The Examination Room
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. (WCxKit)
Back Pain: A Great Case In Point
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.
Author: Nathaniel R. Evans, II, M.D., FACEP is a board-certified occupational medicine physician. He has designed a comprehensive cost-saving program by which a major w/c insurer/payer can remove root causes of unnecessary medical costs and secure evidence-based medical care for w/c claimants nationwide while realizing substantially reduced indemnity payments. Contact Dr. Evans at:
nrevans@comcast.net or 609-351-9734.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
Dr. Nathaniel Evans has been very successful in helping his employer-clients reduce their workers’ comp costs by 50%, and because I have been a huge proponent of using MD's to better manage workers' compensation programs, I thought I'd write about it to let others in on the secrets. These are the eight techniques he uses.
8 Ways to Reduce WC Costs
#1 Time
Doctors are noted for impatience. One study reported that, when listening to patients’ problems, doctors allow patients (on average) 17 seconds to speak without interruption. In occupational medicine, it is critical that the physician acquire an accurate understanding of what the patient is claiming to be the setting, the time, and the mechanism of injury. The patient must be allowed uninterrupted time to describe the injury and the circumstances (time, place, witnesses, etc.) of the injury.
#2 Really Listen
It is so easy for a busy doctor to be distracted by the pressures of the practice. It is very important the occupational medicine physician pay close attention to what is being said and what is being implied by the patient. The tone, content and “meta-messages” in the patient’s words can speak volumes about the patient’s motivation to get better, attitude towards work and impression of the co-workers and supervisors. Information picked up between the lines can help explain why a patient is presenting with symptoms in excess of what the stated mechanism of injury would cause the doctor to expect. Such an explanation can help the physician nudge the patient back to full productivity and help prevent unnecessary lost time.
#3 Examine For Objective Information
Sir William Osler, a professor of medicine who helped establish Johns Hopkins as a world-class medical school, taught that the patient’s history is the doctor’s key to the diagnosis. Dr. Osler practiced medicine before workers’ compensation became law. Occupational medicine physicians must know the patient’s history is subjective and may be the key to the diagnosis. Objective signs should be valued more highly than subjective data. Objective data includes swelling, redness, spasm, vital signs, X-rays, EKGs, lab reports, digital imaging, EEGs, etc. Presence or absence of objective signs can help establish a diagnosis and can help authenticate or invalidate a claim of work-related injury. Some objective signs can suggest that the injury is real but was not caused by work.
#4 Defer to Personal Physician When Appropriate
Sometimes, patients present to occupational medicine physicians (intentionally or unintentionally) with problems not caused by work. Sometimes the described mechanism of injury just does not fit with the complaint, the symptoms and the signs. In those situations it is usually appropriate to consider the problem “not work-related” and refer the patient to their personal physician for examination and treatment. Having the patient sign a statement agreeing to see the personal physician ASAP is a useful way to document the referral.
#5 Look For Signs of Symptom Magnification
Just as a well-prepared lawyer does not ask a question without knowing the answer, the examining physician should have some idea (based upon the patient’s history of the injury) of what responses to expect from the patient at each phase of the physical examination. Specific validity tests can be used to assess the authenticity of a patient’s responses to physical examination. When discrepancies are noted, the physician should look for underlying non-physical causes of the complaint and should not just send the patient off to physical therapy hoping for improvement. Discrepancies are also a reason to reach out to the patient’s supervisor for information from another point of view.
#6 Reassure the Injured
The word “doctor” originates from the Latin word for teacher. Very often, patients need to be taught about their injury. Patients often have unjustified fears and perceptions following minor injury. Patients’ questions need to be anticipated and answered. For example, typical (stated or unstated) questions about back pain include:
1. Could this back injury make me paralyzed?
2. Shouldn’t I stay home until ALL my pain goes away?
3. Don’t I need an MRI?
When appropriate, physicians should provide reassurance to patients and give clear, brief and succinct answers to patient’s questions. We should endeavor to acquaint patients with the basics of what to expect during the recovery process. Even more importantly, we should give patients specific ways (e.g. exercise, stretching, ice, heat or injury care instructions) to expedite recovery. Instructions for wound care or medication usage should be stated clearly and should also be given in written form. Patients who understand their injury and who understand what they can do to expedite recovery generally feel empowered.
#7 Be Familiar With the Workplace
Workplace visits give occupational medicine physicians understanding of the settings from which injured workers come for medical care. Such understanding can increase a doctor’s ability to appreciate the stresses and demands of the workplace. It can also help a physician evaluate the authenticity of patient complaints. I’ve noted that workplace visits also have the effect of causing injured employees to view the doctor as more informed and more credible because the doctor has some understanding of the workplace.
