Tag Archives: trauma

How to Help Veterans on Mental Health

The constant beat of the major media drum often paints a grim picture of veterans and suicide. Sometimes, we wonder if these messages become a self-fulfilling prophecy. Consistent headlines include data such as:

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  • Approximately 22 veterans die by suicide each day (about one every 65 minutes).
  • In 2012, suicide deaths outpaced combat deaths, with 349 active-duty suicides; on average about one per day.
  • The suicide rate among veterans (30 per 100,000) is double the civilian rate.

Listening to this regular narrative, a collective concern and urgency emerges on how best to support our veterans who are making the transition back to civilian jobs and communities. Many veterans have a number of risk factors for suicide, contributing to the dire suicide statistics, including:

  • A strong identity in a fearless, stoic, risk-taking and macho culture
  • Exposure to trauma and possible traumatic brain injury
  • Self-medication through substance abuse
  • Stigmatizing views of mental illness
  • Access to and familiarity with lethal means (firearms)

Veterans show incredible resilience and resourcefulness when facing daunting challenges and learn how to cope, but employers and others who would like to support veterans are not always clear on how to be a “military-friendly community.”

The Carson J Spencer Foundation and our Man Therapy partners Cactus and Colorado’s Office of Suicide Prevention conducted a six-month needs and strengths assessment involving two in-person focus groups and two national focus groups with representation from Army, Air Force, Navy and Marine Corps and family perspectives.

When asked how we could best reach them, what issues they’d like to see addressed and what resources they need, here is what veterans and their advocates told us:

  • “I think that when you reach out to the vets, do it with humor and compassion…Give them something to talk about in the humor; they will come back when no one is looking for the compassion.” People often mentioned they preferred a straightforward approach that wasn’t overly statistical, clinical or wordy.
  • Make seeking help easy. A few veterans mentioned they liked an anonymous opportunity to check out their mental health from the privacy of their own home. Additionally, a concern exists among veterans, who assume some other service member would need a resource more. They hesitate to seek help, in part, because they don’t want to take away a resource from “someone who may really need it.” Having universal access through the Internet gets around this issue.
  • “We need to honor the warrior in transition. The loss of identity is a big deal, along with camaraderie and cohesion. Who I was, who I am now, who I am going to be…” The top request for content was about how to manage the transition from military life to civilian life. The loss of identity and not knowing who “has your back” is significant. Several veterans were incredibly concerned about being judged for PTS (no “D,” for disorder – as the stress they experience is a normal response to an abnormal situation). Veterans also requested content about: post-traumatic stress and growth, traumatic brain injury, military sexual trauma and fatherhood and relationships, especially during deployment.
  • The best ways to reach veterans: trusted peers, family members and leaders with “vicarious credibility.”

Because of these needs and suggestions, an innovative online tool called “Man Therapy” now offers male military/veterans a new way to self-assess for mental health challenges and link to resources.

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In addition to mental health support, many other things can be done to support veterans:

We owe it to our service members to provide them with resources and support and to listen carefully to the challenges and barriers that prevent them from fully thriving. Learn how you can be part of the solution instead of just focusing on the problem.

How to Limit Claims Post-Termination

With increasing frequency, I am seeing post-termination claims being filed against employers who otherwise are doing an excellent job providing a safe work environment and comprehensive safety training.

It is impossible to develop statistics on this kind of claim, but anecdotal evidence indicates that there are more of them being filed. A slow economy exacerbates this problem.

It is important that we find strategies that will limit the number of these claims for the following reasons:

  1. They typically are litigated, so they are incredibly expensive.
  2. They are discouraging and disheartening to an employer who has cared about the safety of the workers and treated them well.
  3. The majority of these claims are without substance. “Fraudulent” is a term that should not be used loosely but is very often applicable here.

We never can completely wring fraud and abuse from the workers’ compensation system. Soft-tissue claims are virtually impossible to prove or disprove, so we must rely on the injured worker to be honest. That means employers must do everything possible to influence employees to be honest.

