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5 Best Practices on Injured Workers

Putting the injured worker first is key to the “advocacy-based claims model,” which puts the worker at the center of all activity. Until now, most employers have focused on corporate outcomes, with goals such as cutting costs and reducing days lost. But experts now say focusing on the worker can improve all outcomes.

The stories of three injured workers provide an opportunity to see the importance of focusing on the injured worker.

Take Melanie. Melanie was working as a lifeguard for the summer at a recreational center. She slipped on some wet pavement that had been targeted for cleanup but not yet addressed. She fell on one knee, sustaining a shattered patella and a deep laceration.

Melanie needed immediate surgery for the laceration. She initially was put into a brace to stabilize her patella but was told by a different provider that she didn’t need the brace. She recalls feeling like there was a lot of uncertainty around how to treat her shattered patella. One provider told her he could wire it together with surgery; another said surgery would be a mistake. Ultimately, after a delay of almost a year, during which she was unable to work, she was referred to physical therapy.

Melanie found the physical therapy helpful in enabling her finally to go back to work. However, she was left with a great deal of concern about the future of her knee and the possibility of late-onset complications. She was also upset about the long delay before she could start physical therapy. Because of this uncertainty, and to ensure that her knee would be taken care of regardless of what happened to it in the future, Melanie retained an attorney to help her obtain lifetime medical benefits for her knee. Her claim is still open.

See also: Perspectives From Injured Workers

Amy’s story has a bit of a different take. Amy was working as an administrative assistant for an apartment complex. A large number of boxes were delivered to the office and were stacked up against her desk, such that she couldn’t leave her desk area without climbing over the boxes. She asked her manager to move the boxes several times, but they were not moved. At one point, while climbing over the boxes, she fell and injured a knee.

Amy reported the injury to her supervisor, who wanted her to go immediately to a hospital emergency room. Amy did not want to wait in an emergency room and successfully argued in favor of seeing an orthopedist the next day. The orthopedist obtained an MRI of her knee that showed both old, long-standing damage and newer areas of injury consistent with the fall Amy had just sustained. However, the day after her injury, Amy’s employer fired her.

The payer in Amy’s case tried to deny the claim based on the older damage in Amy’s knee. Amy did not deny that she had damage from years of being a dancer, but she felt it was the newer damage that was limiting her mobility, as she had previously been able to exercise and now had too much pain in the damaged knee. She simply wanted the payer to pay for a few sessions of physical therapy, but the claim denial coupled with being fired left her with no resources to pay for physical therapy.

Amy found the claims adjuster hostile and inflexible. She felt betrayed by both her former employer and the payer for her claim. She retained an attorney to fight the claim denial. Eventually, the claim was accepted, and Amy was given several sessions of physical therapy. By the time this came to pass, Amy was suffering pain in the other knee because of having to favor the injured knee. What could have been resolved within a limited time had morphed into a time-lost claim with the need for extended physical therapy.

Last, there is Arthur. Arthur was employed as a consultant for a nationally known consulting firm. One day, he was carrying some boxes filled with reports when he dropped a pen and tried to pick it up without dropping the boxes. As he twisted his body to try to pick up the pen, he felt a “pop” in his back and fell to the floor in pain. After a minute or two, he was able to get up without assistance, but the pain in his back remained.

Arthur was knowledgeable about the workers’ comp system and decided to file a claim. His pain was persistent and intrusive, but Arthur was still able to work, so his was a “medical-only” claim. Arthur told the claims adjuster that he wanted to see his own physician, with whom he already had a relationship. He alluded to wanting “to avoid retaining an attorney if at all possible.”

After an MRI, Arthur’s physician told him that he now had a protruding disk that he was going to have to deal with for the rest of his life. Arthur’s physician gave him the evidence-based statistics about the success rate of surgery for a protruding disk, which were not good, and recommended that he avoid surgery and deal with his problem with stretching and physical therapy.

Arthur told the claims adjuster that he preferred to have physical therapy over surgery. The claims adjuster not only approved the physical therapy but also, unsolicited, ordered a special desk chair for Arthur to use in his home office. Arthur felt well taken care of, and after six months of following the regimen his physical therapist had designed, Arthur’s back pain resolved, and his claim was closed. He had not needed an attorney and was extremely satisfied with how his claim had been handled.

