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Workers' Compensation

Beating Back Opioids – Now What?

WorkComp Central published a new report,“We’re Beating Back Opioids — Now What?” this past June, by Peter Rousmaniere in cooperation with CompPharma. It narrates a 20-year story and poses some provocative recommendations, noting that we are at a turning point in treating chronic pain though the statistics remain daunting. Every workday, some 5,000 workers sustain injuries which disable them for at least a week; on any given day in the U.S. 500,000 injured workers are treated for chronic pain. The majority of treatments includes opioids, and for individuals with chronic pain, care and wage replacement can reach $1,000,000 in cost per claim.

Per the study’s author: “This report does two things. First, it chronicles the two decade-long story of how opioid use greatly expanded in workers’ comp, then halted and began to retreat in the face of fierce criticism. Workers’ comp professionals can use this story to tell their friends about a war they still are fighting.”

Rousmanier also credits several organizations in the detection and reporting on trends and solutions. They include the California Workers’ Compensation Institute, CompPharma, the National Council for Compensation Insurance, Washington State, and the Workers’ Compensation Research Institute. Read more…

 

A Clinical Story Worth Sharing

Most IMEs answer straight-forward questions on known issues. But there are those rare but important moments where we are reminded that things are not always as they seem, and that an examination can have extraordinary and unexpected value and impact on peoples’ lives. Allow me to share such a story.

Recently MCN conducted an IME on a 46-year-old woman who had back pain complaints in a workers’ compensation claim. The physicians who evaluated her found her to not be fixed and stable, and elected to order an MRI of the spine. It should be noted that the doctors felt that the findings they observed did not wholly fit with the injury claim but that they were significant. Typically an MRI would not be ordered for a low back pain complaint.

Five days after the evaluation she underwent the study. That same day MCN received a call from the radiologist who reviewed the film, calling our attention to unexpected findings of a mixed signal intensity mass involving the lower pole of the right kidney, approximately 4.5 by 4.4 centimeter. He noted that this may represent a renal cyst, but that a renal cell neoplasm could not be ruled out.

We informed the examining doctors who saw the claimant about these findings as well as the claims manager. As Medical Director, my priority at MCN changed in part from processing a report for her claim to doing right clinically by the claimant and ensuring that she was aware of these findings. I called her and told her that we had found something unexpected and explained to her the importance of prompt follow-up, and forwarded her the radiology report along with this email:

It was nice speaking to you this evening. As I mentioned, I am the Medical Director of MCN where you were seen for an IME on November 9, 2013 for your workplace injury. The report is in draft form at this point in time and when completed, will be sent to the department. I do note that the doctors who evaluated you did not regard you as fixed and stable and that you warrant either further treatment or evaluation.

As part of your evaluation, you underwent an MRI on November 14, 2013. The report is attached to this email.

As you can see, the radiologist reading this study noted an unusual mass that caused them to call our office, and it thus came to my attention. We will be letting the examining doctors know about this as well.

While I do not wish to alarm you, it is most important that you seek evaluation for this finding. It is possible that some of the symptoms you experience may be related to this rather than the injury. Regardless, it should be assessed to determine if it is of significance and warrants treatment.

I would recommend that you present these findings to your personal physician and work with them to investigate and follow up as appropriate.

I would appreciate any follow-up that you wish to offer and hope that the findings turn out to be insignificant and that you recover nicely from your injury.

Please let me know if you have any questions or if we can be of further assistance.

Thank you for your attention.

Brian L. Grant, MD

One week later I was surprised and touched by the following text:

Hi, this is (name withheld). I found out yesterday at the mass on my kidney is cancer. Will know more on Monday. Seeing oncologists and urologist. Thank you and please please please thank the two wonderful doctors that ordered the MRI and for taking my complaints seriously. Bless you all.

Several weeks later she underwent a partial nephrectomy at a large University medical center in the region. The subsequent weeks were rocky emotionally for her but in the end she was relieved to learn that she had a clear cell renal carcinoma and that the surgery was able to completely remove the tumor with all margins clear for carcinoma.

And by the way, her claim was also processed with an impairment rating relative to the back findings, and a settlement from the carrier.

My point in sharing this is that the work we do has impact, sometimes in ways we would never anticipate. In this case we identified a tumor causing back symptoms and took the necessary steps to help this patient get the right care in a timeframe that perhaps contributed to a great outcome. I am proud of all involved in this case and we all wish the claimant the best outcome.

Brian L. Grant, MD

Modern Love

It is not often that a reader contribution column from The New York Times called—“Modern Love”—has something of relevance to the work that we do at MCN.