Besides getting the terminated employee to sign a waiver that she is injury-free on her last day, here are a few additional recommendations:

  • After a layoff has been announced, but before the termination has taken place, honor those people who have worked safely and injury-free during their employment with the company. Adding a small gift card is a way to thank them. By recognizing them and thanking them in a public setting, you show your appreciation, and lack of appreciation is one of the primary reasons that people file fraudulent claims.
  • If the soon-to-be laid-off workers are part of a safety team or department, make sure that they are included in any awards or recognition that is given at the end of the measured safety time period.
  • Indicate to the workforce that the company policy is to contest and deny any claims that are filed after a layoff or termination. Don’t just threaten, do it.
  • Gain agreement from your insurance carrier that it will contest any post-termination claim and not simply offer a settlement to have it go away.
  • Contact the physician who is issuing the cumulative trauma report and let him know that you intend to contest his finding. Your insurance carrier should be your ally in exposing repeat offenders.

Remember that an injury that occurs after a layoff has been announced, but before the termination takes place, sets up any post-termination claim as legitimate.

Treating employees well and creating the strongest possible safety culture are the best defenses, but incorporating additional strategies can help prevent a discouraging and expensive post-termination claim.

Better Approach to Soft Tissue Injury

Musculoskeletal diseases, defined as injuries to the soft tissues, currently affect more than one out of every two persons in the U.S. age 18 and older, and nearly three out of four over the age of 65. Low back pain affects at least 80% of adults at some point, with an estimated annual cost of more than $100 billion. Trauma, back pain and arthritis — the three most common musculoskeletal conditions — are the most common reason for patient visits to physicians’ offices, emergency departments and hospitals every year. With the aging U.S. population, musculoskeletal diseases are becoming a greater burden every year.

A determination must be made if the pain generator is muscular or structural, and incorrect diagnoses can lead to inappropriate treatments and, in the worst case, unnecessary surgeries.

About 80% of healthcare and social costs related to low back pain are attributed to just 10% of patients with chronic pain and disability. This statistic suggests that improved interventions to reduce the recurrence of low back pain can underpin significant cost savings and improvement in patient outcomes.

The standard approach to managing soft tissue injuries is to obtain a medical history and perform a physical examination. Imaging or testing usually is not needed in the early phases of treatment. In most cases, the natural history of a soft tissue injury resolves without intervention.

There are excellent tools to diagnose structural abnormalities or nerve injuries. These include imaging studies, nerve condition tests and disograms. X-rays can be used to assess the possibility of fracture or dislocation. Nerve conduction studies may be used to localize nerve dysfunction.

But they are not adequate for soft tissue injury or functional assessments. MRI and CT scans, while excellent tests to evaluate structure, are generally static and not designed to assess muscle function dynamically. In addition, these standard tests all carry a high rate of false positives.

There is no magic bullet or one test that does everything. While many tests are good for what they are designed to evaluate, they are not appropriate to diagnose a soft tissue injury.

Enter electrodiagnostic functional assessment — EFA testing. The EFA is a diagnostic tool that combines and enhances five medically accepted tests: electromyography, range of motion, functional capacity evaluation, pinch and grip strength. The EFA is non-invasive and non-loading. The advantage the EFA presents over performing these tests individually is that it performs all tests simultaneously and in a dynamic fashion.

This equipment has a 510 (k) registration with the Food and Drug Administration as a Class II diagnostic device. Furthermore, the FDA has recognized in the intended use section that the technology can distinguish between acute and chronic pathology, is able to look at referred pain patterns and is useful with treatment recommendations and baseline testing.

Physicians encounter patients daily with complaints of injuries to the soft tissues, particularly the paraspinal muscles. In many cases, objective findings are obvious, but many patients may have injuries that are subtle but continue to cause symptoms. In other cases, the injuries may be less recent, and the physical findings may not be apparent. Direct palpation of soft tissues can, in some cases, reveal the nature or type of injury, but this manner of diagnosis relies on static testing. For some individuals, problems may only be encountered during activity. Measuring muscle activity during range-of-motion testing is difficult at best. The extent to which a patient exerts herself also presents a subjective bias with soft tissue injury.

