By Ruth Estrich, Chief Strategy Officer of MedRisk, Inc.
Musculoskeletal injuries include any injury that occurs to a skeletal muscle, tendon, ligament, or joint. These types of injuries constitute the largest class of athletic injuries as well as the largest trigger of on-the-job injuries. The successful recovery from these injuries, then, impacts the quality of many lives and the success of many employers – whether their employee sustains the injury on the plant floor or on the basketball court.
A large percentage of musculoskeletal injuries resolve with standard treatment, defined here as biomedical interventions. But many do not. And it is those that don’t that become the chronic cases that drive up group health and workers’ compensation costs, challenge employers’ productivity, and damage lives. What causes some situations to resolve easily and others to not?
The distinction between disease and illness is at the heart of understanding the factors at play here. The basic concept was articulated well (although politically incorrect for our times) by Eric Cassell in 1978: “Disease…is something an organ has; illness is something a man has.” In other words and in our context here, disease is the damage to the skeletal muscle or tendon or ligament or joint. It is the injury that has occurred to the affected body part, and biomedical treatment addresses the interventions appropriate for the resolution of that damage.
Illness, on the other hand, includes more than just the damaged part. Illness refers to the whole person, and includes the feelings that the injured person has about their injury. It is illness that causes someone seek care. Likewise, it is often illness that keeps someone disabled. For example, many people have had injuries or medical conditions that have resulted in chronic pain. And many of those people live full, functional lives. They don’t experience their pain as limiting or frightening. But others do and delayed recovery or continuing disablement results. And only treating the biology will not resolve the problem. The psychological and social issues must be successfully addressed to resolve the illness and support the injured person in living a full, functional life.
Musculoskeletal injuries are particularly subject to psychosocial concerns. Pain is always the result of a back injury, and few people understand the actual biomechanics of such an injury. Avoiding pain, expectations of no pain, and fear of re-injury all contribute to delayed recovery.
Healing and recovery are not always synonyms. In fact, psychosocial issues can actually delay both. In the May 2011 issue of Physical Therapy Magazine, Christopher Main, a UK psychologist who specializes in musculoskeletal injuries, and Steven George, a US PT PhD who specializes in the utilization of biopsychosocial models for the prevention and treatment of chronic musculoskeletal pain, suggest that “there is persuasive evidence for the influence of a patient’s beliefs, emotional responses, and pain behavior on response to pain, treatment participation and cost.” They add that “the costs of ignoring or inappropriately managing psychosocial factors potentially leads to unnecessary patient suffering, restricted participation in valued activities, loss of productivity at work and a waste of valuable health care resources.”
Successful musculoskeletal management, then, has two challenges to face. The first is how to identify, early on, the person with at-risk characteristics. Obviously, the person who does not get well and whose biomedical treatment was sufficient is probably suffering from psychosocial concerns. Realizing this at any time is better than not realizing it at all. But identifying these situations proactively, predicting the person who has these tendencies early on can significantly impact the eventual outcome.
Screening tools have been developed that can be deployed in multiple ways. Employers, insurance carriers, physical therapists, and nurse case managers can access systems that allow for structured interviews with the injured patient. Proprietary algorithms score the information garnered from the interview and identify a psychosocial risk profile that is predictive of the development of a chronic situation.
This leads to the second challenge: once an at-risk person is identified, what can be done to address these psychosocial challenges? How can an employer or carrier or their managed care company intervene with the injured person to address the identified issues?
There is growing evidence that a structured cognitive behavior program can significantly reduce psychosocial barriers to rehabilitation, especially when delivered in combination with a therapeutic physical therapy treatment plan. Through structured activity scheduling, graded activity involvement, goal-setting, problem-solving and motivational coaching, the injured patient addresses the specific psychosocial obstacles to recovery, including fear of symptom exacerbation, catastrophic thinking and limiting beliefs about their disability. Recent studies have shown that return to functionality can be significantly improved by the coordinated delivery of a physical therapy and cognitive behavior program.
So to answer the leading question, everyone should care about musculoskeletal injuries and psychosocial considerations – if patient outcomes and employer productivity and healthcare costs impact you. But caring is not enough. Working with a company that can identify high-risk patients sooner and can treat the illness, and not just the disease might be just what the doctor ordered.
About Ruth Estrich
Ruth Estrich is the Chief Strategy Officer for MedRisk, Inc. and a dynamic industry expert in the areas of Property & Casualty and Group Health Managed Care. As part of MedRisk’s executive management team, she is responsible for new product development.
Under Ms. Estrich’s expert leadership, MedRisk has identified and implemented new business models for a number of Workers’ Compensation processes including guideline driven utilization management services and strategic managed care integration.
Ms. Estrich has held senior management positions at national insurance companies where she managed many key operations including planning and budgeting, claims, product development, and managed care.
Ms. Estrich holds a Bachelors degree from Simmons College and has chaired a number of key industry committees including the Health Insurance Association of America’s (HIAA) Prevailing Healthcare Charges System Committee. She also represented the insurance industry on the Patient Record Committee at the Institute of Medicine, National Academy of Sciences, and she is the Chair of the Board of Directors of the Insurance Accounting and Systems Association (IASA). She can be reached at firstname.lastname@example.org.
Founded in 1994 and based in King of Prussia, Pa., MedRisk, Inc. is ranked as one of the fastest-growing companies in the Greater Philadelphia area on the Inc. 500|5,000 and the Deloitte “Technology Fast 50” lists. The company provides specialty managed care services for the physical rehabilitation of injured workers. MedRisk is fully accredited under URAC and has successfully completed a SSAE 16 Type II examination. MedRisk’s programs deliver savings and operational efficiencies that are significantly greater than traditional programs. Customers include insurance carriers, self-insured employers, third-party administrators, state funds, general managed care companies, case management companies, claims adjusters and physical medicine providers. To make a referral or obtain more information, visit www.medrisknet.com or call 800-225-9675.