By Steven Moskowitz, MD, Senior Medical Director, Paradigm Outcomes
Catastrophic injuries, such as spinal cord injury, brain injury, multiple trauma, and major burns, are often life-threatening and costly. Each poses a high likelihood of permanent impairment and long-term medical needs. This classification can also apply to progressive medical illnesses like asbestosis or valley fever, as well as minor injuries with oversized impairments. In each instance the inherent complexity makes these cases prone to fall into the cracks in our fractured healthcare system.
Catastrophic injury management begins with the initial case assessment. Without a proper assessment, these circumstances will not only negatively impact the injured person’s acute recovery, but his long term health and lifetime claim costs, as well. I recommend a seven point plan to avoid this critical claims management mistake. The road to recovery for a complex injury is long, and when you set off on the wrong foot, it can be arduous to get back on course.
The Nature of Catastrophic Injuries
Catastrophic injury claims will defy our desire for quick, dramatic and permanent resolution. The cases frequently exhibit delayed medical stability and functional recovery, avoidable medical complications, repetitive diagnostics, poor care planning, inadequate communication, an over-reliance on medication and technology, and a trial and error approach to complex problems.
Some may respond to these challenges by suggesting the goal of preventing catastrophic injuries all together. Workplace safety is certainly important, but like a natural catastrophe, we often cannot do that. Expert urgent clinical care is vital in saving lives and mitigating secondary damage from the initial injury. And in that space, there is an opportunity to mitigate further risks. In terms of prevention, a good first step to managing a catastrophic claim is building relationships with providers and case managers familiar with these types of injuries.
Seven Steps to a Successful Recovery
You can strengthen your workers’ compensation case management program with a systematic approach. Your program should be based on defining the desired results and coordinating the care that will reach those outcomes with a personalized approach. As an added benefit, much of the same information will assist you when trying to set accurate reserves.
1. Clarify the major and minor diagnoses.
It is well known that minor, but impactful, injury-related comorbidities can be missed during the initial lifesaving treatment. For this reason, trauma centers have as part of their operating instructions a process to do a tertiary examination once the case is stabilized. Similarly the various injuries of an individual case combine to create unique recovery challenges. For example, fractures can delay ambulation training in a worker recovering from acquired brain injury. Having a clinician with expertise in these diagnoses review the records and discuss the findings with the treating physician is an invaluable approach.
2. Determine severity of the injury and the impairment.
The severity of the injury impacts recovery expectations (long-term outcome) and predicted speed of recovery. Standardized measures of severity, such as the ASIA/ISCOS SCI classification system for spinal cord injury and the Glasgow Coma Scale and the Coma Recovery Scale-Revised for acquired brain injury, are two resources that can help measure an individual’s status along a recovery continuum. Other diagnoses also have corresponding scales. These tools do have some predictive value and can help you determine what the injured worker’s needs are and what resources should be made available (versus those that are not medically indicated). Note that interpretation of the measurements requires some expertise and the scale result must be taken in the context of the other concurrent diagnoses.
3. Predict complications and determine a mitigation strategy for each.
Each diagnostic group—major burns, SCI, ABI, multiple trauma—is at risk of numerous acute and long-term complications. These may include wound infection, hardware non-union, skin or wound contracture, depression, non-compliance and chronic pain. These complications can become a rabbit hole from which a case may emerge forever changed and unlikely to get back on track. Chronic pain alone can add tens of thousands to hundreds of thousands of dollars to the reserve on a case. Osteomyelitis can lead to multiple operations and even amputation at a similar cost. Confront these risks proactively by remaining on the lookout for early signs of these complications. Then, act to prevent and/or mitigate the problem and expense.
4. Predict long-term outcomes and determine the most direct treatment strategy to those results.
This is the big picture approach. It is also a way to get a more accurate understanding of the long-term costs. The questions to be answered are: Where will this case end up? What are realistic expectations? How do we help the injured worker get there efficiently? What will it cost? Most treating physicians, however, are not trained to predict long-term treatment outcomes or complications. Traditional medicine is more of a “see how it goes” endeavor. Studies repeatedly reveal the challenge in getting treating physicians to use objective prediction tools due to, among other things, the perception that their experience is sufficient. Identify a clinical resource who can synthesize the medical information and the severity scales and make the functional and medical outcome predictions and use that information to develop the care plan. Ideally this clinician is well versed in both the clinical topic, as well as insurance concerns.
5. Understand early that these conditions are biopsychosocial conditions, not just medical.
Emotion, health literacy, family issues, depression, anxiety, avocational activities and more affect how people report symptoms, cope with recovery, comply with treatment, and accept residual disability. Incorporating a psychosocial assessment in your case conceptualization allows you to monitor psychosocial issues and intervene appropriately. It is critical to be aware of address any condition that may delay or limit medical and functional outcomes as part of the care plan.
6. Have a process to navigate and steer a case when it goes off track.
Even better, identify the risks and react before it goes off track. This requires processes that systematically conduct close tracking, ensure ongoing communication between all parties, including the injured worker, and regularly involve your clinical expert.
7. Invest in the outcome.
It is tempting to try to carve out hospital days and apply necessary utilization measures. These are appropriate actions. But at times it is important to temper the short-term approach with a reality check on the longer term issues. Is potentially saving a week in rehabilitation, for example, going to facilitate the recovery plan, or might it lead to unintended consequences such as development of a pressure wound at home? Carefully weigh the consequences of short-term decisions.
By following these seven steps, workers’ compensation claims managers can gain better foresight into the recovery of a catastrophically injured person. The process begins with a careful case assessment, and will likely conclude with a better medical recovery at a lower cost.
About Steven M. Moskowitz, MD
Steven M. Moskowitz, MD, is the Senior Medical Director and supervisor of Paradigm Outcome’s pain program. Dr. Moskowitz is a specialist in physical medicine and rehabilitation with clinical expertise in complex musculoskeletal and neurologic rehabilitation including spinal cord injury, multiple sclerosis and chronic pain. He began his clinical practice in 1989 and currently practices at the Life Care Center of Nashoba Valley, MA. Dr. Moskowitz earned his medical degree from Tufts University School of Medicine, is certified in Managed Care Medicine, and he is a member of the American Academy of Pain Medicine, the American Academy of Physical Medicine and Rehabilitation, and the American Pain Society.
About Paradigm Outcomes
Paradigm Outcomes is the nation’s leading provider of catastrophic and complex case management, Paradigm achieves 5x better medical outcomes and lowers total costs by 40%. Paradigm accomplishes this by bringing together nationally recognized doctors, the best providers in the country, and 25 years of clinical data to guide decisions. Paradigm is the only company designed and built specifically to address the needs of those with acquired brain injuries, spinal cord injuries, amputations, burns and chronic pain, and is the only company to stand behind their promises with medical and financial guarantees. Visit www.paradigmcorp.com to learn more.