In this column, the writer, Sarah Kishpaugh eloquently conveys the impact of a work injury on her husband, herself and their lives together. Rarely does one have the opportunity to hear from a fine writer how a significant injury can impact their life, as well as an interaction with the workers’ compensation system. Read more…

Should California Workers’ Comp Cover Pro Athletes from Any Team?

Workers’ Compensation has a clear place in society.

Professional athletes, especially football players, often sustain chronic injuries from their play.

The Los Angeles Times article, “Athletes Cash In On California Workers’ Comp,” addresses how many California workers’ compensation judges have held that any professional athlete who plays in the state is eligible to receive benefits from employers.

“Over the last three decades, California’s workers’ compensation system has awarded millions of dollars in benefits for job-related injuries to thousands of professional athletes. The vast majority worked for out-of-state teams; some played as little as one game in the Golden State.

All states allow professional athletes to claim workers’ compensation payments for specific job-related injuries — such as a busted knee, torn tendon or ruptured spinal disc — that happened within their borders. But California is one of the few that provides additional payments for the cumulative effect of injuries that occur over years of playing.” Read More…

California’s particular workers’ compensation regulations appear to have created coverage for players from any team that played in California during their career. Is this good policy?

The 5 Most Common Workplace Injuries

Every year thousands of employees are injured in the course of their employment.

Injuries in the workplace are costly and while it is nearly impossible to prevent every single exposure and injury in the workplace, it is important to proactive identify those that are most common in order to find possible solutions.

According to the 2012 Liberty Mutual Workplace Safety Index, the top five leading causes of workplace injuries drive 73%  of the nation’s direct workers’ compensation costs.

The study found that the top five injuries were:

1. Overexertion: Injuries from excessive lifting, pushing, pulling, holding, carrying, throwing, which accounted for $13.61 billion in costs.
2. Fall on same level: a slip, trip, or a fall in which the worker impacts either the surface or an object at the same level on which he/she is standing. This injury drove $8.61 billion in costs.
3. Fall to lower level: Which accounted to $5.12 billion in costs.
4. Bodily reaction: Injuries from bending, climbing, reaching, standing, sitting, and slipping or tripping without falling, which drove $5.28 billion in expenses.
5. Struck by object: Which accounted for $4.64 billion in costs.

The Liberty Mutual study is available here.

 

 

 

Occupational Carpal Tunnel Syndrome & Potential Cost Savings

By Scott Smith, MD

carpal-tunnel1The cost of treating occupational carpal tunnel syndrome is three to five times greater than and the results considerably less successful than that of non-occupational carpal tunnel syndrome, though the pathology is the same in both.

The diminished success rate is a complex issue, not reviewed here.  However, the excessive costs can be reduced without affecting quality of care through a number of measures reviewed briefly below and confirmed by evidence-based medicine.

First, is reducing the number of claims accepted by more narrowly and accurately defining criteria for the allowance of carpal tunnel syndrome as an occupational disease.

The Washington Department of Labor & Industries Medical Examiner’s Handbook criteria are that it “must arise naturally and proximately out of employment” whereas the Washington Department of L&I Medical Guidelines for the Treatment of Carpal Tunnel Syndrome (2008) merely requires that the occupation “constributed to the development or worsening of the condition” – a much broader and vague definition in which almost any occupation could be interpreted contributory to carpal tunnel syndrome.

Better, in my estimation, would first, like Kansas, use the term “prevailing factor” rather than “contributory factor.”  Second, to use systematic literature reviews that list the occupations in which the risk of carpal tunnel syndrome is at least doubled compared with the general population.

Secondly, whereas the Washington State Medical Treatment Guidelines require electrodiagnostic studies when carpal tunnel release is being considered, they are in classical practice often not needed for diagnosis especially when the signs and symptoms are classic, in which case surgical results are still excellent.  Further, electrodiagnostic studies have only a limited role in predicting successful outcome of carpal tunnel release and hence do not fulfill this more important goal.

The American Academy of Orthopedic Surgeons’ (whose members do the majority of carpal tunnel releases) Clinical Practice Guidelines summary for carpal tunnel syndrome concurs with this conclusion, but add it in combination with history and physical examination, may be more predictive of successful results.  It is unclear, however, whether occupational carpal tunnel syndrome was included.

There are other reasons to decrease the use of electrodiagnostic studies.  For example, postoperative use to determine recurrence or degree of symptoms is not helpful because there is poor correlation with those symptoms and the severity or change in the electrodiagnostic studies.

