Rousmaniere: How to Improve Surgical Outcomes

Many injured workers who undergo spinal surgery fail to benefit from it.  There are two main explanations. One is that the surgeon did a procedure that was not really suited for the spinal problem. Another is that the patient (her or himself), due to other health or behavioral problems, was a risky candidate. Workers’ comp claims payers, sometimes with the support of state regulators, have been trying to bend the curve of poor results, with increasing sophistication.

 Here we track the emergence of strategies by claims payers.  They all try, in effect, to balance surgical with conservative care. 

One approach is formal pre-approval of surgery through utilization review (UR).  Robert Bonner, the former medical director of the Hartford, calls it an “imperfect” tool. He says that the evidence based medical guidelines used in UR “are pretty narrow,” but their practical value varies according to state law.  Only about a third of the states mandate UR or the use of evidence-based guidelines.  Another approach he notes are medical provider networks, but their practical value also varies by state. About half the states leave choice of medical provider entirely in the hands of the injured worker.

Every claims payer who makes a serious effort to improve surgical outcomes knows how important it is for surgeons to decline to perform when the conditions are not right.  In 2010 a landmark study showed the danger.  Trang Nguyen compared lumbar fusion surgery outcomes with non-surgical cases among Ohio injured workers.  She found that 76% of fusion patients continued to use opioids, at higher doses than before surgery, and they had much worse return to work rates than non-surgical cases. 

Stephen Woods, the Ohio Bureau of Workers’ Compensation’s (BWC) chief medical officer between 2012 and 2017, told me that “People love their surgeons.  There is a two-year window when it is better, than it gets worse.”

The BWC took a leap with patient education when, on Jan. 1 of 2018, it published a brief explanation of risks and comparative results of spinal fusion surgery with conservative care. Both the injured worker and her or his prospective surgeon must acknowledge they read the form. Available online here, it distills years of research (including Nguyen’s) into layman’s language.

The BWC also tightened up its UR process.  The form is part of new regulations that prescribe steps surgeons need to take, including conservative care, before they perform a spinal fusion.  The new regulations are here.  Washington’s Labor and Industries started down this path about a decade ago.  Ohio’s approach was a home-grown project involving stakeholders and in-state medical schools.

Another strategy for the claims payer is to invest in medical experts.  Best Doctors Occupational Health Institute uses this strategy for its claims paying clients in New England.

Michael Shor, managing director of Boston-area BDOHI, is concerned that the worker who smokes, has a high BMI or other pre-injury risk factors is at much greater risk for surgical failure. Shor’s loss data shows that injured workers are almost twice as likely as the general population to smoke.

He says that far too often, it is the same surgeons that don’t pay attention to these personal characteristics.  He finds surgeons vary widely in prescribing conservative measures. He told me, “Finding the right non-surgical approach, be it cognitive behavioral therapy, yoga, physical therapy, or acupuncture, takes time. It’s magical thinking to believe that patients know how to find the right path by themselves.” Surgeons when they decline to perform often say “I cannot help you, go somewhere else.”  He does not say, “I am going to stay with you.”

Shor has mapped how to get to the surgeon. The best way, he says, is through the injured worker’s attorney if one is present. Then to engage with the surgeon, one needs to use another surgeon. He says, “We have been successful at identifying them.  We look for those with healthy egos, a commitment to public health, are considered by their colleagues to be expert in their specialty and not afraid to constructively engage with their peers.  You will see this in how they manage their own active medical practices.”

These strategies are not mutually exclusive. Such is the case with yet another strategy, which is intensive data analysis to predict which surgeons will perform better.  Clara Analytics manages a common database for participating claims payers. Greg Moore, an executive with the firm, says that with hundreds of thousands of surgeries, the firm has enough data to evaluate many surgeons. He says there are “significant differences between doctors in multiple surgeries, temporary and permanent disability” and other factors. These differences can be material to the injured worker, for instance, in not having to go to a second surgery, and restoring a better range of motion. 

Whether or not they like to own the phrase, claims payers are trying to influence the practice of surgery by nudging providers and, where feasible, picking the ones they like. Health care practice changes very slowly. Balancing surgical and conservative care is an innovation, and innovations often take 15 years to come about in healthcare.

Marc Miller, a former medical director of a workers’ comp insurer and now medical director of large multi-disciplinary medical clinic in Seattle, says that the insurer needs to do a mix of performance screening of surgeons, peer consultation, and patient education.  “The choices are not either or,” he said.

ABOUT THE AUTHOR

Peter Rousmaniere is widely known throughout the workers’ compensation industry, both for his writing and consulting experience. Based in the picture perfect New England town of Woodstock, VT, he is a regular on the conference circuit, and is deeply in tune with trends and developments within the industry. His passion is writing and presenting on issues largely related to immigration, and he maintains a blog on the subject at www.workingimmigrants.com.

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