long COVID was sort of, you know, signs, symptoms, conditions that continue or develop after initial COVID-19 infection. And honestly, in some of the cases, you know, could we tell brain fog from, say, chronic fatigue syndrome? So, you know, we couldn't sort of distinguish from some other conditions, certainly. And those challenges are still ongoing. And certainly the insurance companies are still struggling, uh, to manage some of that. Uh, so this was the Standing Committee on Emerging Infectious Diseases. And so, you know, they got together, did their scoping phase, did their investigation to see who were the stakeholders that, you know, for whom the definition was important. Uh, so the first phase was information gathering. Uh, I was part of some of those committee meetings. Uh, and, uh, in some of those sessions, you had various stakeholders. In most of those, uh, meetings, I'm the sole occupational medicine physician, right? In some cases, the only physician, but it was quite a diverse group of individuals. There were patients, there were other physicians like pulmonologists, there were people from insurance companies, so quite diverse group. And then there was a recommendation in terms of what the definition should look like. And so what were some of the questions that were asked? Medical and scientific challenges, right? What is the pathophysiology? Can we develop a definition that is more than a collection of symptoms? Is there a biomarker? Can we develop a biomarker or a test to aid with the diagnosis of long COVID? And do we have effective treatment? And in looking at this list, I'm realizing that I don't have all those answers for sure, but we'll continue the dialogue, absolutely. So the exercise was interesting, of course, in and of itself. And of course, as OEM professionals, we do have to interact with various different disciplines, clinical administrative management, as we manage claims together. And dealing with a new diagnosis, I think, posed an interesting challenge for us. It does require some innovation and collaboration with other professionals. It helps us to get along with our colleagues in the sandbox and healthcare and absolutely the scientific community. Sorry, this got a little scrunched together. I promised I'd try to unscrunch it. So why is it important, right? We need a definition that was adaptable over time as new knowledge and understanding emerged, which it still is. We're still seeing studies coming out. We need something that's easily understood by different health literacy levels. A big discussion point at this point was around equity. I'm sure you all remember all those conversations surrounding equity. There were inequities of care and equity. So that was an important consideration. And in fact, they would try to ensure that we were addressing that and coming back to that particular discussion. And then this will help us understand other post-viral syndromes. We're having certainly an evolution of the viruses that's out there. And it helps us, you know, with the epidemiologic discussions, research, clinical insurance, eligibility, certainly patients understanding what their eligibility is, our coverage, and then patient uses of the same. So like I said, very diverse group, you know, policymakers, public health individuals, social and behavioral sciences, bioethicists, and so on. So I won't belabor this point, but just to highlight again, all the different important areas, epidemiologic and surveillance, that's ongoing research that we still are still emerging. There are over 30,000 articles on COVID up to the date, and I haven't read all of them, I promise you, clinical and patient uses. And then of course, if the definition is too nonspecific, it's challenging for patients to understand where they fit in the context of this and navigating their disability and their workers' compensation, particularly in light of the equity conversations that we were having. So you know, we were all there. We saw this come out, the WHO definition, right, post-COVID. So the WHO advised us that, you know, that post-COVID was clinical conditions that occurred 90 days after the onset of COVID-19, with symptoms lasting 60 or more days. I'll give you the answer to the question. The study that we're looking at from the workers' comp standpoint, they use the CDC definition, which I didn't quote at all here. Non-COVID is felt to be more reflective of the patient's complaints of symptom signs, conditions for four weeks or more after the initial infection phase. And then of course, the post-acute sequelae of SARS-CoV-2 is a term used in the scientific and medical community, refers to ongoing relapsing or new symptoms even, and we see some recurrence of symptoms and new symptoms emerging. And some of the studies, particularly the vaccine studies, some of them looked at the both, they use both definitions. They use the 90 days from WHO and the four weeks, the one month from the CDC. So we did see a little bit of both, and how that affected the long COVID prevalence, and we would think that the WHO definition would be more conservative there. So switching gears again a little bit, we're going to look at the effects of the various COVID strains. And from the vaccine standpoint, we do see a bit of Delta as well as Omicron data creeping in. And then in terms of the neurotrophic retinopathy or the P word, how that affected prevalence and severity of long