An MD Offers Ideas About Workers Compensation Cost Solutions

Having practiced occupational medicine for more than 25 years, I know the root cause of much of the waste and the unnecessary costs in workers compensation. When employees are evaluated by medical providers for claimed work-related injury, what occurs in the examination room is the major determinant of the direct and indirect costs resulting from the alleged injury. The communication between patients and providers sets the course of the medical evaluation and treatment of each claimant.

Diagnoses, medication choices, imaging orders, therapy decisions, patient education, surgery referrals, and return-to-work decisions are usually based on the interchange in the examination room. I have specific proprietary proposals by which large worker compensation insurers can increase the safety, cost-effectiveness and clinical effectiveness of what happens in all the examination rooms in which their insureds are evaluated and treated**. Claims managing, bill review and re-pricing, etc. are all after-the-fact efforts to control the costs resulting from decisions made in the examination room.

Of all work-related medical complaints, back pain is the complaint accounting for the greatest cost and is arguably the most mismanaged condition in occupational medicine. Dr. Nortin M. Hadler, a professor of rheumatology at the University of North Carolina, has studied the issue of work-related back pain for decades. He has conducted extensive unbiased reviews of published studies of the effectiveness of various medical tools used to evaluate and treat patients who complain of regional back pain.

He defines regional back pain as “backache suffered by working-age adults who are otherwise well and that occurs in the course of customary activities without neurological damage.” In his excellent book: Stabbed in the Back, Dr. Hadler states the evidence-based conclusion that the various therapies, imaging studies and surgeries commonly ordered by medical providers for regional back pain offer no benefit over a non-steroidal anti-inflammatory medication (e.g. Motrin, Advil or Aleve) and advice to continue activities as tolerated. Just imagine the cost savings if every occupational medicine provider were to learn what Dr. Nortin Hadler is teaching about the management of regional back pain!

Several specific problems converge in the examining room to generate unnecessary costs when workers complain of back pain:

1. Patients often expect an MRI to “find the problem.”

2. Providers often order MRIs expecting to “find the problem.”

3. Providers often do not check for “symptom magnification.”

4. Providers often prescribe what the drug rep suggests for back pain.

5. Too often narcotic medications are inappropriately prescribed.

6. Many providers consider every back pain to be a case for physical therapy.

7. Patients with regional back pain are prematurely sent to orthopedists.

8. Too often patients who could do modified duty are kept out of work.

9. History of past back complaints is often not documented by treating providers.

10.Too often patients’ fears about back pain are not well addressed.

These problems drive up the cost of back pain evaluation and treatment. They ramp up expenses for disability payments and generate additional costs for replacement workers who must take over when employees are medically excused from work.

Perhaps the strongest adverse effect of the examination room encounter between patient and provider is the negative mindset patients can develop as a result of overtreatment. Although I have no studies to prove this belief, it is my perception that overtreatment of regional back pain can worsen patients’ perception of prognosis. After being given a prescription for a narcotic pain medication, a prescription for an MRI, a prescription for four weeks of physical therapy and a note to take a week off from work, how can a patient not conclude that s/he must have sustained major damage to his/her low back when s/he bent over to pick up that piece of paper at work. (WCxKit)

For many years, I have used a basic “Back Care” patient information booklet to help educate patients with regional back pain. The booklet**, authored by back specialists from several well-known medical centers, describes basic anatomy of the back and informs patients that back pain is common and generally transient. The booklet includes pain relief and conditioning exercises that I “assign” patients to do in the comfort of their homes. Rarely have my back pain patients needed physical therapy. Most go to modified duty after the first office visit and to full duty one to three (depending on the demands of their regular duty) weeks later.

In every occupational medicine exam room encounter, top quality care and top value occurs when medical providers choose the safest, most effective and most cost-effective course of management for regional back pain and for all the many other work-related complaints our patients bring to our examination rooms. Our decisions should not be driven by patient preference, drug rep recommendation (remember Vioxx), our fear of being sued, nor the “bottom line profitability” of our clinics. Our medical expertise and our medical procedures and options should be solely focused on appropriately and efficiently promoting the claimants’ (i.e. our patients’) return to full productivity.

**for details, contact Dr. Evans at nrevans@comcast.net

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