What can these three journeys tell us about how to put the injured worker first? Here are five best practices:

  1. Ensure the injured worker is educated about the claims process and what to expect. One of the most common reasons why injured workers retain an attorney is because they are worried about whether their claim will be accepted and their bills paid. Reducing uncertainty and fear on the part of the injured worker improves his or her engagement in the treatment process and reduces the attorney involvement rate, which improves quality of care and reduces cost.
  2. Use technology to facilitate the injured worker’s interactions with other stakeholders, from the initial reporting of the injury (think mobile app, direct self-reporting of injuries) to selection of the right physician and finally to the collection of feedback from the injured worker on treatment. Technology is a powerful tool to provide high-quality, personalized, yet cost-effective service. However, it needs to be backed up by strong operational processes.
  3. Encourage injured workers to plan on returning to work right from the beginning. This means helping them select the right physicians proven to have good outcomes and encouraging them to be partners with their treating physicians in choosing wisely among treatment options. For example, there are several physicians who are waging an admirable fight against the opioid epidemic and pushing for more holistic pain-management techniques. We need to send more injured workers to them instead of physicians who have been proven to encourage opioid use.
  4. Trust the injured worker to want to return to work as soon as possible. Most injured workers honestly want to recover, not to game the system. We need to go with that assumption upfront. A good marriage of Math+Trust can help reduce attorney involvement in claims from 13% to 4%.
  5. Stay in close contact with the injured worker; keep the lines of communication open. Use this opportunity to determine if there are any treatment delays that can be mitigated or any questionable treatments that are being recommended. Expectations on communication speed have increased in this constantly connected world. We need to be as close to them as possible throughout their journey to recovery.

Gently guiding the injured worker to the best possible course of treatment will optimize outcomes, improve injured worker satisfaction and minimize costs.

See also: 3 Reasons to Talk With Injured Workers  

The primary purpose of the workers’ compensation system is to get injured workers back on track rapidly. As an industry, it’s time we realigned ourselves toward that goal. Using the “injured worker comes first” principle as a true north improves claim outcomes, lowers costs and improves workplace productivity. No longer do you need to make false trade-offs between cost and quality, cost and speed, etc. Just focus on getting the worker back on his or her feet fast. All operational metrics will follow.

As first published in Claims Journal.

In Opioid Guidelines We Trust?

A common recommendation to combat the current opioid epidemic is to provide physicians with opioid prescribing guidelines. Opioid guidelines synthesize the available research to inform judicious prescribing behaviors and safe dosages when opioids are needed. Given the seriousness of the opioid epidemic, it is not surprising that multiple organizations currently produce opioid prescribing guidelines. Opioid guidelines are based on evaluations of the research, but the guidelines themselves need to be evaluated critically, as well.

Guideline Evaluation

Fortunately, there are multiple standards currently available to evaluate guidelines, including AGREE (Appraisal of Guidelines, Research and Evaluation), IOM (Institute of Medicine), GRADE (Grading of Recommendations Assessment, Development and Evaluation) and AMSTAR (A Measurement Tool to Assess Systematic Reviews). For example, the AGREE consortium’s latest standard (AGREE II) provides a 23-point checklist covering six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability and editorial independence. While some AGREE II domains are obvious criteria including “rigor of development” and “editorial independence,” other domains such as “applicability” are less obvious but important.

See also: Who’s Going to Pay for the Opioid Crisis?  

For example, one part of “applicability” is about providing advice or tools for translating recommendations into practice. This point is important considering opioid prescribing guidelines will only work if practitioners can integrate use of the guidelines into their workflow and can apply them effectively to the appropriate individuals. Most chronic opioid users’ first exposure to opioids is through a physician’s prescription, and physicians’ opioid-prescribing patterns have been shown to be associated with opioid abuse and deaths. Therefore, preventing unnecessary first exposure to opioids is crucial.

