By Dr. Steven Feinberg
In my previous post, I discussed the importance of injured workers’ empowerment and taking responsibility for their health and well-being and rehabilitation through a biopsychosocial functional restoration education approach. While this concept has been around for as long as I can remember (I learned about it during my PMR residency training at the University of Washington in the early 1970s), it is only in the last few years that the light bulb has gone on in the healthcare community with recognition of the importance of intervening early in general, and especially for injured workers with risks factors for delayed recovery as well as the importance of stay at work (SAW) or early return to work (RTW) post-injury. This acknowledgment has been coupled with the realization that we can’t solve chronic pain by flooding injured workers with opioids.
In this article, I would like to focus on how all of us in the workers’ compensation community (although I will focus on physicians) hold some responsibility for contributing to claims going “South” or what we also term, disaster cases. This does not mean that the injury was disastrous, and in fact often the injury was minor, yet the results are disastrous in terms of claim costs and a poor functional outcome for the injured worker.
First and foremost in my mind is that there is not enough “good will” in workers’ compensation. We need to put the injured worker first. Ask yourself a simple question, how would you like to be treated if you were an injured worker? When I lecture and ask an audience of employers/claims people if they had to choose between using their private insurance and workers’ compensation; there is almost unanimity of hands raised for use of private insurance.
At a very personal level, when my wife or I need medical attention, we get an appointment with our primary physician almost immediately and whatever tests she orders or prescriptions she writes, they get taken care of without having to fill out special forms or wait for a utilization review decision. We do not get 6-8 page denial letters. We do not get a letter denying a body part we believe was injured. We get to see the physician and specialist of our choice rather than trying to identify a physician who will treat us – assuming we can find one at all. We do not “lawyer-up” because we are confused or feel abused.
Many of my colleagues have chosen not to treat injured workers given the complexities of the system (paperwork, special forms, litigation, system complexities, etc.). We need to find ways to encourage physicians to engage in the workers’ compensation system. While simplification would be ideal, we may need to be satisfied with education about how the system works. If you are on the employer or claims side, don’t be hesitant to call the physician and build a bond of working together for the betterment of the injured worker.
Some of you may view physicians as problematic and while there are a minority that abuse the system, in fact, the great majority of physicians want to do a good job and assist injured workers to achieve a good outcome. There are though, a number of reasons why physicians sometimes are part of the problem and not part of the solution.
Physicians have for the most part been trained in a biomedical model of focusing on the body part and not the whole person (a biopsychosocial model). Medical education need to shift focus and to paraphrase Dr. William Osler (1849-1919), “It is more important to know about the patient who has the disease than about the disease the patient has”.
Misaligned incentives are a big problem. Physicians are reimbursed at a higher level for invasive interventions and procedures. It is easier (and better remunerated) to spend 5 minutes with a patient and write a requested/desired opioid prescription than to spend 30 minutes talking to and educating a patient and encouraging increased activities, less medications and staying at or returning to work. Let’s work together to find ways to incentivize physicians to follow evidence based medicine and to practice with the injured worker’s best interest at heart.
In my opinion, electronic medical records (EMR) have had a major negative impact on the provision of quality medical care. Have you seen the multipage dribble that doctors are turning out? Not only are these follow-up reports long and full of repeated and extraneous information, but worse, they often contain erroneous information. The use of a Macro (a prewritten paragraph) is easy and quick but often not attuned to the specific patient and sometimes contains just plain wrong information. One example: do you really believe that the exact same detailed physical examination repeated in every report is truly being carried out? Of course not. Why is it so hard to find out what is actually going on with the injured worker?
Please see the following link to an article I have written, “Getting to YES with UR & IMR” (PDF). While the first part is California specific, starting on page 9 and 10 are universal recommendations for physicians for providing quality report writing. You are welcome to circulate and share this with physicians with whom you work and interact.
I not only appreciate the importance of evidence based medicine but try very hard to practice it with every injured worker I see. Still, I am being stymied in providing good medical care by utilization review. The simplest request will generate a 6-8 page letter which is tolerable when there is an authorization, but intolerable when there is a denial based on stock paragraphs not relevant to the request.
I had a situation several weeks ago where a claims examiner asked for my help with making recommendations for an injured worker and then called me asking for me to make a specific request (a Request for Authorization or RFA in California). I did so as requested, only to get a phone call from a physician reviewer who called at 12:15 pm when I was with a patient and left a message for me to call back before 5:00 pm by the next day or risk denial. I called twice that same afternoon, only to reach an answering machine. I planned to try a third time the next morning but I got a fax at 6:30 AM denying my request. Are you really satisfied that your organization’s utilization review is topnotch? Find ways to work with the physician to reach a good outcome for the injured worker. What can you do to make a positive difference?
Ignoring psychiatric comorbidity, whether it be life-long or related specifically to the industrial injury, can be disastrous for the claim in general, and the injured work specifically. We have seen an increasing recognition that providing psychological care related to a musculoskeletal work injury is good and cost-effective medicine, and does not necessarily lead to a psychiatric claim.
So what are the solutions? Employers need to show concern and followup with workers when they are injured and find a way to get them back to work as soon as possible. Claims examiners need to serve as advocates for injured workers in obtaining care. Physicians need to focus on the whole patient using a biopsychosocial approach. Opioids need to be discouraged, emotional and physical good health encouraged, and return to work emphasized.
It is easy to get discouraged, whatever role you play in the workers’ compensation system, but I encourage you to stay positive. All of us need to be focused on communicating effectively with each other and the injured worker. While the big picture is important, do what I do: focus on one injured worker at a time and how you can help that individual better manage pain, become more functional and return to gainful employment.
Click here to view: Getting to YES with UR & IMR (PDF)
About Dr. Steven Feinberg
Dr. Steven Feinberg is a physiatrist and pain medicine specialist practicing in Palo Alto. He is an Adjunct Clinical Professor and teaches at the Stanford University Pain Service.
Dr. Feinberg is a past president (1996) of the American Academy of Pain Medicine (AAPM). He served as a California Society of Medicine & Surgery (CSIMS) Year 2001 President. He serves on the Board of Directors of the American Chronic Pain Association (www.theacpa.org) and is lead author of the 2017 ACPA Resource Guide to Chronic Pain Treatment.
Dr. Feinberg served as Associate Editor on the ACOEM Chronic Pain Guidelines Panel Chapter 2008 Update and is serving currently serving as Panel Chair for the 2017 update (soon to be released). He served as a Medical Reviewer for the ACOEM 2014 Opioid Guidelines.
About Feinberg Medical Group
FMG is a private practice medical group in Palo Alto which focuses on the treatment of injured workers using a biopsychosocial functional restoration approach following the CA Medical Treatment Utilization Schedule (MTUS) adhering to evidence based medical guidelines.