#8 Utilize Modified Duty When Needed
Of the injured workers who cannot safely return to their regular duties, most can be accommodated in a modified duty position. Employers who do not offer modified duty miss a valuable opportunity to keep workers productive, keep them away from daytime TV, and keep them in the habit of reporting to work daily. When employees spend extended time at home and away from work, some develop a reluctance to return to the workplace. (workersxzcompxzkit)
Summary
An experienced occupational medicine physician can have a massive effect on the quality and the cost effectiveness of occupational medicine care. Unlike patients’ private or personal physicians, the occupational medicine physician cannot be a pure advocate for the interests of patients. Although committed to optimal medical treatment of the patient, the occupational medicine doctor also endeavors to maximize patients’ productivity, minimize lost time from work and limit testing and therapy to what is actually medically necessary. An experienced, attentive and skilled occupational medicine physician can produce great benefits for both patients and employers. The cost savings can be astounding.
Author Nathaniel R. Evans, II, M.D., FACEP, is Medical Director of the Burlington Medical Center in Willingboro, New Jersey. A graduate of the Johns Hopkins School of Medicine, he is board certified in Internal Medicine, Emergency Medicine, Addiction Medicine, and Occupational Medicine. Dr. Evans has been successful in helping employers greatly reduce costs associated with workers’ compensation. Dr. Evans has served as an expert witness in cases involving occupational medicine, emergency medicine and internal medicine. Attorneys praise him for his clear and effective expert reports and expert testimony. He can be reached at nrevans@comcast.net.
Podcast/Webcast: Claim Handling Strategies
Click Here :
http://www.workerscompkit.com/gallagher/podcast/ Claim_Handling_Strategies/index.php
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers' comp issues.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
Here is a true story about how one doctor successfully helped his client-employers reduce workers’ compensation costs by 50%. And further reductions are seen in lost time, light duty days, replacement workers costs, and cost of treatment of employees who claim work-related injury.
His name is Dr. Nathaniel Evans – let’s read his story. Thank you for the contribution, Dr. Evans. It is very enlightening.
As I reflect on almost 25 years of solo practice in occupational medicine, I am grateful for the opportunities I have had to help my clients (employers) and their employees meet their objectives of health, prosperity and productivity.
When I bought my occupational medicine practice, after serving for six years as Chief of the Emergency Department of a local hospital, I entered the practice with a commitment to serve the needs of my patients and their employers with attentive, compassionate, effective and cost-effective care. I know I’ve succeeded in my mission when I am greeted by smiles from patients returning for follow-up visits, annual examinations or new injury treatment.
Equally important to me are the statements from clients telling me I have reduced their lost time, OSHA recordables, and workers’ compensation costs by 50% or more. The principles I’ve used are universal and they work when applied.
Unfortunately, the tendency of most occupational medicine organizations is to seek low-cost providers (often nurse practitioners or physicians’ assistants) to provide primary care in occupational medicine. Such providers often lack the experience and the depth of clinical understanding to allow them to optimally and cost-effectively manage the spectrum of clinical problems seen in an occupational medicine office.
My clients have much to say about savings resulting from my services. Just one year after switching from a local hospital’s occupational medicine service to become my client, the Mid-Atlantic Distribution Center for a very large chain of restaurants wrote to me and reported having seen a more than 50% reduction in lost time and light duty days as a result of my services. He further reported his employees were pleased with the “family doctor type attention” in my office.
Two years after becoming my client, a food processing company employing 500 workers reported, “Our lost days have been reduced drastically: well over 50%.”
The Safety Manager of a plastics manufacturing plant employing 104 people reported that after just two years, my services saved his company $309,000 or $1,485 per employee per year.
Two of my clients (manufacturing companies) each achieved 1,000,000 work hours without a single lost-time injury.
How Did These Substantial Savings Occur?
The underlying essential ingredient making such savings possible is goal-oriented, attentive communication between doctor and patient, coupled with (when necessary) communication with employer, or employer representatives. When such communication is exercised by a knowledgeable occupational medicine provider whose goal is to expedite the safe return of injured patients to productivity and to avoid ineffective or unnecessary medical procedures, tests or therapies, patients do well and employers experience dramatic savings.
Author Nathaniel R. Evans, II, M.D., FACEP, is Medical Director of the Burlington Medical Center in Willingboro, New Jersey. A graduate of the Johns Hopkins School of Medicine, he is board certified in Internal Medicine, Emergency Medicine, Addiction Medicine, and Occupational Medicine. Dr. Evans has been successful in helping employers greatly reduce costs associated with workers’ compensation. Dr. Evans has served as an expert witness in cases involving occupational medicine, emergency medicine and internal medicine. Attorneys praise him for his clear and effective expert reports and expert testimony. He can be reached at nrevans@comcast.net.
Podcast/Webcast: Claim Handling Strategies
Click Here :
http://www.workerscompkit.com/gallagher/podcast/ Claim_Handling_Strategies/index.php
We accept articles about WC cost containment. Contact us at: Info@WorkersCompKit.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers' comp issues.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@WorkersCompKit.com
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