Chronic over-prescription of opioid painkillers is fostering a culture of “sickness” in the American workplace. This was the conclusion recently drawn by a panel discussion, in which we participated, including experts with deep experience in workplace injury, health care, insurance and pain management.
News accounts support this dire claim, including current stories chronicling the increase in heroin use among sufferers looking for a cheap alternative to prescription meds, or the recent Mayo Clinic study that found that one in four people prescribed opioids progressed to longer-term prescriptions.
Historically, prescribing physicians have had few arrows in the [pain management] quiver and painkillers, short-term, are certainly effective for many. But now practices find themselves challenged to come up with new ways to treat pain sufferers, particularly those with workplace injuries that the workers comp system refers to as catastrophic - overburdening the system and remaining largely unresolved to avoid opioids.
Working in concert with employers, the insurance community and other health care professionals, practices have the potential to resolve patient injuries more effectively and return patients to “normal” safely and more quickly. Stakeholders in the system must embrace these five essential changes that have the potential to curtail this continuing “sickness.”
1. Eliminate unproven therapies in favor of accurate diagnosis, followed by evidence-based treatment.
It’s my opinion that the classic model is not successful due to outdated modes of thinking. The current model of treatment consists of using lots of non-steroidal anti-inflammatories (which are meager in efficacy to begin with), referral to physical therapy that is often perfunctory, with a reliance on passive physical therapy (instead of active physical therapy). For persistent complaints, are often provided repeated cortisone injections, which are well known to inhibit tissue healing, rather than trying to regenerate tissue. When these treat fail, patients then often undergo surgery, with various surgical procedures that have become embedded in classic traditional orthopedic treatment, such as partial meniscectomies (removal of a piece of cartilage in your knee that cushions and stabilizes the joint), and spinal fusion procedures. The current medical literature has demonstrated that in many patients partial meniscectomy is no better than physical therapy or even sham meniscal surgery. And yet 700,000 partial meniscectomies are performed every year. (Dr. Gerard Malanga)
Proper diagnosis is closely linked to proper treatment, and providers need to focus more heavily on accurate diagnosis to deliver appropriate care. Yet some 30 percent of patients are misdiagnosed: in the worst cases, what could have been an injury that might heal within weeks with proper treatment can, if improperly diagnosed and treated, snowball into a life-altering, permanent injury that prevents that worker from ever going back to work. Too often, providers choose a conservative intervention in the beginning of a workers’ compensation case, usually due to its low cost. But when applied in the wrong circumstances, conservative treatment can cost more in the long run, as later, more costly treatment is required.
2. Identify at-risk workers early, and invest in wellness as well as sickness.
When we’re dealing with a work-related injury we’re dealing with a very specific population – they make a living pushing, pulling & lifting. In our research, that frequently means an educational level at high school or less. As patients, they’re very ill equipped to really understand how to access the medical system, never mind judge what is good from bad care, so that places a huge burden on the claim professional charged with bringing that claim to a successful result. (Michael Shor, MPH Managing Director, Best Doctors Occupational Health Institute)
At the same time, preventing patients from spiraling downward at the onset of injury is crucial. Energi, Inc. has had demonstrable success with use of nurse case managers (NCMs) for those entering the workers’ comp system. Energi assigns NCMs to every patient, providing services from filing the claim, helping to guide treatment and care, and accompanying patients to doctor visits.
Energi retained Risk Navigation Group, LLC (Risk Navigation) to conduct an analysis of medical management outcomes in two samples of claims. Risk Navigation examined incurred losses to determine if there was a distinction in the disability duration outcomes between two programs, one using NCMs for all claims and the other using NCMs in less than 40 percent of claims. Use of NCMs demonstrated a materially and financially advantageous effect on both overall medical management and, more particularly, a diminution of disability duration in similar claims. Specifically, “days of disability” were reduced from 316.9 to 85.65 when NCMs were activated from “day one.” According to study authors, some companies consider it an extra cost, but nurse case managers have been known to help close workers’ compensation cases at 70 percent of what they would normally cost.
Another example of a company investing in wellness is Horizon Casualty’s innovative Pain Management Medical Home. Anecdotally speaking, patients with an unhealthy lifestyle (e.g. smokers, overweight/ obese, etc.) combined with the psycho-social aspects of negative relationships at work or at home tend to be more likely to have a negative post-injury experience. Strategic new initiatives such as the Pain Management Medical Home approach put people on the best therapeutic course early in their care by implementing a care team approach. The care team consists of a diverse set of healthcare providers, including a Physical Medicine and Rehabilitation physician, a functional rehabilitation provider, and a psychologist. This holistic approach to the patient’s care applies a biopsychosocial model to health care.
