By Gary Rischitelli, MD, JD, MPH, FACOEM, National Medical Director, Bunch CareSolutions
In this era of rapid change in American medicine, with increasing demand from consumers for transparency in health care, who should help patients make treatment decisions based on unbiased information and an overarching concern for patient well-being?
In a recent Leaders Speak article, Tom Ryan, managing director and the market research leader for Marsh’s Workers’ Compensation Center of Excellence, highlighted the contributions nurse case management can provide to reduce costs and improve outcomes in workers’ compensation1.
Nurse case managers provide an important function in evaluating, coordinating and facilitating appropriate care for workers injured on the job. Another critical aspect of their role involves educating injured workers about their diagnosis, prognosis, and treatment options, as well as establishing positive expectations for recovery and return to work. Many injured workers have a poor understanding of their diagnosis and its clinical implications, and this lack of knowledge frequently leads to confusion and fear. How many patients, for example, fully understand the clinical relevance or implications of a “bulging” disk or “annular tear”? The implication of these findings on an MRI is often interpreted by the patient as a dire medical consequence requiring immediate invasive treatment rather than a routine finding in asymptomatic individuals. Such patient misapprehension can lead to a cascade of unnecessary medical interventions and exaggerated disability associated with fear-avoidance beliefs.
As a patient advocate and educator, the nurse case manager is often responsible for helping the injured worker make informed decisions regarding treatment options. Regardless of what we would like to believe, physicians and surgeons have varying individual propensities to recommend medications, surgical procedures, and other medical interventions; and injured workers rarely ask the important questions related to anticipated outcomes, treatment alternatives, and treatment risks. Workers’ compensation also lacks another important stakeholder variable. Unlike other types of insurance programs, injured workers do not have out-of-pocket costs. Therefore, they are less likely to weigh the cost/benefit of expensive procedures in relationship to other effective treatments.
The goals of patient education and case management are to promote patient autonomy and enhance shared decision making. “Shared decision making (SDM) is a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences. SDM honors both the provider’s expert knowledge and the patient’s right to be fully informed of all care options and the potential harms and benefits. This process provides patients with the support they need to make the best individualized care decisions while allowing providers to feel confident in the care they prescribe.”2
Unfortunately, shared decision making is not the norm in the American medical community. One study noted that in “more than 1,000 office visits in which more than 3,500 medical decisions were made, less than 10% of decisions met the minimum standards for informed decision making.”3 Another study of Medicare patients found that only 41% of those queried believed “their treatment reflected their preference for palliative care over more aggressive interventions.”4 Noting the wide geographic and inter-provider variation in the utilization of elective procedures, the authors suggested that “patients may receive care aligned not with their values and preferences, but with their physicians’ payment incentives.”5
In addition to improving outcomes and aligning treatment with patient preferences, shared decision making has the potential to reduce waste and lower medical costs. “Consistently, as many as 20% of patients who participate in shared decision making choose less invasive surgical options and more conservative treatment.”6
Some states have tried to promote shared decision making in workers’ compensation, particularly as it relates to lumbar fusion surgery. For example, the Minnesota Department of Labor and Industry Patient Advocate Program attempts to educate workers on medical outcomes and encourages employees to seek a second opinion if desired7. Similarly, the Washington Department of Labor & Industry requires doctors and patients to review and sign an information sheet regarding lumbar fusion outcomes before the surgery can occur8. Both programs attempt to provide workers with an unbiased summary of the evidence concerning long-term outcomes for these procedures compared to alternate treatment strategies.
Treating providers should always discuss the full range of treatment options available to the patient and provide factual information regarding the potential benefits, risks and alternatives of these options. However, when the patient’s medical record fails to demonstrate this discussion has taken place, payors may want to consider using independent medical examiners, second opinion examiners, specialty nurse case managers or consumer education resources to achieve this goal.
If injured workers had ready access to outcomes data for many treatments, particularly if the data were adjusted for age, gender and disease severity, I believe they might make different treatment choices. This highlights the need for outcomes research, especially in employee populations sufficiently large enough to provide this kind of information.