Guideline standards have shown that not all opioid treatment guidelines are of equal quality. For example, Nuckols et al. (2014) assessed 13 opioid guidelines using the AGREE II and AMSTAR instruments. The authors found AGREE II scores ranged from 3.00 to 6.20 on a 1 to 7 scale, and AMSTAR ratings ranged from poor to high. Four of the guidelines were “recommended against using … because of limited confidence in development methods, lack of evidence summaries or concerns about readability.” This research proves that the quality of opioid guidelines does vary.

The National Guidelines Clearinghouse (www.guideline.gov) is a publicly available resource that provides summaries of guidelines that comply with IOM standards. Although not all guidelines are available free on the National Guidelines Clearinghouse website, it could be a good starting point for finding organizations with guidelines that adhere to a guideline standard.

Jim Smith’s Story

Jim Smith’s occupational injury provides a useful example of how being prescribed opioids contrary to high-quality treatment recommendations may lead to serious health and economic consequences. Jim is a 38-year-old construction worker who suffered an extremely painful lower back strain while attempting to lift a heavy box. Against most guidelines’ recommendations, he was treated from the start with a long-acting opioid, on which he became first dependent and then addicted, taking increasingly higher doses. Even on doses exceeding most guidelines’ recommendations, Jim still suffered from pain and limited mobility. In addition, he began to require supplemental medication to treat the side effects of his opioid use, such as constipation. He subsequently underwent surgery on his lumbar spine, which did not provide him relief from his pain, and he ended up a chronic user of opioids, permanently disabled and housebound.

If Jim had been treated according to any of the current, high-quality opioid treatment guidelines, he would not have received a prescription for an opioid as an initial measure. He would have been counseled to try over-the-counter medications such as ibuprofen or acetaminophen, sent to physical therapy, prescribed exercise and perhaps offered a course in cognitive behavioral therapy (CBT). If opioids had been truly necessary in the acute phase of Jim’s injury, he would have been prescribed a limited course and then been gradually tapered off.

See also: 3 Perspectives on Opioid Crisis in WC  

Conclusion

It is very important to find guidelines that both reduce initial use of opioids and serve to guide the physician in tapering chronic opioid users off these drugs. For someone who has been on opioids for a long time, the tapering process could take many months or years, and there could be both physical and psychological complications during the taper. The process for weaning someone off chronic opioid usage will be discussed in the next article in this series.

In conclusion, users of treatment guidelines put a lot of trust into the recommendations provided. Using only opioid treatment guidelines with sound quality and content helps keep that vital trust so clinicians can continue to use guidelines in combating the prescription opioid epidemic.

3 Perspectives on Opioid Crisis in WC

Over the past two decades, there has been a dramatic increase in the use of opioids in workers’ compensation. Opioids are being prescribed for many conditions for which they were not originally intended. Efforts have begun across the U.S. to create opioid treatment guidelines, change medical practice patterns and curb the opioid epidemic. While much has been written recently about the unintended consequences of opioid use, such as how they increase pain sensitivity and level of disability and can lead to addiction, there is little information available about the perspectives of the key players in workers’ compensation on the opioid issue.

Mark Pew, a prominent managed care organization’s spokesman, has said, “Using opioids as a crutch really is the wrong thing. What you need to be focusing on is coping with it and managing it like the vast majority of humanity does with chronic pain or just the fact of getting old.” But what do the injured workers, physicians and claims adjusters say? I conducted confidential interviews with members of each of these groups to get the perspectives of those who so far have had less of a voice in the debate.

Physicians

Physicians must balance their desire to control their patients’ pain against the known drawbacks of opioids. One physician told me, “When I was in medical school 20 years ago, we were told that we were undertreating pain. Pain was named ‘the fifth vital sign’ (along with blood pressure, heart rate, respiratory rate and temperature), and we were trained to ask patients about their level of pain on a 10-point scale at every visit. At that time, very little was known about the dangers of long-term opioid use. Now, patients with any kind of pain have come to expect to get that narcotics prescription when they see the doctor.”

See also: How to Attack the Opioid Crisis  

Interestingly, in response to the current opioid crisis, delegates at the 2016 annual meeting of the American Medical Association passed a resolution recommending that pain be removed as the fifth vital sign in professional medical standards. Critics, many of them pain management specialists, say the move “will make it even more difficult for pain sufferers to have their pain properly diagnosed and treated.” However, a 2006 study in the Journal of General Internal Medicine concluded that “routinely measuring pain by the fifth vital sign did not increase the quality of pain management.”

