By Mark Pew, Senior Vice President of Product Development, PRIUM
As is often said, beauty is in the eye of the beholder. To me, that means your personal context colors your perspective, and that often similar people can look at similar circumstances and reach dissimilar conclusions. In work comp, that axiom applies to “success.”
Various stakeholders define success differently. To an injured worker, success could be regaining health to his or her pre-injury state while building a retirement nest egg. To a treating physician, success could be restoring health to the patient at a fair price. To an employer, success could be the quick and safe return to work of a colleague that does not impact its work comp premiums. To a carrier or TPA, success could be the proper management of a claim that yields a satisfied customer while maximizing profit. To an attorney representing the injured worker, success could be maximizing the financial payoff for the client and the law firm. To a vendor (pharmacy benefit manager, bill review, utilization review, transportation/translation, or surveillance company), success could be providing services that provide recognized value to their customer.
In some cases, the definition of success can be both positive (appropriate services for a fair price) and negative (maintaining the revenue stream through means that might be inconsistent with “appropriate services” or “fair prices”). It is the business conundrum in work comp – how to balance the need to provide appropriate services with the need to stay financially viable in a system that sometimes rewards the latter more than the former.
Let’s simplify what true success is for work comp: restoring the health of the injured worker and settling the claim efficiently. Realistically, the worker might not be restored fully to pre-injury health, but regaining as much as possible is certainly the goal. When it comes to managing chronic pain that will likely never completely go away, good treatment can be inadvertently sabotaged by issues of tolerance, dependence and addiction. The prescription drug abuse epidemic illustrates that the outcome of over/inappropriate treatment can often create more problems than it resolves.
For those who have received inappropriate treatment with sub-optimal results, success may be less about a full return to health and more about a return to some level of function. That could be something as simple as taking 500 steps per day (thewalkingsite.com offers guidelines for 10,000 steps per day). Maybe return to work is no longer viable, so success is now more about being a meaningful member of family and community. Maybe detoxification is appropriate but abstinence is not attainable, so finding a lower number and dosage of appropriate drugs is success. For those stuck in a cycle of victimization, low self-esteem and poor socioeconomic circumstances, perhaps success is more about acquiring skills to properly cope with pain and change (and life in general).
In other words, maybe success is a lot simpler than we think – if the injured worker wins by regaining health and function, then everyone else wins too.
About Mark Pew
Mark Pew brings 30 years of experience in the property and casualty, technology and healthcare industries to his presentations. He has worked with PRIUM in a variety of roles since 1989, most recently educating stakeholders and developing strategies for managing the overutilization of prescription drugs in workers’ compensation. Mark created PRIUM’s Medical Intervention Program in 2003 and since that time has refined the program and created several other services to address the prescription drug epidemic.
Mark’s data-driven presentations combine industry research, internal analysis and case studies with a touch of humor. Audiences rate them high for their clear descriptions of medical and pharmaceutical cost problems and, more importantly, for their practical and actionable solutions. Audiences take away practical concepts they can immediately apply to current claims.
Since 2012 Mr. Pew has spoken at the National Workers’ Compensation and Disability Conference, work comp conferences in Arizona, California, Georgia, Illinois, Kentucky, Montana, Nevada, Oregon, Pennsylvania, Texas, and West Virginia as well as at numerous training sessions for adjusters and nurses across the country.
About PRIUM
An Ameritox solutions provider, PRIUM sets the industry standard for workers’ compensation medical interventions through its ability to secure higher agreement rates and ensure compliance with modified treatment plans. The hallmark of the medical intervention company’s success is a collaborative physician engagement process encompassing evidence-based medicine, clinical oversight, and jurisdictional guidelines to ensure optimal financial and clinical outcomes. PRIUM eliminates unnecessary treatment through a comprehensive approach that includes complex medical interventions, utilization reviews, urine drug monitoring, and independent medical exams. Based in Duluth, Ga., PRIUM can be reached at www.prium.net or 888-588-4964. For insight on workers’ compensation medical issues, read PRIUM’s blog at www.priumevidencebased.com.