Taming Medical Providers in the Workers Compensation Jungle

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Taming Medical Providers in the Workers
Compensation Jungle

• James Martin, MD, MPH
• Fort HealthCare - Business Health

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Introduction
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Introduction
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Introduction
Bio- Psycho- Social Model of Health
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The Players
Patient/Employee
Employer
Doctor
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Injury with Functional Loss Processes

• Health event that affects ability to function
  triggers 5 parallel process
• Medical care process
• Personal adjustment process
• RTW process
• Disability benefits administration process
• ADA reasonable accommodation process

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1. Medical Care Process

• Fundamental Issues
• What is diagnosis and prognosis?
• Is this treatable?
• What treatment is warranted?
• Leader - Doctor
• Activity- delivery of medical services

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2. Personal Adjustment Process

• Fundamental Issues
• Dealing with life disruption
• What does this mean for the future?
• Leader - Employee
• Activities
• Thinking feeling coping adapting

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3. Return to Work Process

• Fundamental Issues
• Will employee recover on the job?
• When is it safe to resume normal activity?
• What adjustments to usual job?
• Will employee ever return to same job?
• Leaders - Employee Employer Doctor
• Activities - complexity depends

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4. Benefits Administration Process

• Fundamental Issues
• Does this episode qualify?
• Is this person eligible for benefits?
• Is there any evidence of fraud?
• Leader - Claims agent
• Activities - fact finding data gathering claim
  processing

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Injury with Functional Loss Processes
Patient/Employee
Personal Adj Process RTW Process
Employer
Doctor
Med Care Process RTW Process
RTW Process Benefits Process
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Doctor Dynamics

• Intelligence
• Common sense
• Ego
• Obsessive-Compulsive
• Paperwork
• Ignorance about disability

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Doctor Dynamics
Physician - Patient Relationship
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Doctor Dynamics

• Patient care - clinical course
• Medical History
• Physical Examination
• Diagnostic Tests
• LEADS TO A
• Differential Diagnosis

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Doctor Dynamics

• Provisional causation analysis
• Make a diagnosis
• Evaluate causative work exposures
• Done in first visit or two
• Primarily relies on history and physical exam
• Initial assessment other causal factors

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Doctor Dynamics

• Definitive causation analysis
• 1. Evidence of disease
• 2. Epidemiology
• 3. Evidence of exposure
• 4. Consideration of other relevant factors
• 5. Validity of testimony
• 6. Conclusion

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Patient/Employee Dynamics

• Coping determinants
• physical abilities
• financial status
• social support
• psychological status
• Motivation
• Personal identity

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Patient/Employee Dynamics

• Worker psychosocial risk factors for disability
• initial perceived pain levels and functional
  ability
• poor problem solving abilities
• low expectancies about returning to work
• depressive symptoms
• negative attitude at work

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Patient/Employee Dynamics

• Worker psychosocial risk factors for disability
• family history of disability
• family support
• change in family role
• income
• education
• litigation

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Employer Dynamics

• Employee - employer relations
• supervisor
• worker autonomy/control
• systemic abuses
• Benefits administration
• Co-worker attitudes

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Employer Dynamics

• Workplace psychosocial risk factors for
  disability
• job stress and dissatisfaction
• lack of social support at work
• lack of modified work
• limited autonomy in the workplace

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Bio- Psycho- Social Model of Health
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Causation Low Back Pain

• Risk factors for chronic low back pain (Royal
  College of General Practitioners)
• Previous history of low back pain
• Total work loss (due to back pain) past year
• Radiating leg pain
• Signs of nerve root involvement
• Poor physical fitness
• Self-rated poor health

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Causation Low Back Pain

• Risk factors for chronic low back pain (cont)
• Heavy smoking
• Depressive symptoms
• Disproportionate illness behavior
• Low job satisfaction
• Personal problems
• Adversarial medicolegal proceedings

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Intervention

• Primary Prevention - actions to prevent any
  injury from occurring
• Secondary Prevention - at time of injury actions
  to limit the severity of the injury
• Tertiary Prevention - actions to minimize long
  term disability

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Primary Prevention

• Doctor
• Training education
• Work Comp
• Early RTW benefits
• Functional restrictions
• Impairment v. disability
• Patient advocacy
• Standardize methods to exchange information

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Primary Prevention

• Employee/Patient
• Pre-placement physical
• Functional testing
• Wellness program
• Employee Assistance Program
• Psychological testing
• Stretching program

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Primary Prevention

• Employer
• Supervisor training
• Worker empowerment
• Ergonomics
• Control minor abuse (culture)
• Establish relationship with health care providers
• Identify light duty positions

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Primary Prevention

• Employer
• Functional job descriptions
• Injury assessment and prevention program
• Improve internal communication (all levels)
• Drug screening
• Standardize methods to exchange information
• Reimburse doctors for disability prevention

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Secondary Prevention

• Doctor
• Accurate diagnosis
• Sense of urgency
• Identify and address co-morbidity
• Physical
• Psychological
• Social
• Identify work restrictions
• Best practices guidelines
• Communicate

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Secondary Prevention

• Employee/Patient
• Report injury promptly
• Comply with treatment
• Coping with injury
• Communicate

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Secondary Prevention

• Employer
• Direct to provider panel
• Support employee
• Physical
• Psychological
• Social
• Return to work documentation
• Accident investigation

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Secondary Prevention

• Employer
• Provide modified duty
• Independent Medical Evaluation (IME)
• Fitness for duty evaluations
• Expeditious claim evaluation
• Expeditious case management (high risk)
• Communicate

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Tertiary Prevention

• Doctor
• Functional approach
• Positive attitude
• Identify and address co-morbidity
• Physical
• Psychological
• Social
• Functional capacity evaluation

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Tertiary Prevention

• Employee/Patient
• Coping with injury
• Comply with treatment
• Functional capacity evaluation

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Tertiary Prevention

• Employer
• Direct to providers (specialists)
• Support employee
• Physical
• Psychological
• Social
• Point out concerns to health provider/employee
• Provide modified duty

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Tertiary Prevention

• Employer
• Independent Medical Evaluation
• Develop strategies for bad faith behavior
• Coordinate benefits

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Closing Thoughts

• Earlier intervention
• Assess psycho social issues
• communicate findings and concerns
• Advocate for employee
• function orientation
• transitional work
• employer factors