Reduce Overall Costs of Work Comp Claims With “Direct to Specialist” Approach

Would a “Direct to Specialist” orthopaedic approach significantly reduce the overall cost of workers’ compensation claims in comparison to the managed care approach?


We are all aware that the factors which rapidly increase the costs of workers’ compensation claims are: Time off Work, Delayed Treatment of Injuries and Prolonged Medical Care. While an early return to work program is imperative to reducing disability costs of a claim (10%-15%). What about the medical and surgical costs?  


I believe that providing the highest quality of care and the most cost effective approach to reduce the cost of claims is through the “Direct to Specialist” approach.


Pre-employment physicals, drug testing, safety and risk management are prominent aspects of a company’s occupational health program. However, the most costly aspects are injuries, with most of them being orthopaedic in nature.  This includes acute injuries and chronic conditions as well.



What does it take?


Implementation of the Full Spectrum of On-Site Services: Orthopaedic Immediate Care, Occupational Health Services, Case Management, Physical and Occupational Therapy, ancillary services such as X-Ray, MRI, Ultrasound, EMG, as well as an Orthopaedic Ambulatory Surgery Center.


Will a “Direct to Specialist” approach reduce Time off Work, Delayed Treatment of Injuries and Prolonged Medical Care when these services are in one location and are managed under the direct supervision of Orthopaedic Specialists? YES


Orthopaedic Immediate Care means that employees are seen by Orthopaedic Specialists immediately after an injury occurs. Definitive care is provided immediately, whether that individual needs physical/occupational therapy, fracture care, laceration repair or surgery.


The fallacy is that referring directly to a specialist will increase the costs of claims. However, this is falsely based upon the incorrect reasoning that referral to an Orthopaedic Surgeon means that the patient will have surgical treatment as the first option.  All patients are treated with conservative measures at the outset and surgery only considered if non-operative measures fail to resolve the condition.  This of course excludes acute injuries which may require immediate surgical care.


In fact Atcheson, et. al. demonstrated as much as a 63% percent decrease in the cost of claims when patients were referred directly to specialists for their workers’ compensation injuries.  This was true even when specialists were paid at rates higher than for occupational health providers and primary care physicians.





One major difference they found is that the timeline of conservative treatment will be managed appropriately and not extended beyond a reasonable time period for resolution of a patient’s condition before surgery is considered. Furthermore, therapy will not be instituted when it is shown that injections alone are the mainstay of conservative management before surgery becomes necessary.  These two measures alone reduce substantially the costs of claims by eliminating unnecessary occupation and physical therapy prior to surgical reconstruction. Furthermore what is also not considered is the effect of prolonging painful conditions before definitive treatment is instituted? This only serves to prolong the post-operative course, as well as, increasing the amount of post-operative occupational/physical therapy which is required to return an employee to full active duty.  This increases both the medical and TTD costs exponentially.



Managed Care approach: (Example)


An employee who sustains a wrist fracture on a Thursday is sent to the urgent care clinic/emergency room (1-3hrs waiting) and is given a splint. They are then referred to see an orthopaedic specialist, perhaps unable to get an appointment until Tuesday or Wednesday, 5-6 days after the incident. The orthopaedic surgeon will need to re-take the x-rays to ensure that no fracture displacement has occurred since initial injury. At this point a cast will be applied if appropriate or the patient will be scheduled for surgery at the next block time day the surgeon operates. This can add from 1-5 additional days before definitive care is given. We are now approximately 6-12 days from the occurrence of the injury and your employee is out of work and is experiencing pain and yet to have definitive treatment. Is this the best way to manage and reduce your TTD and Medical costs?



“Direct to Specialist” approach:


An employee who experiences a wrist fracture on a Thursday, is now sent directly to the orthopedic specialist for immediate evaluation. X-rays are taken, a diagnosis is made and a plan of care implemented at the initial visit. A cast is applied if appropriate and the employee is sent back to work modified duty SAME DAY OR NEXT DAY.  Surgery, if required, is performed the SAME DAY OR NEXT DAY next day at an on-site Orthopaedic Ambulatory Surgery Center which costs 30-40% less than hospital facility fees.



Managed Care approach VS “Direct to Specialist” approach? You do the math


With a “Direct to Specialist “ approach no longer would an employee need to utilize costly emergency room services, urgent care centers or traditional occupational medicine clinics only to be stabilized and then triaged to the specialist for definitive care for an acute injury.  Furthermore, this would eliminate the repeating of much conservative management after initial orthopaedic referral for a chronic condition or in many cases eliminate altogether unnecessary physical and occupation therapy which is often prescribed for conditions for which corticosteroid injection therapy alone is the mainstay of conservative treatment such as Dequervain’s tenosynovitis.

Furthermore, the “Direct to Specialist” model will not only serve to improve employee morale following their injury, as they will see their direct referral to a specialist as concern on the part of their employer to ensure they obtain the highest quality medical and surgical care for their injury. This combined with an Orthopaedic practice with a strong return to work policy, and employer who institutes a restricted duty policy and you can see where the cost savings on a claim can be substantial.  This does not even factor into the equation that your employee is less likely to obtain legal representation when their impression is that their employer cares for their wellbeing.

As an employer, you have many aspects to your business. You must provide for the health and safety of your employees, reduce the ancillary costs of conducting business through aggressive risk management while maintaining growth and profitability. Reducing the costs of your workers’ compensation claims is an important component of your risk management program.



Author: David Adam, Work Comp Director/Practice Developer, MidAmerica Orthopaedics. David brings over 15 years of experience in business management and development to MidAmerica Orthopaedics. David develops relationships with surrounding businesses and communicates services that are available and beneficial to reduce business costs as it relates to workers compensation. He strives to educate, train, and mentor internal staff and fellow businesses on the benefits of a “Direct to Specialist” approach, adequate Return to Work and Occupational Health Programs.



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