Another physician, a medical director at an insurance carrier, said, “When I see the second opioid prescription come through the system, I start reserving for detox.” She meant the second opioid prescription is an indication to her that there is a high likelihood the injured worker is going to become addicted to the opioids.

Claims Adjusters

Claims adjusters have a unique perspective on the direction a workers’ comp claim takes. They usually speak with both the injured worker and the provider and can influence the process to a certain extent. One claims adjuster said, “I’ve been watching the whole opioid crisis unfold for the last 10 years. We see the opioid prescriptions coming through, and we know that many of them are not indicated by the patient’s condition, but we have limited options for preventing problems. It would be nice if we could identify the providers with good prescribing patterns and direct injured workers to those providers.”

Another claims adjuster told me, “In states with drug formularies, where opioids require prior approval, we are seeing much less opioid use on new claims. Our biggest problems are the older claims where the injured workers have been taking opioids for long periods of time. Then we start to see the prescribing of additional drugs just to treat the side effects of the opioids. The worker is already addicted, is not even getting adequate pain relief anymore, and the claim just goes on and on.”

This claims adjuster thought the best approach to the opioid problem would be to have a claims management system that alerted managers every time a new claim had an opioid prescribed. That way, “we could immediately contact the physician and make sure there was an understanding of the opioid treatment guidelines and a plan in place, right from the start, for weaning the injured worker off the drugs at the appropriate time.”

Injured Workers

In the current climate of awareness about the risks and dangers of opioids, injured workers are often caught in the middle. They must balance their desire for pain control against their growing concerns about side effects and long-term adverse effects. One injured worker said, “I know I’m getting less pain relief than I used to from the pills, but I’m reluctant to tell my physician because I’m afraid of having to deal with my pain on my own. I’d rather suffer with the side effects I’m accustomed to than risk being in constant pain again.”

Another injured worker told me, “I went from eight pills a day to being totally opioid-free, but it took two stints in rehab and a whole lot of willpower. It’s a seductive thought, to place your trust regarding pain relief in a pill, but it’s not a long-term solution. The pills have too many disadvantages. Sooner or later you have to get off the pills and take control of your pain using other methods.” This injured worker has achieved an acceptable level of pain relief using over-the-counter medication and by practicing mindfulness.

A third injured worker reported, “I’ve been on opioids for two years now. My doctor keeps refilling the prescription, so I keep taking the pills. I have a lot of side effects, but it’s worth it to keep my pain under control. I don’t want to make any changes in my regimen and risk being in pain again. I find the negative publicity about opioids very scary. I guess someday I’ll quit them, but just not right now.”

In conclusion, injured workers, providers and claims adjusters are all seeking the right way to deal with pain. Injured workers in pain need pain relief, but they also need non-pharmacologic pain management techniques. Most treatment guidelines in workers’ compensation now recommend opioids only for acute, post-surgical pain relief for three to seven days, ideally. They are not recommended for chronic, musculoskeletal pain, e.g., for pain lasting longer than three months. Providers must take responsibility for engaging their injured workers in an active pain-management process. It doesn’t have to be a formal program; it can be an agreement between doctor and patient. Doctors have to be ready for this responsibility if they prescribe opioids; it’s poor practice — and violates the physician’s imperative to “do no harm” — to prescribe something addictive if you are not able to assist the injured worker with the weaning process.

See also: Opioids: A Stumbling Block to WC Outcomes  

For their part, injured workers must accept the necessity of being actively involved in their pain management and buy into not taking pills long-term that are going to result in more harm than good. They should demand that their prescribing physician discuss the medication plan with them, what the adverse effects are and what the weaning process will be like.

Finally, claims adjusters have the responsibility to be on the lookout for opioid prescriptions and to make sure that providers are prescribing them within guidelines. There are technological solutions for this. The best approach to the opioid crisis is a team approach: providers, claims adjusters and injured workers working together to avoid opioid dependence and maximize recovery, restoration of function and lasting relief from pain.