60 Tips in 60 Minutes

Part of my annual routine at the National Workers’ Compensation & Disability conference in Las Vegas is to attend the “60 Tips in 60 Minutes” session on the last day (this year it was November 8). It is always enlightening – the 2016 session was the first time I heard Dr. Marcos Iglesias use the phrase “worklessness is a co-morbidity” that I have frequently referenced in my own sessions. It is also fun to watch articulate experts struggle with covering an important subject in 60 seconds or less (you don’t want to hear the gong). As usual, the session was fabulously moderated by Stuart Colburn (Downs Stanford). This year’s panel included Phil Walls (myMatrixx), Dawn Watkins (Los Angeles Unified School District), Monica Manske (Rochester Regional Health), Kimberly Radcliffe (One Call), Dr. Marcos Iglesias (Travelers), and Anas Al-Hamwi (Walgreens). As Stuart recapped for me afterwards, “Borrowing the standard statement from the end of each Olympic event … The 2019 60 Tips in 60 Minutes was the best ever!”

Given the different perspectives (pharmacist, risk manager, H/R manager, physical therapist, physicians) there were some very helpful insights that often overlapped. In fact, there were some recurring themes throughout: 

Below are each of the 60 “tips” and my paraphrased essence of their response. Decide for yourself which ones are valuable to your specific role at this specific time and don’t hesitate to incorporate that wisdom into specific action steps for being better. After all, workers’ compensation is an industry where being your best means better helping people regain their lives faster and more fully. 

1.     What part of medical marijuana says “return to work” to you? (Phil) 

     a.      Consider the side effects of cognitive impairment and impacts on learning and memory

2.     Don’t be afraid of the applicant’s attorney. (Dawn)

     a.      Appeal to each attorney’s unique “style” … and the money they get for closing the case

3.     Avoid the “Must find a diagnosis!” (Monica)

     a.      If there is no objectively measured progress, create a new direction in the file by allocating other resources

4.     Beware of the unnecessary diagnostics rabbit hole. (Kim)

     a.      Wait 6-8 weeks unless conservative treatment is not working

5.     Don’t ask about pain. (Marcos)

     a.      They’ll tell you anyway, but if you constantly ask then it’s top-of-mind, so focus on function and not on chasing a pain score

6.     Easy and confidential setting for employee to report an injury. (Anas)

     a.      Encourage trust by setting the tone on the first step and they will be more willing to share important details

7.     Don’t rely on drugs of addiction to treat addiction to other drugs. (Phil)

     a.      Pay attention to what caused the addiction using modalities like CBT

8.     Have you ever spoken with the physical therapist? (Dawn)

     a.      Use PT notes to decipher what’s important to the injured worker so restoring function can be more uniquely focused

9.     Sometimes providers want a lifeline. (Monica)

     a.      RTW plans need to incorporate the injured worker’s concerns about physical capability to do it

10.  Don’t forget dental risk associated with medications. (Kim)

     a.      The drying effect from opioids, and resulting decay, can take up to 3-5 years to be evident and cost up to $100k

11.  Be open to alternative treatments. (Marcos)

     a.      Rx and interventional procedures and surgery are often not effective for chronic pain so scour evidence based medicine for non-traditional options with supporting science

12.  Employee opportunity to become conditioned at work. (Anas)

     a.      Focusing on condition and function on the job can lessen frequency and severity of injuries

13.  Don’t wait until it’s time to calculate an MSA. (Phil)

     a.      CMS is clinically illogical during the settlement process in their calculation of long-term Rx use

14.  Avoid treatment delays – consider “fast track” treatment preapproval. (Dawn)

     a.      Identify treatments that do not require pre-authorization for good facilities and clinicians because unnecessary denials / delays are the primary reason injured workers seek an attorney

15.  Use an advocacy model. (Monica)

     a.      Showing respect and being an available resource can help facilitate a return to function

16.  With prosthesis selection, the most advanced isn’t always the best. (Kim)

     a.      A body-powered device may be best for their style and pace of life (check out eBay for unused prosthetics)

17.  Being off work is a medical emergency. (Marcos)

     a.      The increased negative effects to financial, social, emotional and physical means RTW could actually be a life-or-death matter

18.  Proper health care provider follow-up with employer when needed. (Anas)

     a.      The employer is responsible for lines of communication and lack of follow-up increases the possibility of staying out of work

19.  Make sure medical providers treating injured workers are aware of Beers Criteria. (Phil)

     a.      Proper use of prescription drugs can be different for geriatric patients (https://qioprogram.org/sites/default/files/2019BeersCriteria_JAGS.pdf) just like pediatric patients

20.  Avoid overutilization of occupational medical clinics over specialty referrals. (Dawn)

     a.      Use the right provider at the right time, not just what is most convenient, to get the injured worker as well as possible as fast as possible

21.  Understand there may be outside factors. (Monica)

     a.      So many things can affect the claim beyond the injury – children, disabled family members, caring for parents, depression, socioeconomic pressures

22.  Use data for insights. (Kim)

     a.      Use data to identify and address deviations from the norm, and not just from providers but also info from the injured worker

23.  Use nurse case managers strategically. (Marcos)

     a.      They have skills in both healthcare and the administrative system and understand the biopsychosocial approach to treatment

24.  Proper planning and tracking of employee MSD issues, ensuring effective treatment plan. (Anas)

     a.      Be involved and show concern by helping step-by-step and utilizing the right protocols / treatment / methodology

25.  Ask your pharmacist. (Phil)

     a.      A hopeful future where prescriptions are filled via AI to free up the pharmacist to counsel each patient on proper use

26.  Catastrophic claims are different! Catastrophic claims are not different! (Dawn)

     a.      Claims handling basics don’t change regardless of the severity of the injury, but catastrophic claims require extra communication and expertise