COVID. And we're seeing some interesting things. So the longer people were positive for COVID, tested positive for COVID, the more likely that they were to be diagnosed with long COVID certainly. And some other interesting things, which we'll talk about. And of course, if you met the indication for the, you know, Nirmatrelville retinovir, we still recommended that you got it, whether or not, you know, that would impact your development of long COVID. Clearly, if you met the indications, you probably should get it. One interesting thing, if you were vaccinated, we didn't see as much benefit from the Nirmatrelville retinovir, but I think the general recommendation is to still make sure that individuals were getting that medication if they met criteria for it, obesity or what have you. So does the vaccine decrease risk of long COVID? And I'm one of those, I just give you the answers, you know, for the test. So does everyone need yearly COVID booster? I know this is still controversial. This is not the vaccine hesitancy talk. But CDC does recommend that everyone six months and older get an updated COVID-19 vaccine to protect against, you know, serious outcomes, you know, hospitalizations, deaths. And what we're seeing is certainly that the variant-specific boosters result in higher concentration of neutralizing antibodies. On the left in stripes, I don't know if you can actually see those stripes on the left, but that's pre-booster. And then we see a spike in our neutralizing antibodies, and they test it out to 29 days. I think most of us would understand that it takes about two weeks to get, you know, your full antibody response to a vaccine. And then, of course, long COVID occurs more in those who are unvaccinated. And certainly those who are unvaccinated had more severe illness. But even people with milder COVID-19 infections, particularly the Omicron era, they could experience long COVID. And those of us who were in hospital settings who had to deal with exposures, you were testing people who were asymptomatic, right? So then you had people who tested positive, which you were now still responsible for quarantining and the like, getting them back to work and so forth. But even some of those individuals who were asymptomatic, we found out, you know, by testing and even subsequent antibody testing. And so for us, our definition for those who were asymptomatic, we started at the start point would have been the date of their test as opposed to symptom onset because they did not have symptoms. So certainly some interesting experiences there. So not only does the vaccine help to prevent infection, but it can reduce your severity of symptoms, viral burden, transmission risk if infected, and reduce the development of long COVID symptoms. And there are quite a number of studies that show the vaccine efficacy, so I won't belabor the point. This is out of Lancet, and I will highlight this Kaplan-Meier curve, where we saw significantly less COVID among those receiving any prior vaccination. So the other two types of studies we saw, we saw studies where they looked at, you know, up-to-date vaccination, which that depended on where, you know, what time point you were in, right, what that looked like. And then also those who had three, you know, three vaccines. So we saw both sets of studies, but both were protective, just so you know that. So here, I'm sure you can look at that, but on the y-axis there, you saw one minus the probability of long COVID diagnosis compared to time from COVID on the x-axis there. And you can see the separation of those curves stepwise on that model-based graph on the left, at least my left, and then non-vaccinated in the blue there. And then the one on the right was more clinic-based, reduced scale. So you know, back to the Nermatt-Trellville-Rotondover conversation. This is out of Johns Hopkins with 700 patients. We saw a decrease of long COVID in prospective observational study. And I'm going to switch gears a little bit. So while I have a little bit of an audience here, so I'll ask, how many of you are still managing clinically, you know, long COVID cases, like your clinical care, like I'm giving? Just raise your hand. Yeah. Old-fashioned polling. Okay. Absolutely. And how many of you are doing, or did, causation analyses? Okay. Okay. So some still. And how many are from, like, insurance companies, that work for insurance companies? Okay. Got it. And how many specifically are, you know, did a lot of workers' compensation with a long COVID, workers' compensation care or insurance? Okay. So you do have some interest. And this is a niche topic. I get that. So we'll look a little bit now on the effects of worker and industry characteristics, some of the state variations, as well as symptom severity and hospitalizations on claim outcomes. And we see hospitalizations as separated in terms of ICU care versus non-ICU care, right? It sort of makes obvious sense there. So a little bit more on WCRI. So it's Workers' Compensation Research Institute. They're based out of Cambridge, Massachusetts. They do studies across the states, and notably, absent from their data, are some of those states that have very well-developed workers' compensation systems, as we can probably think about Colorado and New York. And the studies that we talk about only cover 31 states. That's at least presented here. But they try to objectively look at, you know, rigorous