December 14, 2017

Mark Pew: Paying for the Person

By Mark Pew, Senior Vice President, PRIUM

Mark PewBioPsychoSocial is a popular buzzword in workers’ compensation. Some have recently added Spiritual (not necessarily referring to religion, but a person’s relationship with transcendence). Every conference talks about it in some way, shape or form. If the audience is listening, they’ll hear tips on how to treat the “whole person” by addressing not just the physical ailment but also the psychological, emotional, and social environment. Terms like “worklessness, enablers, and adverse childhood experiences” are presented as potential disruptors to the willingness or ability to get better. Modalities like functional restoration, cognitive behavioral therapy (CBT) and mindfulness are mentioned as potential solutions. Strategies like an outcomes-based payment (rather than fee-for-service) model, patient advocacy (empathetic) model, and corporate/personal wellness programs are discussed in broad terms.

In short, what happens between the ears and at home has as much to do with the ability and willingness to get better as what is physically wrong.

A BioPsychoSocial model is common sense. It acknowledges that a patient – in the case of workers’ compensation, an injured worker – is built of more than just skin and bones and muscles. And the entire fiber of that person – everything that makes them a human being – has to be actively engaged in a recovery process for it to produce positive clinical outcomes.

There is a lot of talk about the concept. A lot of apparent agreement. But how committed, in dollars and cents, is the work comp industry in paying for the “person?”

The health and behavior CPT codes 96150 and 96155 are often used in work comp to establish them as treatment modalities and not diagnostic tools (so “psych” doesn’t become a compensable diagnosis). Dr. Geralyn Datz, a Mississippi psychologist, has been quoted as saying those codes are often reimbursed by work comp at $12-$20 per 15-minute increment, a total of $40-$80 for an hour-long engagement. In contrast, a commercial (i.e., not work comp) payer will reimburse $125-$150 per hour for doctoral level psychotherapy. Summarizing the issue, she says “frequently the only way to treat a worker’s comp patient with cognitive behavioral therapy is if the patient has co-occurring pain and if the provider is willing to be underpaid.”

I have seen instances where the treating physicians, the patients and their attorneys, and the payers have all agreed that CBT is clinically appropriate, only to see it denied through the Utilization Review or Bill Review process for either a technicality or because nobody communicated the approval in advance.

I have seen people giggle when mindfulness or meditation is mentioned as a treatment modality. I have seen people raise their hands, acknowledging that they practice yoga but never thought about how it might help in a functional restoration scenario. I have heard people question how a gym membership, smoking cessation, weight loss program, or nutritionist could ever be considered compensable.

“But for” are the two most dangerous words in insurance. “But for” the work-related injury, the surgery would never have been needed. “But for” the opioids prescribed after the surgery the patient would have never developed a dependency. “But for” the grief associated with losing one’s purpose by no longer being able to work would they have developed anxiety and depression and loss of relationship.

Think about “but for” from the BioPsychoSocial-Spiritual standpoint. “But for” being abused as a child, he would have more resiliency. “But for” an enabling friend, she would not be frozen by indecision or peer pressure. “But for” a lack of self-esteem, he would not subconsciously hold onto pain as being part of his identity. “But for” a history of making bad choices, she could make good choices.

The list of “but for” in each individual circumstance MUST be taken into account when attempting to facilitate recovery – over pain, over addiction, and so on.

So is the BioPsychoSocial movement only talk? Or is it something that we as an industry not just understand but actually underwrite? Are we being “penny wise” and “pound foolish” by paying for the wrong things or not paying enough for the right things? There are many in work comp who believe in the BioPsychoSocial model and are proving it with their dollars. But there are just as many, if not more, who have yet to adjust their mode of thinking.

Because “psych” and “social” are pertinent to treatment and recovery by definition they are “compensable” to work comp, either by direct payment or by increased duration of disability and delayed return to work. They can have a tremendous impact on whether that person gets better. And facilitating “better” is the goal of workers’ compensation. Ignoring the BioPsychoSocial-Spiritual aspect of recovery – in words, deeds or money – is most likely going to lead to worse outcomes for the patient (they don’t get better) and the payer (they pay and pay and pay and nothing gets better).

The challenge for today? Pay for the whole person.

About Mark Pew
Mark Pew, Senior Vice President of PRIUM, is a passionate educator and agitator. He has been focused since 2003 on the intersection of chronic pain and appropriate treatment. That ranges from the clinical and financial costs of opioids and benzodiazepines to the corresponding epidemic of heroin use and the evolution in medical cannabis. Pew was the recipient of the 2016 Magna Comp Laude award and was named one of the “Best Blogs of 2016.” Contact Mark at mpew@prium.net, on his LinkedIn blog at linkedin.com/in/markpew, or on Twitter @RxProfessor.

About PRIUM
PriumAn Ameritox solutions provider, PRIUM is a leader in the market for workers’ compensation medical interventions through a collaborative physician engagement process encompassing evidence-based medicine, clinical oversight, and jurisdictional guidelines to ensure optimal financial and clinical outcomes. PRIUM’s ability to secure higher agreement rates with physicians to modify treatment plans and ensure compliance is unmatched. The hallmark of the medical intervention company’s success is to eliminate unnecessary treatment through a comprehensive approach that includes complex medical interventions, utilization reviews, and independent medical exams. Based in Duluth, Ga., PRIUM can be reached at www.prium.com or 888-588-4964.

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