Zachry: Medical Treatment in Workers Compensation

Quote: If your doctor’s last name is Google, you should get a second opinion.

System observations 

• In the workers compensation systems throughout the world, the first and most important benefit is medical care.
• The right medical care at the right time results in an earlier return to work, less permanent residual disability and a lower overall total cost of the claim. 
• All medical care in workers compensation should be focused on improving function, and (when possible) getting the patient back to work (full duties, modified duties, transitional return to work duties.)
• Medical benefits are usually defined as “All medical care necessary to cure or relieve from the effects of the injury”.
• Medical care is to be provided for the life of the injury (which may be the lifetime of the injured worker).
• Workers’ compensation medical care is first dollar and there are no upper limits to the medical expense (as compared to group health where there may be a deductible, as well as an upper cap on the total costs)
• The cost of Medical care is not apportioned between industrial and non-industrial factors (as compared to some jurisdictions where Permanent Disability is apportioned).
• Medical care may include the intervention with underlying nonindustrial medical conditions. For instance, it may be necessary to pay for and treat the non-industrial diabetes to help facilitate recovery from a broken foot.
• Some jurisdictions do not allow medical care to be settled. Some jurisdictions allow a lump sum to be paid which is intended to cover all future medical care expenses.
• To avoid cost shifting to the Medicare system there is a formal set-aside process to ensure that future medical care is paid for by the workers compensation system and not by Medicare. This process includes the reporting of all potential cases to the Medicare system. 
• States which have medical treatment fee schedules usually base them on the Medicare system (for instance 125% of Medicare for the same treatment)
• Evidence-based medicine is usually the right care at the right time for the legitimately injured workers. (There is a scientific hierarchy on the analysis of the methods to apply evidence-based medicine).
• In Workers Compensation, there are many (known and unknown) underlying non-industrial, economic, and psyche/social issues that may hinder or completely stop optimum medical recovery. For this reason, all involved in the system, adjusters, physicians, lawyers, etc. should strive to identify these obstacles and work to ensure resolution such obstacles that inhibit the return to full function.
• The medical results are always much worse if the employer does not offer light or modified duties or if the employer attempts to use the workers compensation system to get rid of marginal employees.
• There are currently enough treating physicians and specialty physicians in most urban areas. However, there are not enough physicians (treating, orthopedic or neurosurgeons, etc.) in the rural areas to meet the demand. Telemedicine can help solve the rural access problem. The access problem will worsen as the population ages and more doctors retire. It will also be compounded if physicians leave workers' compensation as the demand for their services increase due to the implementation of the federal universal health care programs. Medical treatment access is one of the biggest challenges which the workers compensation system faces.  
• Much of the system wide fight over medical issues is over what is known as “medical control”. Some states (Washington, N.Y. and a few others) do not allow any medical control by the employer or claims administrator with the belief that such medical control will result in limited or marginal care being provided or the belief that doctors who are under the control of the claims administrators will inappropriately push workers back to the job before they are capable of performing work duties. Other states give the employer or claims administrator medical control for a pre-determined number of days. Employers believe that unfettered control on the part of the injured worker results in increased medical costs and delayed return to work. 
• Though it is believed that there is cost shifting between the group health and workers compensation system, I know of no definitive study on which system is the giver and which is the receiver. Prior to the implementation of the Medicare Set Aside program there was cost shifting into the Medicare system for future medical treatment.
• Texas allows workers and employers to opt out of the workers compensation system. Many employers who opt out have greater controls on the length of time to report claims, and other system limits.

Financial issues

• Poorly (inappropriate) placed incentives in the workers compensation system result in poor medical outcomes. Several studies have been published showing abuse in this regard, including self-referrals, inappropriate dispensing of pharmacy goods from medical offices and other practices that may result in unnecessary services or inappropriate dispensing of drugs).
• A small % of the injured workers account for a significant % of the total medical spend. At two insurance companies and one self-insured, my numbers usually were 3% of the injured workers accounted for 60% of the dollars. I have seen figures for some employers and insurance carriers that 5% of the claims accounted for 80% of the medical spend. The high-cost claims are usually catastrophic claims such as quads, paras, severe burns, amputations, loss of vision and head injuries. The other high-cost claims are “Jumper” claims, also known as “Sisterhood of the Traveling Body Part Injury” claims. These claims were not driven by specific body parts or by severity of the injury but were driven by the poor coping skills due to the Adverse Childhood Experiences (ACE’s). They are claims involving workers who fell into the hands of the wrong doctor or attorney who pushed disability rather than encouraged return to work; which resulted in loss of job and total disability.
• A fee-for-service system may result in incentivizing physicians and others to inappropriately over-treat and over-utilize. Of note, in several jurisdictions Worker's Compensation is the last fee-for-service system. Experience has shown that a financial interest in a diagnostic tool or a program can result in over utilization of that tool or program (e,g., in-office MRI machines) – thus, safeguards to ensure appropriate judgement in these situations are strongly encouraged.
• In many jurisdictions Worker's Compensation is generally the last fee-for-service system. Most group health programs are not fee for service.
• Medical treatment fee schedules should be clear, easy to use, accurate and reflect the latest technology. Lack of clear definitions usually results in medical providers “upcoding” and bill review systems then “down coding” which adds to system wide administration expense.
• Standalone fee schedules do not result in control of medical costs in the workers compensation system. The control of worker's compensation medical costs requires both a fee schedule and an ability to limit unnecessary treatment. One without the others usually results in significant unnecessary medical costs for the system (over billing or over treatment). Evidence based medicine is the proven way to make sure the appropriate care is being provided.