scientific data. They use unbiased peer-review procedures. And so they do present the data to us about twice a year. The first set of data they talk about, usually in the winter we meet, is mostly cost-related data. And then in the summertime, in July is typically when our meeting is, we're looking at the emerging trends in workers' compensation, you know, from a medical standpoint. And of course, COVID was huge. It gave us this huge opportunity to sort of to explore various interesting emerging topics and challenges. Very diverse group, employers, insurers, and like us, you know, we're self-insured, governmental entities, managed care companies, healthcare providers, regulators, and so on. So around the table, when we do meet in person, since COVID, we've gotten virtual, too. So we always have a, we had a virtual option during COVID. Now we're hybrid. So even our model's changed. However, around the table, you'll have judges, attorneys, physicians, chiropractors, you know, TPA representatives. So quite a diverse group having these conversations and trying to figure out, you know, what are the important areas to study and to look at? So this is what the industry classification, and I'll just highlight a couple things. So we saw our high-risk services, so surprise, surprise, right? Healthcare services are on there. Nursing homes, we know the nursing homes were hit hard. They were hit early. And then some of the low-risk services. So we're seeing physicians and dentists, and I'm just picking on a couple here. Physicians and dentists, those have come down a little bit. We know those were also very targeted at the beginning, and that could have been because of, you know, vaccination availability, you know, adequate PPE protection and the like, and certain other industries, manufacturing, construction. One of the things that they did highlight, for example, food services, very young ages associated with that particular industry that was noted. This was just the graph that got my attention. This came out last summer, and we saw that, you know, the COVID-19 pandemic continued to impact our indemnity benefits and medical payments, and not only with COVID claims, right, also with non-COVID claims. And last year, I don't know if anybody caught a bit of my talk, we touched on some of the non-COVID claims as well. So it's impacting, you know, both clearly. So in addition to the prevalence, and prevalence was huge, and we're looking at some of the different factors that affect our prevalence, and we'll touch on some of that in just a bit, but we're looking at the state variations, as we mentioned, costs of claims, duration of temporary disability benefits, so we're looking at all of that, and another opportunity for OEM professionals to sort of showcase our talent in using a very new emerging diagnosis to help us to manage our claims, whether clinically or as we continue to adjudicate claims. So some of the questions that were posed. So prevalence was huge, obviously, costs, also huge, temporary disability benefits, and our industry and worker characteristics, and then the variations across states. Some things to consider. So there were two cohorts. The cohort I discussed last year was sort of March 2020 to September 2020, and so they had a little bit of data from that, but now they've been able to continue out to September of 2021, so you're seeing more data, but, you know, they looked at the data from both sets of cohorts, and then the continuity. You know, what I can tell you is exactly when people are dropping out of that, like I mentioned, we did not have specific job titles, like I couldn't tell, you know, the RNs versus the LPNs, the technicians, and so on, even in terms of physicians and dentists, they were looking at the offices, so specific job tasks, it was not teased out, just so that you're aware of that, and I don't know if they'll be able to do that in the future. We are looking at billing data, so for this particular discussion that we're going to be having, we're limited to what the billing data can provide us with. By this point, of course, last year's conversation was different from this year's conversation is now we have COVID vaccines widely available. The post-infection period, so they assessed the data, you know, March of 2022, so we may have had some experience as far out as 24 months, and so our data are coming from our workers' comp claims nationally, regionally, state funds, self-insured employers like us, medical billing records, and then the COVID-19 injury code, which, as you know, changed, you know, now we're up to the U09.7, you know, we're 31 states that we're looking at. You'll see some of what those states are, and what are some of the limitations? There are obviously going to be limitations to study like this, right? So we might recall some employers, you know, they were just anxious to sort of get people back to work, so there may have been other pairs that, you know, may have captured some of this, right? So group health insurance, short-term disability, you know, whether or not there was a post-COVID test, some might have been presumed, right, presumed COVID, and so the long COVID might have been, you know, sort of a carryover from some of that, so there were definitely some of those limitations, but they did point out that that was the less, you know, certainly less than the other. Also the PICS, and I hate acronyms too, too early in