3. Embrace innovative treatment solutions.
What is evidence-based medicine? It’s the publications and the journals, but it’s also the history and knowledge of the physician with the different techniques, and the history and goals and desires of the patient. That’s evidence-based medicine. (Dr. Ralph Ortiz, Board of Directors of the New York State Pain Society)
The panelists agreed that physicians have limited options when it comes to treating musculo-skeletal pain, the most common form of workplace injury. Today, treatments are geared towards what’s reimbursable rather than what is best for the patient. According to Dr. Ralph Ortiz, “Pills, passive physical therapy and injections only mask the pain – there are newer therapies available, showing real patient improvement - let’s get rid of the red tape, be the innovators and try them.”
Dr. Ortiz is mainly speaking of innovative, new treatments currently available, but not yet considered part of the generally accepted standard treatment protocol (and thus unlikely to be covered) by the insurance industry. However, more progressive workers’ compensation providers are opening the door for patients to have access to new and innovative treatment options because they recognize the importance of the quality of care, and appreciate each injured worker as a patient, not just a line item.
Some of the novel therapies that may be useful in some circumstances that were discussed by the Panel include four distinct therapeutics that enhance the human body’s natural healing processes. Although well-supported and researched in the medical community, they are today largely “not covered” by insurance carriers:
Prolotherapy: Widely considered the progenitor of each of the following treatments, it is also called proliferation therapy or regenerative injection therapy, a treatment of tissue with the injection of an irritant solution into a joint space, weakened ligament, or tendon insertion to relieve pain.
Platelet-Rich Plasma (PRP) Injections: an in-office procedure that uses the body’s own healing mechanisms by injecting the patient at the site of injury with a sample of their own blood enriched for platelets as a means to promote the healing of injured soft tissues.
Sustained Acoustic Medicine (sam®): a portable, wearable medical device that delivers long duration, low-intensity therapeutic ultrasonic energy to relieve pain and muscle spasms, and to increase local circulation that will support natural healing processes.
Stem Cell Therapy: an in-office procedure using the unique capability of stem cells to differentiate and proliferate into distinct cell types throughout the body; the harvesting of stem cells from bone marrow for reinjecting into the injury site aids the natural repair process for damaged or degenerated tissues and joints.
4. Advocate for a paradigm shift that alleviates the implications of current public policy.
When group health squeezes the financial balloon, its workers comp that makes up the difference. (Michael Shor)
The Affordable Care Act had one key change that, intentionally or not, had major ramifications for the workers’ compensation industry. Historically, group health and workers’ compensation were billed as “fee for service,” meaning health care providers were reimbursed based on the services provided for a patient (including diagnostics, procedures, office visits, etc.) But post-ACA, workers’ compensation remains fee for service while group health switched over to capitation, in which doctors are reimbursed a lump sum per patient based on their diagnosis and thus must manage the patient’s healthcare within a fixed budget. The result: for patients with chronic degenerative conditions – a bad knee, a bad shoulder, a bad back -- it’s more efficient and more financially sound for insurance and medical professionals if patients can be classified under workers’ compensation because the patient’s cost of care is not capped.
While the primary goal of all stakeholders should be to ensure quality patient care, the financial motivations (where can a provider make the most money) and budget considerations (how can a payer save the most money) are real. Says panel participant and employer, David Cohen, “What all involved must keep in mind is, getting a patient back to good health – and work - faster, will always be the ultimate money saver.”
Reversing this trend requires the collaborative efforts of key stakeholders: workers’ compensation insurance carriers, employers, and providers. Through productive and transparent collaboration, evidence-based coverage policies can be established to support diagnostic and therapeutic products and services that deliver high-quality health outcomes. This represents a shift in the workers’ compensation industry from “fee-for-service” to “pay for performance,” in which financial rewards are only realized upon production of quality health outcomes.
5. Move out of your comfort zone. True, disruptive change in any industry comes when the participants move beyond their comfort zone.
To break the cycle of ineffective pain treatment and workplace injuries that go unresolved for years, medical professionals need to stop treating patients according to old patterns. All players should take a fresh and unbiased look at evidence-based medicine and adopt a more open attitude to promising new therapies. Taken together, these recommendations have the potential to unlock a bright new future for all who are involved in treating workplace injury.
Dr. Gerard Malanga is the founder and partner of New Jersey Sports Medicine LLC and New Jersey Regenerative Institute. He also serves as the medical director at Horizon Casualty Services. He has expertise in the non-operative treatment of a variety of orthopedic disorders, including neck and back pain, as well as shoulder, knee and other sport medicine and musculoskeletal problems. His expertise includes EMG testing, spinal and joint injections, musculoskeletal ultrasound and Platelet Rich Plasma and stem cell therapy treatments for orthopedic conditions.
Robert D. Woods Jr. (Bob) has more than 40 years of claim experience, including all areas of commercial and personal lines and currently serves as the senior VP of claims at Energi Inc. He has extensive experience in developing and implementing claim automation programs and has spoken nationally at both the ACORD and LOMA conferences on the topic of claim automation.