Better outcomes will be demonstrated by using the correct tools to evaluate the underlying pathology. In Adam Seidner’s paper “Assessing disease and wellness in the occupational setting: Electrodiagnostic Functional Assessment from wired to wireless,” he demonstrated that, when the EFA was implemented as a case management tool, it enhanced the level of discussion among treating providers, injured workers and claim professionals. The study demonstrated that medical and lost wage payments to injured workers and their healthcare providers were 25% lower in the EFA group, for an average savings of $10,000 per claim versus the control group. Most importantly, the average return to work was 213 days in the EFA group versus 275 for the control group, or an average of 62 days sooner. The EFA was able to provide better diagnostic information on soft tissue injuries and return the individual back to activities of daily living sooner. Better patient care leads to better outcomes.

The EFA results are further demonstrated in the paper “Musculoskeletal disorders early diagnosis: A retrospective study in the occupational medicine setting.” The study found EFA test results affected the course of treatment, improved clinical and functional outcomes, increased patient satisfaction and decreased dispute litigation. In fact, 98 of the 100 cases resulted in return to maximum medical improvement with no rateable impairment and full release to active duty. Only 2% of the cases were challenged, and 98% of those in the EFA control group returned to their pre-injury jobs. These cases were tracked over a three-year period.

The EFA-STM baseline program is just another example of better diagnostics providing better patient care. This book-end solution allows for the best care possible for the work-related injury. If a condition is not deemed to be work-related, the individual can still receive the best care and a quicker resolution.

The EFA does not replace the other, well-established diagnostic tests; it is simply a better diagnostic alternative for soft tissue injuries. All the tests can complement one another.

At the end of the day, when it comes workers’ compensation, the issue is providing better patient care. It’s a win-win for all parties.

 

Debunking ‘Opt-Out’ Myths (Part 2)

This is the second of eight parts. The first article in the series is here.

“Opt-out” advocates have taken time to understand how workers’ compensation systems work, so it is fair to expect option opponents to take time to understand how options work. Sometimes, option myths are simply because of misunderstandings. Sometimes, they are outright lies in a desperate attempt to maintain the status quo for workers’ compensation programs that are championed only by a subset of interested insurance carriers, regulators and trial lawyers.

Despite what some myths say, most (if not all) option programs:

  • Cover all common law employees
  • Require immediate injury reporting, subject to a “good cause” exception (leading to faster medical care, more appropriate medical treatment, safer workplaces for co-workers and other advantages for workers and employers. For a further discussion of reporting requirements, go to http://journalrecord.com/2015/05/20/minick-oklahoma-option-works-for-companies-workers/)
  • Pay all reasonable and necessary medical expenses
  • Include no employee premium payments, deductibles or co-pays
  • Pay for emergency care, surgeries (without regard to outcome) and skilled nursing care
  • Cover mental injuries, like being a victim or witness to a criminal act and post-traumatic stress disorder
  • Cover cumulative trauma claims supported by medical evidence
  • Cover aggravations of pre-existing conditions to the extent caused by the course and scope of employment
  • Cover catastrophic injuries (including impairments and death)
  • Gain access to more of the best medical providers
  • Allow employees to object to a treating provider’s findings, request a change in physician or seek a second medical opinion
  • Use independent medical examinations

Opponents also do their best to avoid the fact that opt-out programs:

  • Pay higher wage replacement benefits than workers’ compensation (even after applicable taxes, if any – a subject addressed later in this series of articles)
  • Deny fewer claims, result in fewer disputes and deliver more predictable outcomes than workers’ compensation
  • Rely on the same claim procedures used for more than 40 years in group health plans. Option programs allow appeals of denied claims, including employee discovery, submission of information and access to state and federal courts and are not subject to run-away jury verdicts
  • Include employer liability exposure for any wrongful denial of benefits, discrimination, wrongful termination or retaliatory discharge or failure to provide information
  • Are subject to the Americans with Disabilities Act, the Family and Medical Leave Act, the Occupational Health and Safety Act and other applicable state and federal laws (including civil and criminal penalties for any employer compliance failures)
  • Do not require employees to have a lawyer to understand basic rights and responsibilities
  • Are implemented primarily by small employers supported by independent insurance agents

Interested in learning more? Consider this public policy paper or FAQ on the Oklahoma Option. In-depth information is also available from many insurance carriers and third-party administrators with whom you likely already do business. Let me know if you need contacts, legal citations, actuarially credible data or other detail on any point above.