the morning for acronyms, so the PICS is the post-ICU conditions, and you know, if somebody's been in the ICU, clearly they're going to have a lot of neuromuscular challenges and the like, so there's a bit of overlap clearly a month out of, you know, the ICU, for example, you know, how much of that is really PICS versus, you know, long COVID, stuff like that, but clearly the non-ICU, you know, it doesn't preclude the non-ICU explanation of some of what we're looking at, presumption laws we mentioned, and then can we really extrapolate this data to the entire population, and you know, they were careful not to make a lot of assumptions, but I think a lot of us in here perhaps are familiar with some of the challenges that we have in interpreting workers' compensation behavior, workers' compensation data, certainly couldn't extrapolate to, say, you know, children or, you know, older individuals and so on, so definitely some limitations here, again, the answer to the test. So just some definitions, I will not read them all to you. I will highlight, though, that for the long COVID was considered when workers received care for any of the medical conditions that are associated with long COVID during the post-acute period. So I'll just highlight that one, but just in terms of just what to look for, hospital inpatient services, indemnity payments or income replacement benefits, infection date, medical payments, and temporary disability duration. So I think everybody can understand this. So the percentage of workers with COVID who received medical care and indemnity benefits, so majority of people, so 67%, they got indemnity payments, no medical care, so those are, you know, your healthy, you know, healthcare workers, they, you know, they get their positive tests, you know, minor symptoms, they do their isolation period, they're back to work, right? So that's majority of what we're dealing with. We have those with medical care, no indemnity payments, so those payments may have gone through some other systems, right? And then our medical care and indemnity payments at 14%, and then our fatality, thankfully, less than 1%. And so just to highlight here, so most people got better, got back to work, I think we know that, and this was just our timeline, so we saw there at our, you know, our cut point there, illness date for those non-hospitalized workers or the hospital discharge date for hospital workers. You know, if you were asymptomatic, clearly it was your, you know, your test date, and then a month out, and then we're seeing, we're following, they did look at, you know, one month out, but then they also looked at that three month out period, and then, and they're following the data as far as 18 months, and I think they went as far out as 24 months in some instances, but not all, not all cases were followed out that far, and I can tell you when people are dropping off, but this does show you the percentage of workers who receive care in each month, and you see that huge drop there, right? But things are not going quite down to zero, we're not quite getting there, but we're seeing the progression over the time in months, and this is the percentage of workers with medical care by infection, by infection month, and we see that nice spike there, and that's about the delta, I guess the peak of the delta variant there. And so, in terms of gender, we're looking at sample characteristics now, so we saw predominance of female in terms of gender, and sorry, I'm not even being bad about my gender, well, actually, it's their fault, so the gender notifications are not, perhaps, quite as exhaustive as they could be, and again, we're limited to the data that we have, right? But predominance of females, and some discussion surrounding that was that we know that healthcare workers are predominantly female, in this particular study, it was four out of five, so 90% of the group that we're looking at are females, and of course, if you're working for healthcare, you have access to care, right, so more access to care, so there may have been some, certainly, self-selection bias involved in that particular discussion there, and we saw that relationship compared to males. In terms of age, we're just going to highlight, let's say, 65 and over, so those teetering on retirement age, only 3% of claims with that age group, and we'll see that they were responsible for something as high as 22% of the diagnosis of long COVID. The prevalence of long COVID compared to, say, the 15- to 24-year-old group there at 12%. Types of areas, so metropolitan was predominant, we have a micropolitan, the CSB, I have to define for you, because that was your nursing facilities and your retirement settings, right, not too surprising, and so those were a pretty small fraction, but they have disproportionately high numbers associated with long COVID development with that particular group. And then I'll pick on a couple of other industries. We saw, you know, facility living, establishments, hospitals, physicians and dentist offices, perhaps not surprising. We'll highlight the food service industry where we have, you know, a lot of younger age group in that particular industry, manufacturing, construction, and so on, which generally are younger, healthier cohort also. So, and I'll just give the big picture here. So you can see there, the breakdown, those characteristics are what we just discussed, right? You can see those