By Dr. Steven Feinberg, CMO, American Pain Solutions (APS)
and Dr. Melvin Belsky, CCO, APS & Medical Director, Corporate WC, Safeway, Inc.
Remarkably, there is an evidenced-based alternative to out of control and unnecessary medical and indemnity costs where the injured worker’s functional recovery is delayed. Its implementation on a larger scale requires a paradigm shift in the perspective of all parties, but it is doable and necessary. The alternative is identification and multidisciplinary treatment of injured workers at risk for “delayed recovery.” This disability management approach to potential disability is known as a functional restoration (a term often misunderstood).
Thankfully, the great majority of injured workers return to work with minimal and reasonable medical care in a timely manner. Early intervention (EI) focuses on the small but significant ten (10) percent of injured workers with non-catastrophic injuries who experience “delayed recovery” (the lack of anticipated functional recovery in a medically reasonable period of time). Treatment in delayed recovery cases is, by definition, protracted. Those experiencing “delayed recovery” become over-utilizers of medical services without significant symptomatic/functional benefit. In fact, costs escalate over time while but they experience drug dependency, debilitation and reactive depression/anxiety. These individuals ultimately are now labeled “chronic pain” patients.
Although the process of “delayed recovery” rarely begins with catastrophic injury or impairment, “delayed recovery”/chronic pain claims consume an astonishing 75% of medical and indemnity resources. Just as amazing is the fact that a majority of such expenditures are unnecessary. Why? Because “delayed recovery,” when identified and addressed properly at an early stage, is largely a preventable or reversible clinical phenomenon.
The earlier an injured worker is identified as “at risk” for developing delayed recovery or chronic pain along the timeline from Date of Injury (DOI) to claim closure, the more likely a well-designed multidisciplinary therapeutic effort will be effective in minimizing the otherwise predictable consequences of drug dependency, physical debilitation and reactive depression/anxiety. Effective, efficient, and timely intervention will significantly reduce needless work disability and associated medical and indemnity costs, while supporting timely return-to-work.
Even in chronic pain cases, appropriate interdisciplinary care can result in huge savings of resources while still resulting in significantly increased function and manageable pain for the injured worker.
The workers’ compensation industry and the medical community need to support a medical treatment approach where the singular goal is to minimize needless work disability and drug dependency, while promoting return-to-work and maximum overall functioning through independent self-management.
This mission will be accomplished through the earliest possible application of the disability management/minimization principles of Functional Restoration, as supported by the California Medical Treatment Utilization Schedule (MTUS).
Some people do not cope well when injured and there can be a multitude of reasons for delayed recovery, but one of great importance is adverse childhood experiences or ACE (physical, emotional, sexual abuse, household dysfunction, etc.) which constitute a routinely overlooked, second etiologic factor for subsequent adult morbidity, mortality, and disability.
Delayed recovery characteristics can include the following:
- Distress, depression, anxiety
- Excessive pain/disability behaviors
- High pain ratings
- Fear-avoidance/maladaptive beliefs
- Focus on litigation
- Job dissatisfaction
- Adverse Childhood Experiences (A.C.E.)
Physicians, however well-meaning, can be part of the problem rather than part of the solution. The treater may focus on the pathology in a search for the “pain generator” while not recognizing the confounding psychosocial and cultural barriers.
Physicians are trained in the biomedical cause and effect model. In this approach, the physician must search and identify the “cause” or the pain generator and has been taught that the “effect” or the disability/problem can be mitigated by medicating, blocking, operating on or obliterating the lesion. In individuals with “delayed recovery” this approach can be disastrous and often results in chronic pain or nonspecific chronic pain (NSCP).
The current Introduction to Chronic Pain Guideline in the CA MTUS supports the biopsychosocial model and the principles of functional restoration (FR). This model recognizes that the perception of chronic pain is ultimately the result of pathophysiology, the psychological state, the life experiences, cultural and belief systems, and to relationships with people and interactions with the environment.
Functional restoration is not an expensive chronic pain program but rather a process by which the injured worker acquires the skills, knowledge and behavioral change necessary to assume or reassume primary responsibility for his/her physical and emotional well-being post ill illness or injury. It is a coordinated, multidisciplinary process, individualized for each patient. It is educational and functionally oriented (not pain oriented) where the injured person rehabilitates to re-engage in work and every day.
Treatment team members often include a rehabilitation oriented pain specialist, a psychologist and a physical and/or occupational therapist. Treatment is individualized and can include medication optimization, limited interventional procedures, supportive counseling, cognitive behavioral therapy, and physical restorative therapies.
The FR approach educates the patient about the tools and resources available. The injured worker learns acceptance of, or willingness to experience chronic pain and distress rather than attempt to prevent, control or reduce such symptoms.
This functional restoration/early intervention approach is a win-win for all concerned parties. The injured worker returns to life activities including work, stabilizes medically, and avoids iatrogenic complications. The employer avoids unnecessary costs and achieves an early return to the work place of an able bodied employee.
Roadmap for Success
- Avoid work injuries with education, health and safety programs.
- Utilize tools already available for early identification of individuals at risk for “delayed recovery” post injury, followed by individualized, focused care for rapid return to work (RTW).
- Build systems to incentivize all players (payers, injured workers, attorneys, and physicians) to help injured workers rebuild their lives at return to gainful employment.
- Provide medical care along the lines of functional restoration as supported by the MTUS Chronic Pain Medical Treatment Guidelines.
- Resolve cases fairly and equitably for the injured worker and the employer/payer.
This approach is not theoretical. Safeway,Inc., has implemented a successful Early Intervention Pilot with Kaiser-On-The-Job (KOJ). The pilot project was limited to Safeway, Inc., stores within a specific KOJ catchment area in Northern California, for injured workers presenting at those clinics with low back pain. Five KOJ Occupational Clinics participated over 4 plus years. Although limited in scope, the results were dramatic. No delayed recovery cases were created, no injured worker sought legal counsel, Modified Duty and TTD days were markedly reduced, and everyone returned to work. The results were so positive that Safeway and KOJ plan to expand the approach to other KOJ clinics.
At the Feinberg Medical Group we have successfully partnered with employers and payers to offer an early intervention functional restoration program. For even chronic cases, detoxification coordinated with a functional restoration program has proven cost effective.
Are you ready to be part of the solution and to be for a part of the paradigm shift proven to prevent needless work disability?
About Dr. Steven Feinberg
Dr. Steven Feinberg is a physiatrist and pain medicine specialist practicing in Palo Alto. Dr. Feinberg is an Adjunct Clinical Professor and teaches at the Stanford University Pain Service. Dr. Feinberg is the Chief Medical Officer of American Pain Solutions.
He is a past president (1996) of the American Academy of Pain Medicine (AAPM). He served as a California Society of Medicine & Surgery (CSIMS) Year 2001 President. He serves on the Board of Directors of the American Chronic Pain Association (www.theacpa.org) and is lead author of the 2011 ACPA Consumer Guide to Pain Medication & Treatment. Dr. Feinberg served on the ACOEM Chronic Pain Guidelines Panel Chapter Update and also as Associate Editor and he also serves as a consultant to the Official Disability Guidelines (ODG).
About Feinberg Medical Group
Feinberg Medical Group (FMG) in Palo Alto is dedicated to preventing needless work disability. FMG provides accurate and timely diagnoses, followed by a customized, effective, and efficient goal-oriented individualized treatment plan. We are committed to quality patient care, timely communication with all parties, cost-containment, patient independent self-management and most importantly, return to work. Our treatment approaches maximize functional recovery for return to work through the application of the treatment principles of Functional Restoration.