27.  Engage the resources available to you. (Monica)

     a.      Itemize all of the available resources and implement metrics for accountability in using and applying them appropriately

28.  Address specific needs for post-op/post-hospitalization facility care selection. (Kim)

     a.      The controls provided and expertise required by Work Comp is unique so constantly evaluate the most appropriate venue (e.g. skilled nursing facilities vs. in-patient rehab)

29.  Look for ways to make physicians’ lives easier. (Marcos)

     a.      Making the lives of good physicians “easier” is thru reduced administrative burden, fast-tracking requests and consistent communication standards

30.  Cohesive approach including wellness and preventive services. (Anas)

     a.      Take a step back on how comprehensive wellness programs support the health needs before an injury occurs (or even preventing it)

31.  Dear Doctor – how will a urine drug screen impact my injured worker care? (Phil)

     a.      Appropriate frequency depends (once/year with no red flags, once/quarter with some red flags) but always ask doctor how the report will be used

32.  Listen to the injured worker. (Dawn)

     a.      Active listening helps put disparate pieces of intel together into the puzzle of motivation for RTW

33.  Be open to leveraging technology. (Monica)

     a.      Technology is shifting / progressing all the time – and some states aren’t – so adaptability should be your keyword

34.  Carefully monitor and manage transition through the continuum of care. (Kim)

     a.      Care coordination does not happen by coincidence, so using predictive analytics and evidence based medicine can help prepare a strategy

35.  How do you evaluate medical providers? (Marcos)

     a.      The best metrics are total cost of claims and disability duration

36.  Specific referral time frame based on each type of health issue. (Anas)

     a.      Talking to the injured worker on a regular basis and timely follow-up will help get them where they need to go

37.  There’s no such thing as a new opioid! (Phil)

     a.      Big Pharma repackages drugs but the same ingredients (or metabolize into the same chemicals) don’t lead to increased clinical benefit

38.  You do not know everything – consult experts as needed! (Dawn)

     a.      Don’t be afraid to consult with experts, for example paying a doctor to develop deposition questions

39.  Know the best timing to do an IME or FCE. (Monica)

     a.      The wrong timing could backfire by prompting litigation

40.  Set patient expectations for recovery. (Kim)

     a.      Most injured workers have not had this kind of injury before so explain the normal timeline and process for recovery

41.  Simplify utilization review. (Marcos)

     a.      Good UR reduces the variance of care by applying evidence based medicine standards and both protects the injured worker and validates the competence of the network

42.  Detailed intake script, no time limit on triage provider/employee conversation. (Anas)

     a.      Getting accurate, detailed information ASAP during intake will establish the standard of someone listening to them

43.  Clean out your medicine cabinet. (Phil)

     a.      The first target for a home invasion / burglary heads is the medicine cabinet

44.  Know when to make an exception – every claim is not the same. (Dawn)

     a.      Comorbidities and psychosocial issues create uniqueness so identify outliers early

45.  Know your panel of medical providers. (Monica)

     a.      Setup a meeting every six months to identify trends and create a collaborative relationship (at their office and at your office – context is helpful)

46.  Review long-term files for current home health and DME needs. (Kim)

     a.      DME wears out over time, auto-renewals become outdated (e.g. biohazard supplies needed upon hospital discharge but not for life)

47.  Don’t expect a silver bullet. (Marcos)

     a.      The toolbox needs to have many tools and everybody needs to be willing to use them

48.  Good care coordination plan. (Anas)

     a.      The employer needs to leverage the opportunity to support the practitioners and identify process improvements

49.  What has the DEA done for you lately? (Phil)

     a.      They list publicly every provider they are investigating / has been convicted at https://www.deadiversion.usdoj.gov/crim_admin_actions/index.html - Are they in your network?

50.  Read utilization review non-certification decision and override when necessary! (Dawn)

     a.      Just because a UR decision is denial – encouraging friction – will it help everyone achieve the ultimate goal of return to function/work?

51.  Don’t deny-deny-deny. (Monica)

     a.      Don’t deny due to a technicality (e.g. help them fill out an incomplete form)

52.  Have on-site safety supervisors respond compassionately. (Kim)

     a.      The biggest factor in RTW is trusted and open first responder (i.e. supervisor) that can quickly guide them to where they need to go and how they need to get there

53.  Explain medical benefits clearly to the injured worker. (Marcos)

     a.      Injured workers can be afraid of the medical and administrative systems because of their foreign language and obtuse processes, and fear increases the cost of a claim while slowing down RTW

54.  Go beyond pain scale with questions that better determine degree of pain. (Anas)

     a.      Are you able to walk? Do you have difficulty breathing?

55.  Know the five steps to follow before administering naloxone overdose drug. (Phil)

     a.      Call for help, check for signs of overdose, support the person’s breathing, administer naloxone, monitor their response (https://www.integration.samhsa.gov/opioid_toolkit_firstresponders.pdf)

56.  Review utilization review practices annually. (Dawn)

     a.      Look at the data for approve/deny, give claims the authority to override when it makes sense, and develop a fast-track system for the good providers

57.  Take a pause on how you view consequential psych disorders like depression. (Monica)

     a.      Don’t auto-deny but put limits on it to get “over the hump” on a case by case basis

58.  Maintain current job descriptions including detailed physical demand requirements. (Kim)

     a.      Self-report on job descriptions are highly unreliable so having an objective job description helps create a plan to build up to goals at an appropriate pace

59.  Medical practice guidelines are guidelines. (Marcos)

     a.      Evidence based medicine identifies the right way to do it for the general population but it’s important to know how to apply it to this specific injured worker

60.  Complete medical records. (Anas)

     a.      Accuracy and completeness from first report of injury is important for the full picture

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