there on my left, and then to the right, you're seeing higher numbers in terms of those with medical care, those with medical and indemnity care, we're seeing higher association. The females have higher claim percentages, but less in terms of the long COVID, we saw 6% versus 7% for the male and female differential there, but those with medical care was a little higher in the female side, 21% versus those with medical and indemnity care. So they felt that the medical care itself was an association, and of course, we're not going to make a lot of causation statements, no pun intended. You know, we're going to focus on the associations that we're seeing here. And we do see with the age differential, with the 65 and up, 3% of claims, but greater numbers associated with those with medical care, and those with medical and indemnity. so there's a differential that we're seeing there. In terms of types of area, again, we'll pick on the nursing homes and the retirement facilities. We have 4% of claims compared to on the far right, we're seeing higher numbers with medical care versus medical and indemnity, looking like 20-something percent and 30-something percent, and I could see them when they were closer. In the elderly group, we're seeing our facility living establishments, hospitals, physicians and dentists, still high, still leading the pack with this, unfortunately, and we can see how that's impacted on the right in terms of overall sample, medical care, and medical indemnity. And then we'll pick on the comparison, the food service industry, younger group, a percent of claims, 9% compared to only 2% in the overall sample, 2% with medical care, but much higher. Much higher with those who had to have medical and indemnity. So, you know, you do wonder about the incentives and workers' compensation, how much it's influencing what we're seeing here, particularly in terms of the medical and indemnity payments. And then, of course, for manufacturing and construction, perhaps another very much younger group at 2%, and a pretty relatively lower number in terms of the prevalence of long COVID, but once we start throwing in medical and indemnity costs, those numbers seem to have jumped up. And this is our state variation, so I'll just pick on a couple states. So California, we know, is always influenced with the presumption laws, they kind of led the pack with that. Florida, we can see there, I'll pick on New Jersey, Pennsylvania, and you can see some of the other states. And quite a bit of a range there, and that was impacted by presumption laws, and certainly our policies, and how the states influenced what was happening. So I won't belabor this point, just to highlight some of the services, mostly cognitive services, as you might imagine, right, evaluation and management at 82% of claims versus 11% of payments. And if you compare that to, say, let's say hospital inpatient, at 3% of claims, but as high as 22% of payments. Perhaps not too surprising there, absolutely. And then, in terms of ICU care, we have that in the light green, we're seeing a trend there, it's certainly higher than the other categories of hospitalization, non-ICU care in darker green, and then those with two or more days of care, and then those with one day of care. So you know, those with one day of care, two days of care, presumably they do their one or two days, their isolation period, they're back to work, hospitalizations, ICU care can certainly go on for a longer duration, and then we start counting down from when they were discharged from the hospital, for example, to see who was really having long COVID, and some overlap with, undoubtedly, the post-ICU syndromes there. So last year, I think this is just about the kind of data that we had. Not surprising, predominantly lungs, right, 64%, heart at 33%, mental health at 12%. I won't disappoint you as much this year, I know people were raising their hands complaining. So we do have, in other categories, we do have a little more breakdown, so they kind of lumped everything in at 42% of other, but we have a little more of the data is teased out now, and I think the top part doesn't surprise anybody, but in terms of other conditions now, we're seeing some fatigue, some brain fog, some GI distress, and so on, that's being teased out for us. So perhaps not too surprising, you know, one of the questions I got was, you know, can we distinguish this from, say, chronic fatigue syndrome or some other conditions? Not, you know, no, that would be the short answer to that. One of the other things we were able to do was to look at the, you know, multiple diagnoses or multiple conditions or symptoms, right? So we were able to see some cross-reference there, and that was also kind of interesting, and we have some interesting breakdown on that in terms of costs. So in terms of the number of body systems affected, of course, the greater number of body systems affected, more expensive, perhaps not surprising, but that looks a bit multiplicative if you look at that, in terms of medical payments per claim, indemnity payments, and in terms of weeks of temporary disability benefits. This I'm glad, so this was interesting. So we talked about that first cohort there on the left. That's the first set of discussions that we had last year where you saw your, you know, your all claims. Let's pick that to make it easier. Let's say 7% of all claims. This was your first cohort, March 