Treatment

• Work really is the best medicine.
• An accurate diagnosis is the foundation for appropriate treatment. Obstacles to an accurate diagnosis include economically limiting the time the physician may spend with the patient, delays in the reporting of the claims resulting in delays in treatment, and financial incentives driving the silo approach of physicians to only focus on the specific injury rather than on the whole person.
• Injured workers recover faster and with fewer residual problems when they believe that they will recover, have confidence in the medical provider and confidence in the quality of the care being provided.
• The best medicine encourages the patient to engage with the recovery. Therefore, it is important for the physician to clearly communicate with the injured workers the diagnosis the reasons for the treatment and instill expected timelines for returning to work.
• Doctors who address the fear of re-injury with both the employee and employer have much better medical outcomes.
• Studies (CWCI) have shown that doctors who regularly practice industrial medicine have better results than physicians who only occasionally dabble in occupational medicine.
• Many people believe that when it comes to medicine “More is Better”. When evidence-based medicine treatment guidelines limit the number or kinds of treatment, it can be perceived as poor treatment rather than as the right medicine.
• Medical decisions for treatment should be made by appropriately trained medical professionals. Most Workers' Compensation judges, attorneys, and claims adjusters have little to no formal medical training and are not medical professionals. There are studies that show claims examiners make the correct decision (to approve or deny care) 48% of the time. This is worse than flipping a coin.
• Many surgeons and other physicians want to perform their craft (do surgery, provide injections, etc.). They believe that their surgery or injections will work even if the prior treatments have not been successful or if current evidence-based medicine says surgery is not appropriate. (This is known as if you have a hammer in your hand everything looks like a nail syndrome. Most surgeons want to perform surgery and believe that the patient in front of them is a surgical candidate.
• The skill level of the physician will not overcome the barrier of a poor candidate for a medical procedure. Therefore, it is important for the physician know the patient’s psychological make up as well as co-morbidities and symptoms.
• Patient advocacy is the process of ensuring the application of appropriate treatment, patient encouragement and facilitation of resolution obstacles to return to full function that allows the patient to remain as functional and productive as possible.
• Patient advocacy does not always mean the pursuit of the treatment a patient desires; but rather it involves the actions to properly inform patients of the facts and rationale(s) governing appropriate care in those cases where the patient’s desires for a particular treatment may be misguided. "If your doctor's last name is Google, It is time to get a second opinion."
• Patient advocacy may require the physician to decline to do the treatment sought by the patient when that treatment is inappropriate. In such cases, the physician should properly inform patients of the facts and rationale(s) governing appropriate care as part of his professional obligation.
• Physicians can get better results if they have an accurate job description from the employer, if there are light or modified duties available at the employers and if they are fully informed of employment issues or other psychosocial issues.
• Medical technology is rapidly changing. The advent of CRISPR can potentially eliminate all genetic diseases. The number of knee and hip replacements have dramatically increased as the working populations has aged and as the technology has improved. We will also be able to use remote sensing devices like Plethy to determine home compliance for PT.
• The workers compensation system does not encourage the use all the tools in the treatment toolbox to facilitate recovery. Examples of potential tools for full recovery are: Faith, Humor, Sleep and Nutrition.
• Elected officials in the Ca State Legislature were incensed when UR denied paying for aspirin (a $150 expense to say no to a $.01 treatment) however with the other drugs that the patient was taking if she had also taken the aspirin, she would have destroyed her kidneys. UR IMR is specifically designed to make sure the patient gets the right treatment. It was not intended to save money or limit treatment. In this case it also saved the patients’ life.

