By Gary Rischitelli, MD, JD, MPH, FACOEM
One of the unique privileges of being an occupational health physician is the opportunity to step out of the health care sector and learn about other industries and how they function. The chance to learn “how things are made” and see behind the scenes is one of the things that attracted me to this field. In fact, one of those experiences is what made me choose a career in occupational medicine.
While working as a clinic director, I was invited by a local aerospace manufacturing firm to tour their facility and gain a firsthand perspective of their work demands and work environment. I was stunned by the cleanliness, order and simplicity of their manufacturing lines as they had adopted many of the lean manufacturing principles that had been pioneered in the Japanese automobile manufacturing industry in the early 1980s. The lean approach was very different than what I had experienced in my medical training where waste, inefficiency, ambiguity and doing things the way we had always done them “because that’s the way we were trained” was rampant. Since that time, and as my career evolved, I have had a keen interest in health care economics and physician behavior.
My role as a medical director in insurance and managed care provided me with an opportunity to review thousands or even tens of thousands of cases over the past twenty years and to observe the consequences of waste and inefficiency. The cost cannot be measured solely in dollars, and the impact on individuals and their families of pain and disability from unnecessary care can be disturbing. I recently evaluated a young man in his thirties who was in chronic pain, totally disabled and had lost everything, including his wife and family, because of four failed back surgeries that were unnecessary. The root cause of his surgical misadventures was a decision by a primary care physician to order an MRI that was not medically indicated.
Employed as a temporary worker, and only a few days on the job, the young man reported back pain after lifting a fifteen pound flat screen monitor. Only a few weeks into treatment, he was improving with physical therapy, and reported no leg pain or radicular symptoms. His physical examination was unremarkable except for range of motion limited by pain. He saw a different physician on one of his follow up visits who, for reasons that remain unclear and not documented in the visit note, ordered an MRI of his lumbar spine. That MRI, ten years ago, revealed a clinically insignificant disk bulge, that would lead to a microdisckectomy, then another, and ultimately a spinal fusion that several experienced, independent surgeons cautioned would likely not result in significant pain relief or functional improvement.
Despite admitting that he was worse after the fusion, the young man said he did not regret the decision because his doctor told him that he had a “collapsed disk” that needed surgery and he was under the impression that it was necessary. In contrast, the surgeon’s notes dutifully outlined that he had counseled the patient regarding the risks and expected outcomes, had offered him a range of treatment alternatives, and that the patient had “elected” surgery. Obviously, one of these stories is incorrect or there was a complete failure of communication in the physician-patient relationship.
In the aerospace company I mentioned above, a “scrapped part” is a serious event that leads to an investigation of where the process failed and to identify process changes or interventions to prevent the failure from occurring again. Despite the individual and societal cost of treatment failures, no such similar effort occurs when a “failed back” is the outcome of work-related injury. Were there reasonable pre-operative expectations, fully informed consent and shared decision making? Was it a technical issue related to the surgeon’s training, skill or experience with a particular procedure or approach? Was it a failure of patient selection, or disregard of pertinent psychosocial issues or comorbid conditions? Was it a lack of adequate post-operative rehabilitation?
Why isn’t there an attempt to identify the root cause of the failure, and the steps that can be taken to prevent this from happening again? Behavioral psychology and economics teach us that you get what you reward and discourage what you punish. As long as our health care system remains a “fee for service” rather than “fee for outcomes” system, the only incentive to providers is to “do more,” whether it is helpful or not. Similarly, the penalty for treatment failures is not on the providers but placed squarely on the “backs” of injured workers and the rest of society. Identifying providers who consistently produce positive outcomes, documenting and promoting the use of best practices, and eliminating waste, inefficiency and fraud should be the focus of medical cost containment in workers’ compensation. The tools are available, all that is lacking is commitment of all the parties and stakeholders to coordinate that effort.
About Gary Rischitelli, MD, JD, MPH, FACOEM
Dr. Rischitelli is the national medical director for Bunch CareSolutions, A Xerox Company, 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.
Source: Bunch CareSolutions, A Xerox Company