2020 to September 2020. Now we're looking at a longer duration out to 2021, so now they're able to cut point and look at both sets of cohorts, and we do see somewhat of a decline in or a percentage of long COVID claims, 7% on the left compared to 6% and 5% on the right, and that was consistent throughout in terms of the type of medical care. We did see somewhat of a decrease, and we're attributing that, you know, to some of the vaccine or associating that with some of the vaccine developments and perhaps a treatment that was, we're not getting into the treatment discussions. We only talked about the protease inhibitor, but we're attributing some of that differential to vaccines and treatment. So we saw definitely, and I have a bunch of conclusion slides, it's a lot to discuss, but we want to give some time for questions and comments as well. So we saw various prevalence data, right? The studies show a lot of variation, and we saw how that prevalence is also impacted by various factors, right? And we definitely saw some significant limitations affecting individuals getting back to work, affecting, you know, getting back to normal life, and so on and so forth, and some more severe than others based on different factors, and we're not getting into the comorbid discussions, right, of, you know, some of the various factors that influence that, whether obesity or what have you. So we saw that long COVID was less among those receiving any prior COVID vaccination. The early protease inhibitors was mixed. So if you were vaccinated, you didn't see as much of a benefit, right? And we wouldn't let this data necessarily preclude us from offering that if someone, you know, met the indication to get that medication. And of course, we saw a lot of symptom management, and I think perhaps we're still struggling with some of those challenges. So with the cohort that we talked about, a majority had minor symptoms, got back to work. I think we saw that, and we kind of can intuit that perhaps. Small percentage were hospitalized and really drove up the claims costs. And among all the workers, so this was the overall sample, because we saw if you cut point different factors, you would see different prevalence data, right? So perhaps not too surprising there either, but in terms of claims with medical care, as much as 19% received care for long COVID, those with medical care and indemnity benefits as high as 35% received care for long COVID. And then we saw the intensity of medical care. We saw that one slide with ICU data versus non-ICU hospitalization, you know, one day of care, two day of care. We saw a nice curve with that. And so the intensity of medical care itself was felt to be a strong predictor of long COVID. And then those who were in the ICU care were substantially impacted. And then even those with minor symptoms could still develop long COVID, and even some asymptomatic who develop positive antibodies subsequently. Those have not been completely ruled out as well. So long COVID is an important driver. We saw claims with long COVID, higher average medical payments, indemnity benefits, duration of temporary disability. With hospital and ICU really driving up the costs there as high as $190,000 for ICU care and $66,000 for hospital workers. So some things to consider for the future, absolutely. So remember the early part of the pandemic, patients were told, don't go to the hospital, don't go to the ER, don't go to urgent care, because we were trying to contain things, right? So some individuals may not have sought care, certainly initially. And we didn't have a lot of guidance, clearly, as well. You know, once things opened up, people were getting the care that they needed, absolutely. And we did see that patterns of recovery did change slightly with subsequent waves of infection, you know, through the wild type, alpha, delta. We didn't have as much as Omicron, but, you know, maybe that's the next study. And vaccines became available and certainly helped with some of those outcomes. And we definitely need further analysis and evaluation to understand the prevalence, how the subsequent waves of infection will help us to figure out long-term disability implications from long COVID. And this is just to remind myself that we're talking about associations and not necessarily, you know, all the factors that we're talking about are going to be causally related, just to make sure that we're aware of that. So open up for comments and questions. How are we doing on time? Clear as mud? Thank you. Any friendly faces? I'll go ahead, make sure you speak into a microphone so that they can capture that. Thank you. So I work for, I see a lot of people with worker compensation for COVID, long COVID. So some of the challenges we face, is there an echo coming? No, we can hear you, I can hear you fine. Some of the challenges we see are, yeah, like causal, is it, are those symptoms because of long COVID or something else? And then for workers' compensation, we need to, because all are subjective symptoms, we need some objective data to keep the claim forward. So those are the challenges we face from the workers' compensation. Why is the claim still open? What are the objective, what are the objective findings for the claim to be open this long? Those are the things we face usually. Yeah. Thank you for saying that. I forgot to mention. So with the second case that we talked about, the one