Pharmacy

• Pharmacy utilization is problematic because of the “Medicalization” of the general population. (Medicalization is the direct advertising of symptoms and diagnoses to the general population, to legislators and to guideline authors by drug and device manufacturers, resulting in an overuse and/or misuse of some types of drugs and therapies, and sometimes skewed recommendations based on scanty or non-existent evidence).
• There are significant problems with “compounding” of drugs in the worker's compensation system. It is currently one of the biggest areas of fraud and abuse in the workers compensation system.
• There is a significant trend for the “off label use” of drugs in the worker's compensation system. It is the use of a drug for treatment that was not the reason for its approval from the FDA.  Not all off label use of drugs is bad.
• Studies (WCRI) that when physicians dispense drugs out of their offices, they over dispense drugs which have questionable efficacy. They also do not have the capacity to monitor the pedigree of the drugs. They do not know if they are selling (or re-selling) counterfeit or stale dated drugs. Manufacturing of counterfeit drugs is currently one of the largest sources of hard currency for North Korea.

Pain

• When the injured worker is severe pain, they always believe that “doing something is better than doing nothing”. 
• If a surgeon says that surgery will not be successful in eliminating all the pain, the injured worker will attempt to find someone who will say that the surgery “will be more successful than not having surgery,” and will then attempt to have the surgery. For this reason, spending the time needed to properly educate patients as to the TRUE clinical outcomes of the proposed surgery noted in the peer reviewed medical, and of that surgeon’s outcomes, should be as mandatory as pre-surgical medical clearance.
• It is difficult for a patient who is in intractable pain to believe that not having back surgery will have the same ultimate result as having surgery when the surgeon is saying (with confidence) that the surgery will stop their pain. Even though current evidence-based medicine says differently.
• It is difficult for a patient who is in intractable pain to believe that strong medications (including opiates) are not appropriate or are not the best solution. 

Opioids

• Opioids remain one of the system cost drivers even after most States have instituted formularies.
• Even if the physician is not dispensing opioids out of his or her office, opiates require regular visits to the doctor for renewal of the prescription, medical assessments, and may involve expensive drug testing – which can generate additional revenue and may foster perverse incentives such as a financial interest for unethical providers to prescribe opiates.
• With the implementation of opioid formularies, many chronic opioid users have been cut off from their sources to opioids without appropriately going through weaning or detoxing. This has resulted in their use of street drugs such as fentanyl and heroin. The workers compensation system has not kept track of the deaths resulting from street drugs where the original addiction was the result of an industrial accident.
• Under no circumstances should opioids be prescribed or dispensed to children under the age of 21. It permanently changes their brains; not for the better.
• Some physicians who continue prescribe opiates do not fully appreciate the addictive power of the drugs that they are prescribing or the difficulty inherent in discontinuation of opioids, particularly for patients using opioid for chronic conditions. It should be mandatory that the patient is well educated on the dangers of opioids at the first dispensing of an opioid drug.

Fraud and abuse 

• Like all areas of the workers compensation system there is fraud and abuse in medical treatment. In California, most of the fraud is not associated with workers faking injuries, rather it has been physicians providing inappropriate and unnecessary medical treatment. Attempts to stop this fraud has made it more difficult (UR IMR and billing process) for the legitimate providers to practice medicine.
• UR IMR is intended to provide a treatment safety net for the injured workers. Almost 100% of the UR / IMR appeals for additional treatment in Ca are signed by attorneys and not by the treating doctors. The appeal for additional treatment has become an income generator for some system abusers.  
• California has a significant number of Cumulative Injury Application First Notice claims filed in LA, and Orange County. Not all CT claims are fraud.  However, the volume of these cases are an example of abuse by identifying weakness in the system and then exploiting the weakness. There are groups of “Cappers” who sign up unsuspecting citizens with promises of “Free Medical Care” and then get paid for referrals to chiropractors, treating doctors, MRI companies, translations services, transportation services, physical therapy, etc. This abuse significantly drives up the medical spend in California.
• Some workers compensation claims are filed when employees are laid off. This can be an attempt to maintain medical coverage.
• One example of potential medical fraud is when a WC claim is filed to avoid paying the deductible in the group health system. I have personally found this to be quite rare. The advent of multiple security cameras in the workplace has rendered this scenario unlikely.
• Opioids are a significant source of fraud. Doctors and addicted injured workers have significant financial incentives to abuse the system. Methods are not to dispense the same number of pills as written on the prescription, or having the patient give the doctor some of the pills which were dispensed from the pharmacy for re-selling.  Diversion is a problem.

Share This Article: