I was reviewing an article that was of no surprise to me: Insurance companies are getting even worse at dealing with back pain.
(http://archinte.jamanetwork.com/article.aspx?articleid=1722522)
Stop the presses! Yes it is true. Even if you still get your news from an actual hard copy of a newspaper, you must have seen at least one article about physicians failing to be proactive with back pain, especially when insurance injury scenarios are present. This is because doctors are really fantastic at making money. As long as there is a demand for care, doctors will continue to benefit.
Time for my normal disclaimer: Not all doctors are bad and trying to abuse the system. However, it seems that article after article is studying the ways that back pain was handled in the past, compared to how it is handled now.
Why is this? Well, if I am a marketer at a pharmaceutical company, I am not going to make much money unless I have some doctors on board with my products. In order to get them on board, I market my product’s to doctors, a lot of doctors. Maybe I choose to market to doctors who have a large workload of work comp care, or auto accident victims. Maybe I market to every doctor who will let me in their waiting room. Marketing is a numbers game. The more places you get in to, the more business you should eventually get.
Good Business and Good Medicine Often Conflict
But it is not just the marketers that are the problem. Due to increased litigation, depositions, injuries, and so on some of the doctors themselves have become part of the problem. Instead of dealing with treating the patient, all of the sudden the patient becomes in charge of steering care. They want Vicodin. They want an MRI. They want a CT scan. They want physical therapy. They want this. They want that. Since when did Joe Worker have “M.D.” after their name? In order to avoid conflict, the doctor is sure to please in most cases. This is because if they fail to do as the patient wishes, they leave the care of said provider and find a doctor that will listen to them and one that will give them what they want. As I have said before, if you have an empty waiting room you are a fantastic doctor and a terrible businessperson.
For example, going back to the article I was reviewing, acetaminophen treatment decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010. But narcotic use jumped from 19.3% to 29.1% in the same time period. Not only is this ineffective, but the cost is insanely higher. You can get Motrin at any store for under $10 for a big bottle. Narcotics can cost in the hundreds per month, and those RXs are filled month after month after month, even when the patient tells the doctor that they are not helping.
The culprit is not just narcotic use. The study also notes that X-ray referrals stayed about the same, but CT scan and MRI use jumped from 7.2% to 11.3%. Depending on the jurisdiction you are in, an MRI could cost anywhere from $850 to over $3,000. Even when the clinical signs that warrant an MRI are absent, patients are still being sent for them, often at their own request.
In the past, you had back pain, you were prescribed an acetaminophen and sent for physical therapy. This is not always the case in present time. During the above-mentioned study, PT referrals remained constant, but physician referrals spiked from 6.8% to 14%. It takes time for a patient to get in to see specialists, and this stretches out the time they are out on work comp wage loss. It extends the life of the claim. Patients do not think that a primary care physician or occupational doctor is well-equipped enough to handle their “back pain” and they want to see an orthopedic surgeon. This is true even if the clinical signs do not necessarily warrant referral to a spinal specialist.
Adjuster Has Tools At Their Disposal
What are adjusters to do? Sure the patient is not an MD, and neither is the adjuster. But the adjuster does have a few weapons at their disposal in order to steer the claim down the right path before it gets out of hand. One of the most important tools is the Independent Medical Exam (IME). An adjuster can tell right away if the personality of an injured worker is going to be difficult. If a few weeks have gone by and the patient states they have no improvement, even if clinically they are much improved, an Independent Medical Exam should be set up. This tells the injured worker right away that they are not going to be the one in control of steering the claim.
Another great tool is the onsite nurse case manager. The nurse can talk with the doctor, to really find out why this referral is being performed, or why this worker is prescribed strong narcotics for a standard back strain. Injured workers know that the nurse is there, so they cannot be in control of getting what they want.
The third weapon in the arsenal is when the adjuster knows their doctors, especially in a jurisdiction where you can steer the injured party for medical care. You can stop the worker from running to their Primary Care Physcian right from the get-go, and get them in to your occupational doctor who you know proven to provide good care without prescribing Oxycontin for a week-long back injury.
The employer has a duty as well to help the overall process. The sooner the employer gets the claim to the carrier, the sooner an adjuster can become involved. The longer the employer waits to call the claim in, the worse the outcome. This is because the adjuster needs to step in at the beginning to stop an issue from occurring. Injured workers hear many fables about what you can and cannot do when a work injury occurs. The only person that knows for sure though is the adjuster. So as an employer, save yourself the time and expense and get your claims called in right away.
Control of Claims Needs to Be Out of Patient’s Hands
In workers compensation, you have to take most of the control away from the patient. Failure to do this will result in failure of claim handling. Doctors are increasingly doing what the patients tell them, instead of doing what clinically needs to be done. This won’t last forever, but for now if this is the trend, then it is time for the adjusters to stand up and take control of these claims. They are the ones paying the bills, and they are the ones who have to authorize testing and procedures. Adjusters are sometimes just as soft as the doctors, and this needs to stop.
Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: [email protected].
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