who claimed the brain fog. So when she came in, we definitely did our cognitive assessment at baseline, at least. And she had some issues on the cognitive testing, and so we were able to refer her on, but absolutely. So let's say for the brain fog complaint, I know that's a favorite one, for example. So cognitive assessments may help you, whatever flavor of the month, you know, we did the mini mental status exam, which may have some other cognitive testing that you're doing from a clinical standpoint that might help you to document, you know, baseline and if there are any changes. Of course, we went as far as a neuropsych test, which, you know, that helps to, turns out more for the fitness for duty, but a neuropsych test can certainly help you to document objective, you know, findings. And in our particular case, you know, she didn't turn out to be workers' comp for the brain fog, and we were fortunate to have a lot of brain fog cases, but objective testing can help you. Obviously, if you have something like, you know, the AFib, that's kind of obvious, you've got an EKG, you know, a pulmonary hypertension case, that we have objective testing. And this, I did some other smaller talks on like fitness for duty, return to work, all the testing we were using, and we definitely, you know, we have some objective testing that we took advantage of, the cardiopulmonary exercise testing, and, you know, our six-minute walk test, I utilized that in my office, and I had the capacity in my office to perform some of that for the functional complaints. For orthostatic, the POTS, we were able to check orthostatic measures. That's pretty easy enough. That's something you can do in your office. And, you know, we were, you know, I guess, I don't know, we were very aggressive with managing our claims, certainly. So if they had objective findings of orthostatic hypertension, then, you know, we would move forward. But if they're complaining about all these symptoms, and they didn't really have any orthostatic findings, then, you know, we could assess that they are probably functionally able to work. So objective testing definitely are quite helpful, and to be able to document those, you know, throughout your case to help you. But if somebody just writes in the record, oh, you know, this patient's complaining of, you know, brain fog, patient's complaining of fatigue, that's not as helpful for someone, I imagine, who's trying to adjudicate claims, because then you don't have any objective data to go on to make your decision. Also, you know, the policy determinations and claims will help, because I know some insurance companies, for example, let's pick on, say, psychiatric complaints. They may have, like, a set point, like, we'll only accept, you know, subjective complaints for two years, or what have you, and that may be the end of the policy. So I know there's some policy decisions that drive some of that, but yeah, I definitely recommend objective testing for some of these more nebulous, nonspecific complaints. Thank you for that question. You reminded me to mention that. Thank you. Absolutely. Hi. Linda Forrest from University of Illinois Chicago. That was a fantastic talk. Oh, thank you. I appreciate that. Very comprehensive. Interesting. I feel like I have to watch it two more times to take it all in. Absolutely. It's a lot. Wonderful. The question that I have is about workers' comp, so I continue to be impressed with the fact that workers' comp initiated as a no-fault insurance situation has a lot of adversarial interactions around it, evidenced here and with COVID, number one. And number two, I'm wondering if this is going to break the bank. You know, there was a lot of cost shifting during COVID as well, right? I know my own health system took care of our own employees, bore the costs of that, the time lost and everything about that. They didn't file workers' comp claims. I'm guessing the vast majority of at least health care didn't result in workers' comp claims. It just got eaten by the health systems where it happened. And so I'm wondering, you know, what's going to happen here if the costs are just going to be exorbitant, out of control, nobody can cover them or, you know, what you think the scenario is here? Yeah, no, we got smart very quickly. So we were, like I mentioned, we were self-insured, so we had to manage everything internally. But, you know, once we started getting a real good handle on, say, our PPE, our protective equipment, we had vaccination. We'd mandated the vaccination when the vaccines came out. Only last year, our governor in New Jersey there lifted that mandate for health care workers. So it's no longer mandated. Definitely encouraged. You know, so we were ensuring that people were in compliance with their respirator fit, that they had respirators, that, you know, that they were using them and the like. And so we got pretty savvy. At some point, we had to have a cut point and say, well, you know, now we have compliance, we have PPE in supply, because we had supply chain issues like many other hospitals, I'm sure. So once we had a handle on all that and we were able to get up to speed, we really started declining those from a workers' compensation standpoint. So really, I would say not as many, very few now would be accepted under workers' compensation. So we had that. We had our vaccinations. Now we have treatment. And, you know, I probably, like