Your Biggest Unmeasured Cost

Some claims resolve unremarkably. People heal, they go back to work, they resolve their claim around permanent impairment, if any, and adapt to their post-injury circumstances. We don’t focus on those claims. They simply pass through the system, without fuss and without remark. There are no water cooler conversations about the claimant who did what was expected of him or her. This group represents about 80% of our claims, but only about 20% of our resources in loss costs and processing headaches.

There’s another much smaller group that do attract our time, attention and concern. They are the claims, often with similar injuries to those that heal unremarkably, that fail to resolve, demand disproportionate amounts of time to administer, result in serial disputes and cost significantly more. They cause considerably more wear and tear on claims personnel and demand more time from our dispute resolution systems. They are the 20% who represent 80% of the claims costs, and most of the excess stomach acid for system administrators, claims managers and regulators.

The difference is often the development of a secondary condition that focuses claimants on what they have lost, on their symptoms and on their “new identity” as injured (and often disabled) persons.

Sometimes, this secondary condition is explicitly claimed as a compensable injury, but, in the U.S., psychological conditions are generally not compensable without a direct causal connection to a discernible traumatic incident. Harm that occurs as a reaction to the experience of the compensation system is often dismissed as malingering, secondary gain behavior or personal weakness, and you may thinking, “We don’t compensate that.” Think again.

To be sure, you may not be using the words, “exacerbation of primary claims due to secondary psychological overlay,” but you are still paying for it. The research evidence is now overwhelming. Psychological conditions, whether pre-existing or acquired after a claim arises, affect the physical healing as well as the probability that an injured person will return to his pre-injury life.

You are paying for secondary psychological overlay, whether or not your systems are set up to detect and measure this cost driver. It is very likely your largest unmeasured cost driver.

All of these conditions are attributable to secondary psychological overlay:

  • Unexplained failure to thrive and return to work;
  • Functional syndromes that have neither explained cause nor effective treatment;
  • Unexplained chronic pain (and all the expensive treatments and addiction problems that go with it); and
  • The appearance of secondary physical symptoms that complicate recovery

There are indirect repercussions, as well. Some people seem to develop the attitude that they are entitled to whatever treatment or benefits that they request, or that they deserve special treatment by the system. There is burnout, desensitization and turnover among staff, with the very significant attendant costs of recruitment and training of new personnel. These claims drive (and are driven by) lawyer behavior that enables “victimhood” and doctor behavior that “medicalizes” symptoms and sets inappropriate patient expectations.  The list of cost centers goes on and on.

We haven’t done a very good job of measuring this cost driver. Partly, that’s because our analytics are limited by the data we’ve collected. If we haven’t collected the right data (or haven’t even asked the right questions in the first place), then it’s hard to directly analyze the phenomenon. Partly, it’s a matter of the complexity of the calculation. Factoring personnel costs and systemic behavior changes by lawyers and doctors makes things a lot more complicated.

We avoid useful thinking about these claims. In fact, we habitually avoid thinking about anything psychological. Effective treatment is elusive, and we have too many examples of ineffective treatment stretching into lifelong periodic sessions with “the shrink.” We can’t see the injury associated with these claims, and tend to think that they aren’t “real” in the same way as physical injuries. This outmoded approach isn’t serving us well, as increasing claims severity in many jurisdictions clearly demonstrates. And there’s an element of fear of the unknown — if we acknowledge those claims, we just might have to learn different approaches to claims management and develop different substantive knowledge that we’ve needed in the past.

Unfortunately, this avoidance of all things psychological is a holdover from “person as a machine” thinking — the idea that we can fix the broken part, and the mechanism will go back into the production cycle. Alternatively, the thinking may presume that the difficulty with the worker is a disease, for which discovery of the right medication or treatment will restore equilibrium. Either way, it’s gotten much harder to maintain these simplistic views of injury and disability, given the overwhelming evidence that people are significantly affected by factors that have to do with their biopsychosocial environment and experience.

