But what happens when the injury is catastrophic, the injured worker has been stabilized and wants to go home? If the injured worker is from the local community, the case manager assists with home modifications, transportation, and coordinating on-going medical care. If the injured worker will be living with family in another state, the adjuster transfers the case to a new case manager. This is a little more complicated, but with today's selection of national case management companies, the adjuster can find a good case manager who can set the injured worker up with new physicians in the new location.

In our global economy, just as goods and services cross borders, so do workers. In cases of a catastrophic injury to a foreign worker in the U.S., the employer/carrier remains responsible for on-going care. It is not unusual for the injured worker's family to want him to return to home, and for the injured worker to want to be with family. With complications such as language barriers and health-care providers unfamiliar with the U.S. workers' compensation system, the need for case management increases.

A good international case manager brings value to the case by assisting the carrier identify local (i.e., injured workers' home country) medical providers and facilities that not only provide the appropriate level of medical care, but also represent a significant cost savings for the care (when compared to the cost of that care in the U.S.). The following examples of recent cases are typical of the cost of medical care in another country:

Example 1. Pneumonia, traumatic brain injury. Total Cost: $27,000

• $25,000: 10-day in-patient hospitalization, Mexico City Private Hospital
• $12,000: Second 10-day in-patient hospitalization, Mexico City, National Institute for Respiratory Diseases

Example 2. Paraplegic/spinal cord Injury. Patient lives in rural area in Mexico. Total costs per year: $1,200 - $1,800

• Spinal cord injury evaluation every two years, two-day in-patient stay, renal sonogram, renal ultrasound, X-rays, EKG, laboratory studies, family physician, internal medicine, urology
• Additional annual costs: $1,700

International Team

These examples illustrate the cost containment advantages that may result from using local health-care providers. However, integral to the success of the process is an experienced international rehabilitation team. The team typically includes a seasoned U.S.-based case manager, a U.S.-based rehabilitation physician with a background in carrying for injured workers, and a non-U.S.-based physician who serves as the local medical director.

The case manager performs the usual case management roles, with the added responsibility of identifying the other members of the international rehabilitation team and coordinating their activities. The U.S.-based physician is a board certified physical medicine and rehabilitation (PM&R) physician with experience treating spinal cord and other traumatic injuries. In addition, the U.S. physician must be knowledgeable on disability guidelines and compensability issues. The third member of the team, the local physician (licensed as a treating physician in the country of the injured worker) is an extremely important member. This doctor advises on, and helps evaluate, the local health-care resources. As part of that countries' local medical community, he establishes the credibility of the other team members. The international physician is similar licensed in PM&R and is familiar with the various medical and disability management of spinal cord injuries, head injuries, and poly-trauma cases in his country. The international physician also works closely with the international case manager for coordination of medical services and payment of medical providers, in accordance with required medical documentation processes.

A successful international program:

• Evaluates local health-care providers to make sure their services are equal to the care standards the injured worker would receive in the U.S.
• Assures that only medically necessary treatment related to the work injury is paid for by the insurance carrier. As adjusters know, it is often difficult to educate U.S. providers on this issue. Educating health-care providers in another country is even more challenging.
• Provides communication during the year, as needed, with local providers
• Facilitates a smooth transfer of care from the U.S. to the home country

As dramatic as the cost savings can be, equally important are the socio-psychological benefits for the injured worker. A language barrier often exists when an injured worker whose native language is not English receives care in the U.S. This hinders not only the patient's full under understanding of his medical condition, but also the development of a good physician/patient relationship. Cultural differences and expectations may be subtler, but just as much of a barrier to the patient's wellbeing. Returning the patient to his home country reunites him with his family and to a medical system that is complementary to his beliefs and culture. Additionally, the indemnity benefits the injured worker continues to receive most likely will provide a higher level of living in the local economy.

For settled cases, the trust administrator retains a higher level of control and oversight by the on-going involvement of an international case manager.

Naomi G. Anderson, RN, CDMS, CCM, CLCP, is president of Aries Management Services, a case management and life care plan company. She may be reached at 432-426-3080 or [email protected]; www.ariesmanagementservices.net.