many other clinicians, had challenges with individuals who, you know, contracted COVID in that setting. We got them to the hospital. We got them the care they needed, the treatment that they needed to make sure that they were recovering. So that's one way we were able to get a handle on the workers' compensation internal costs, certainly. But, of course, you're right. That cost is shifting. You know, somebody's paying for it. So that would be your group health insurance. So and, of course, as a hospital, we're paying for both of it, right? We're different parts, but we're responsible for both of it. So definitely some cost shifting going around. But certainly your risk management, ensuring that individuals, you know, risk stratify might help your vaccinations, your treatment, you know, your protection, and then just paying attention to your claims. Or we just happen to have a very aggressive internal management department. We're ensuring that return to work, which, you know, also helps with containing those costs. So we got people back to work. We didn't have too many people that remained out of work. This one individual that we talked about who was perhaps the sickest with pulmonary hypertension, even she remained working, very optimistic about getting back to work. Not likely. Most likely she'll end up in a different department. She'll be placed in a modified capacity permanently. But I think all those factors help to sort of contain our costs and ensure that our patients were healthy and our employees were healthy. Good question. Thank you. Go ahead. By the way, you guys made me look smart at the summer board meeting. When I go, I'll have all these great ideas to take back. Thank you for a very thoughtful talk. This is a follow-up to the previous question. If we reflect upon how things were in the summer of 2020 in terms of cases in ICUs, and we had a cluster of five respiratory therapists who were misbehaving. So at what point when community incidence was widespread, did you cut a cut point in terms of saying that your case could just be as easily acquired in the community as in work? I think, and I'm trying to figure out, I'm trying to remember exactly when we said, no, we're not going to accept this as being a work-related case anymore. What we would do is we would determine what their use of PPE was at that time and their risk being substantially mitigated by that, that we said, no. We had problems with batteries and pappers and things like that. I was just curious in terms of, are you continuing to kind of look at things at a case-by-case basis? Tanisha, or you said, at this point, the likelihood, certainly at this point, at this point. I don't recall the last time we had any kind of concern over an occupational case in the hospital environment. Excellent. And at this point, we certainly haven't had any recently. I don't think we had a clear cut point like this particular date, but as I mentioned, as we got more compliant with our respirator fits, so now the burden was on the employer to ensure that we were protecting our workers. So once we had that in place, we felt more confident to do our investigation. And there still was some investigative work case-by-case in New Jersey, pretty much in terms of having a handle on the cases. It was case-by-case basis. But once we had our PPE in place in terms of supply, in terms of respirator fit compliance, we got pretty aggressive. You know, we would do our investigation to see, you know, what was the exposure duration? You know, were they wearing PPE? And even our state health department came out with an algorithm. Some of you may recall, I resisted the urge to put the algorithm up today. I think we all remember that algorithm. But yeah, if they didn't meet criteria for exposure, then we would just do a cut point and say no. So at some point, we got pretty savvy, and we started denying claims. Of course, we do a little investigation. We talked about the travel history. We were reminded how to take a travel history for medical school, right? So I think a lot of those factors played in. There was a bit of investigative work. We do have, you know, our department go as far as to do, you know, surveillance if we have to for those who are saying that they're unable to, you know, work or what have you. So we're pretty aggressive in terms of return to work opportunities, light duties provided to help to control those costs. So we're able to really contain our costs from a lot of those standpoints. So it wasn't a cut point on a particular date, still case by case, but I haven't really had any recent cases. In terms of just COVID itself, just COVID infections, we're still seeing it. And we still get exposures. My last exposure was maybe a few weeks ago. So we do still see it. But we haven't had anybody contract COVID or develop lung COVID certainly in recent times because of some of those mechanisms that were in place. So we're down just literally single digits in terms of what I'm actually managing at this point. But great question. Thank you. It's 9.02. So thank you so much for your time. And thanks for being a great audience. And appreciate your attention and time on an 8 o'clock on a Monday morning.

OEM physician

long COVID

workers' compensation system

causation assessments

vaccination importance

diagnostics implications

vaccine efficacy data

workers' compensation meetings

claim costs

pandemic challenges