But that’s the trouble. How do we deal with this relatively small cohort of expensive claims without opening the proverbial Pandora’s box? On the one hand, acknowledging the biopsychosocial elements of the claims process may open the door to psychological claiming, which in the past has been a nightmare of unending expensive interventions with few or no positive outcomes. (Alternatively, focus on biopsychosocial factors exposes underlying matters about which the claim manager often has little or no control, such as the claimant’s prior history or the nature of the person’s off-work relationships.) On the other hand, failure to acknowledge the biopsychosocial elements flies in the face of an avalanche of research findings associating a bewildering and seemingly inconsistent array of factors correlated with good or poor outcomes. So what are you supposed to do?

First, quit pretending that the biopsychosocial flagging systems that have flooded the market are going to save you. There has never been a published properly controlled study that could show that the identification of people pursuant to a flagging system and subsequent intervention efforts had any more impact than just providing more personalized attention to claimants generally. Flagging systems have value for predicting outcomes for groups, rather than individuals. They are useful for managing reserves and initiating increased scrutiny of behavior. When misused, they also carry a potential for adverse impact through the mechanism of self-fulfilling prophesy. When you tell a well-intentioned claims manager that certain claimants have “flags,” it’s hard to predict the subtle ways in which the manager will treat the claimant differently, but it’s almost certain that the differences will be there. Identification of a person at risk, without more, has never made anyone recover faster or better.

Second, acknowledge that the presence of a secondary psychological overlay is very likely to affect the worker’s physical recovery. The research findings overwhelmingly demonstrate that psychological conditions such as depression and anxiety, a sense that personal control has been transferred to others and individual expectations for recovery have significant physical impact on physical welfare and healing of the claimant and the experience of things like chronic pain. The research shows that even the way that we talk to a patient about pain can have significant impact on the clinical outcome. It’s time to stop blaming the worker or assuming that the person is out to take advantage of the system. Just as the medical profession has acknowledged “iatrogenic” (system-created) injury, the workers’ compensation world would benefit from understanding that our compensation systems actually cause additional harm to the people we are supposed to be helping. Our system design should be more focused on preventing that harm than trying to suppress the costs associated with it.

Third, find a way of thinking about secondary psychological overlay to original injury that helps you understand how it all fits together. Such a conceptual model will help you to understand the relationship between findings that aren’t obviously related. For example, understanding the relationship between the positive impact of early intervention programs, the negative impact of lawyer representation and the negative impact of sleeplessness may be difficult without an overarching explanatory framework. There are several models out there, but I suggest that most everyone agrees that a very basic place to start is the understanding that the worker’s loss of an internalized sense of control over one’s own life is critical to explaining what’s happening to people in the claiming environment.

Finally, whatever your model of secondary psychological harm, find the places that you can control or improve the claims environment. Can you encourage early intervention or other activity that maintains the important sense of identity as a “worker” that is endangered by injury and absence from the workplace? Can you institute mechanisms that reduce the time and stress of dispute resolution and attend to the real personal needs of people in dispute? Can you arrange circumstances so that claimants get their calls returned more quickly to preserve their feeling of being valued, or minimize the repetition of their story, to prevent unnecessary entrenchment of a changed view of self? There are literally dozens of systemic changes that you can control that will have a positive impact on the worker and his recovery. It’s a different orientation than mere “cost cutting,” but it will have a greater long-term and sustainable impact.

The complication of claims because of undiagnosed and unmitigated secondary psychological overlays threatens the integrity of workers’ compensation generally. Whether you recognize it or not, it is a very significant underlying cost driver. In the absence of understanding this phenomenon, systemic attempts to control costs have led to the increasing perception of a failure of the underlying quid pro quo that is reflected in recent litigation in Florida and changes in the structure of the Oklahoma system.  Most of us have within our control some aspect of the system can lead to the reduced incidence of secondary psychological complication of a claim.  All of us can insist that our policy makers and regulators open their eyes to this hidden source of complexity and poor outcomes, and that they respond to it in a meaningful way.