Additionally, I believe that injured workers should be provided with the estimated costs of recommended and alternative treatments. Studies have shown that even when workers have no out-of-pocket costs, their treatment choices are affected when they know the actual cost of some recommended treatments. For example, a pilot study by Express Scripts Inc. demonstrated that injured workers who received a “social responsibility” letter—explaining how their prescription drug choices could help control the rising cost of health care—were 60% more likely to choose a generic equivalent. As a result, the 11,000 injured workers targeted in the pilot potentially avoided $373,000 in excess costs generated from the use of brand name medications.9
Data regarding outcomes and the comparative effectiveness of treatments is difficult to access, and often difficult for consumers to interpret. Nurse case managers familiar with the use of evidence-based medical treatment guidelines can help injured workers find and understand information regarding treatment outcomes and compare treatment alternatives based on their individual preferences and expectations. Nurse case managers often have considerable firsthand experience of the benefits and burdens associated with various treatment choices. Moreover, they are free from the potential conscious or unconscious financial biases of treating providers created by our fee for service reimbursement model.
Nurses continue to be ranked the most trusted profession in America10. Who better to engage workers in making rational decisions about their care and to promote shared decision making leading to lower medical costs, better outcomes and fewer complications and treatment failures?
In Part 2, we will explore a few specific strategies nurse case managers should be deploying to reduce the total medical expense associated with workers’ compensation claims.
About Gary Rischitelli, MD, JD, MPH, FACOEM
Dr. Rischitelli is the national medical director for Bunch CareSolutions and provides medical oversight to the clinical services unit and its operational components, including the organization’s clinical peer review program. He also leads the firm’s quality and compliance team, which is responsible for URAC accreditation, maintenance of state utilization review plans and regulatory compliance initiatives.
Dr. Rischitelli is a practicing physician and nationally renowned speaker with wide-ranging experience in the workers’ compensation industry. His specialties and areas of expertise include occupational and environmental medicine, managed care, toxicology, occupational exposures, disability evaluation and accommodation, return to work, and fitness for duty. Dr. Rischitelli’s academic research has led to the publication of copious articles on the delivery of health services, injury prevention and transmission of occupational infectious diseases. He is a Fellow of the American College of Occupational & Environmental Medicine with board certifications in occupational medicine and health care quality management. In addition to his medical credentials, Dr. Rischitelli holds a Juris Doctor, a Master of Public Health degree, and a Certificate in Clinical Research and Human Investigation.
About Bunch CareSolutions, A Xerox Company
Bunch CareSolutions is a national medical management company based in Lakeland, Florida. The company operates exclusively in the workers’ compensation industry as a full-service, managed care firm offering injury triage, case management, utilization review, peer review and medical bill review. Since its founding in 1988, Bunch CareSolutions has consistently grown in size, scope of services and standards of excellence. It has done so without compromising its clinical focus or mission of “making the world a better place—one life at time.” To learn more, visit www.bunchcare.com.
Notes
1 Tom Ryan, “Enhancing Your Workers’ Compensation Program Through Nurse Case Management,” WorkCompWire, June 9, 2015, https://www.workcompwire.com/2015/06/tom-ryan-enhancing-your-workers-compensation-program-through-nurse-case-management/, accessed June 2015.
2 Informed Medical Decisions Foundation, “What Is Shared Decision Making,” http://www.informedmedicaldecisions.org/what-is-shared-decision-making/, accessed June 2015.
3 Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D., “Shared Decision Making to Improve Care and Reduce Costs,” N Engl J Med 2013; 386 (1): 6-8, http://www.nejm.org/doi/full/10.1056/NEJMp1209500, accessed June 2015.
4 Lee and Emanuel, 2015.
5 Lee and Emanuel, 2015.
6 Lee and Emanuel, 2015.
7 Minnesota Dept. of Labor & Industry, “Patient Advocate Program,” http://www.dli.mn.gov/WC/OmbudsmanPatientAdvocate.asp, accessed June 2015.
8 Washington Dept. of Labor & Industries, “Surgical Guideline for Lumbar Fusion (Arthrodesis)” (PDF file), downloaded from Washington L&I website, http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/LumbarFusion.pdf, accessed June 2015.
9 “Helping Injured Workers Do the Right Thing,” The Express Scripts Lab, August 16, 2012, http://lab.express-scripts.com/insights/workers-compensation/helping-injured-workers-do-the-right-thing, accessed June 2015.
10 Rebecca Riffkin, “Americans Rate Nurses Highest on Honesty, Ethical Standards,” Gallup News, December 18, 2014, http://www.gallup.com/poll/180260/americans-rate-nurses-highest-honesty-ethical-standards.aspx, accessed June 2015.