October 20, 2017

Guest Post: Michael Shor: How Did Joanne’s Claim Go Off The Rails?

By Michael J Shor, MPH, Managing Director, Best Doctors Occupational Health Institute (BDOHI)

Most injured workers recover well, but some go through a special kind of hell caused by medical misadventures. Such as the story of Joanne’s years of struggling with pain and how four chances to get medical care on the right track were blown.

Joanne’s case is a typical example of how ignoring the key pivot points of care can run things right off the rails. (This is an actual Best Doctors’ case – name and other identifying facts have been altered.) Her story is not an outlier. I often see cases like hers.

A 56 year old truck driver, she was struggling to open the hood of her vehicle when radiating pain in her lower back dropped her to her knees. Initially, a physician diagnosed her, by examination and MRI evidence, with an intervertebral disc disorder.

Potential problems from the outset! There is a very high error rate in the reading of both MRI’s and X-Rays. With backs upwards of 70% of these initial diagnoses are subsequently revised. And, findings of a disc disorder (if accurate) can lead to overzealous surgery, such as
decompressions and in too many cases spinal fusion.

In Joanne’s particular case. there was no mention in the initial medical record of her body mass index, smoking history or other factors that might compromise her recovery. Regardless of diagnostic findings, the presence of these factors can preclude a successful therapeutic outcome.

Should Joanne’s adjuster, whom we’ll call Rob, have looked for risk factors at the time of injury, questioned the diagnosis? Yes. First chance missed.

Joanne’s treating doctor prescribed conservative care – a very reasonable decision. Some 90% of back injuries will resolve themselves in six weeks regardless of the type of treatment. But it went on for far too long – two years. Injections, physical therapy, relaxation classes and other efforts failed to relieve her pain.

Should the adjuster have looked more closely at the course of her care at the six week mark?
Yes. Second chance missed.

If at week six, progress is not being made, something was clearly being missed. Getting an expert second opinion with careful attention to risk factors and the accuracy of diagnosis could head off a lot of ineffective care.

Rob relied on utilization review, which approved the treatment because it met guidelines. But UR fails when treatment within guidelines fails to work. Conservative care at the sixth week, or even the sixth month mark, would probably get UR approval. And he also engaged a telephonic case manager – effective in many cases but not here. Joanne’s doctor was determined to continue with his course of care. Case managers are usually ineffective in persuading a doctor to drop a firm plan of care.

After referral for pain management, her doctor prescribed escalating doses of opioids, essentially chasing her pain. Joanne became dependent on them. She most likely developed hyperalgesia, a condition associated with escalating opiate dosage that increases rather than decreases pain symptoms. Once opiate dependence occurs, patients often perceive opioids as their only solution.

Should Rob have brought in expert medical advice when her opiate dosage began to climb? Yes.

Thousands of injured workers today are taking opioids for the long term. Most of these cases likely squeezed through in spite of UR, pharmacy review, case management, and/or an independent medical exam and despite there being no widely accepted research findings that long term use of opioids provides effective relief to persons with Joanne’s type of condition.

A medical expert in spine, opioid and pain management would likely have been able, at a minimum, to engage with the prescribing physician and present practical alternative treatment. Third chance missed.

In the fifth year post injury and failing conservative care, a surgeon essentially threw a “hail Mary pass” performing a L5-S1 laminotomy and micro-discectomy with nerve root decompression. Nothing else worked so let’s operate…

Unfortunately, her symptoms persisted.

Should Rob have seriously questioned the rationale for a surgical solution, after she was not considered a surgical candidate and the other approaches had failed for years? Yes. Fourth chance missed.

An expert reviewer would actually read the MRI rather than just depend on a radiologist review. The peer reviewer would have asked:

  • Is the assessment of the pathology correct?
  • Is the requested surgery appropriate for this patient?
  • Does the injured worker have risk factors that may preclude a successful surgical intervention?
  • What other non-invasive therapies that would be more appropriate?
  • Does the patient have an interest in recovery?

A key lesson from Joanne’s and similar cases is that the traditional managed care tools, such as UR and nurse case management, cannot be expected to apply this intense, expert clinical assessment.

After surgery, Joanne had multiple therapeutic injections and had a spinal cord stimulator implanted, again without improvement. She continued on high-dose opioids. At this point it becomes almost impossible to parse what is causing what, because of opiate dependence and potential for hyperalgesia.

Much like a very badly produced theatrical production, every actor, or in this case the physicians, claim professionals and case managers played their part, but none really stopped to expertly assess the patient.

Joanne was now headed toward a lifetime of misery, depression, decreased libido, constipation, sleeplessness, and the risks of dependence, addiction or overdose. The claims adjustor Rob is facing a potential lifetime of medical costs, many times increased by treatment for the side effects of the opioid.

Had an expert second set of eyes become involved early in the process and if necessary, at each pivot point, there is a good chance that the diagnosis would have been revised and an even higher odds that the treatment strategy would have changed.

About Michael Shor
Michael Shor, is Managing Director of the Best Doctors Occupational Health Institute(BDOHI).
As the self-described “man who fell from space” and into WC, the focus of his work is on
understanding how patient demographics effect clinical outcomes, the practical clinical needs
of very busy claims professionals and rigorous attention to reducing misdiagnosis and
inappropriate care. His publications have appeared in the Journal of Workers Compensation,
The Orthopedic Clinics of North America, the Boston Globe among others. He is a graduate of
the Whitman School of Management at Syracuse University and the Boston University School of
Public Health.

About Best Doctors
Founded in 1989 by Harvard Medical School physicians, Best Doctors, now part of Teladoc
serves more than 40+ million members in countries across the world. For more than 28 years,
we have asked physicians to identify the doctors they consider the leaders in their field. Today,
our peer-selected network has more than 50,000 medical experts in over 450 specialties and
subspecialties. As a medical advisory organization, we differ from managed care and medical
review companies. From catastrophic/acute care through rehabilitation and return to work, we
partner closely with injured workers, their treating teams and claims professionals to act as a
trusted clinical advocate.

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