Third, ergonomic evaluations and recommendations seem to be overused.  Ergonomic modifications of the workplace at least intuitively, given the association of carpal tunnel syndrome with various activities involving repetition, vibration, force, and awkward postures, should diminish the incidence of carpal tunnel syndrome in the workplace and reduce its symptoms. Hence, the Washington L & I Medical Treatment Guidelines recommend “ergonomic assessment of work site within two weeks of the first healthcare visit for people with carpal tunnel syndrome to assist with work modification.” Nonetheless in a series of 24 studies on the subject in the year 2000, none of them conclusively demonstrated that the interventions would result in the prevention of carpal tunnel syndrome or its amelioration in a working population.  They do not seem therefore to be a cost-effective intervention.

Lastly and for multiple reasons, return to work issues are always very important in a workman’s compensation setting and an important concept because in genera, return to work is actually in the best interest of the worker as well as the employer. 

Medical Disability Guidelines have recommended optimum return to work durations after carpal tunnel release that range from two to eight weeks depending on the work classification, whereas other “optimum recommendations” are from 0 to 4 weeks, demonstrating considerable variation.  Considering the relatively simple nature of carpal tunnel release, return to work for sedentary and light job classifications should actually be less than one week.  Longer periods would reflect worker desires and pain tolerance rather than any risk of harm.

In association with return to work are Functional Capacity Evaluations (FCEs), though less commonly done for carpal tunnel releases than other conditions, their purpose is to improve return to work by determining what limitations, if any, are required physically. In fact, for reasons beyond the scope of this brief review, that is unfortunately not the case and can even diminish the chances of return to work compared with giving no restrictions.

Summary: The above are methods that without altering quality of care, could potentially lead to significant cost savings in diagnosis and treatment of carpal tunnel syndrome in the occupational setting.  According to an August 2012 Washington Department of Labor and Industries news communication, L & I is currently contracting with an independent researcher to study occupational disease claims in Washington.  Hopefully some of the cost savings noted above would be considered.

 D. Scott Smith has been an Orthopedic Surgeon who has worked on MCN’s provider panel for 12 years and has spoken at CEU events sponsored by MCN. To learn more, please email MCNTalk@mcn.com.

Announcing MCN’s Newly Revised Cover Letter Creator

Medical Consultants Network (MCN) is pleased to announce the launch of our newly revised Cover Letter Creator. To simplify the claims process, we have designed the Cover Letter Creator so clients may select questions specifically for their requested service.

Whether the client is requesting a independent medical examination or peer review on a workers’ compensation, disability, or auto/liability/PIP claim, the Cover Letter Creator addresses questions on causality, return-to-work timing, medical improvement, and many other aspects of claims.

Each product type has been carefully evaluated by our staff so that corresponding Cover Letter Creator questions are always geared toward the specific aspects of the insurance and assessment type their clients are working with. The combination of MCN’s fully integrated nationwide systems, expansive physician network, and staff policies results in an efficient and conflict-free client experience.

With nationwide staffing, 20 regional offices, and over 20,000 scheduling locations among physicians and consultants across the country in all medical specialties, MCN is dedicated to providing our clients with actionable independent medical assessments.

To try the new Cover Letter Creator, contact a local MCN representative (information on MCN.com) or submit a referral through our on-line client portal.

 

Washington Couple Charged with Stealing $223,000 in Workers’ Comp

After nearly two years of receiving workers’ compensation benefits, a Tacoma, WA couple has been charged with one felony count each for illegally collecting $223,758 in workers’ comp benefits.

From March 2009 through July 2011, Jamie Beroth, 63, collected $100, 664 on a shoulder injury she claimed happened on the job. Her husband,  Lawrence Beroth, 67, also received $123,094.02 in time-loss benefit payments from August 2009 to October 2011 for an industrial injury. Both claimed they could not work during this period.An investigation by the Washington State Department of Labor & Industries found that the couple had continued to work on their drywall company ever since the alleged work injuries occurred. The couple was arraigned in Peirce County Superior Court on November 15, 2012 and pled not guilty.

“We discovered that Mrs. Beroth continued to work at Beroth Drywall after her injury, actually preparing and submitting her husband’s injury paperwork to L&I…

We also took videos of Mr. Beroth working at his drywall business during the time he was receiving benefits and claiming he could not. The video shows him submitting bids, purchasing and hauling supplies, preparing for and working the jobs he received,” ” said Greg McPherson, an investigator in L&I’s Fraud Prevention and Compliance Program.

Not only could they be forced to pay restitution in full, but they are also  faced with a maximum penalty of 10 years in prison and a $20,000 fine each.

Workplace injuries are unfortunate events for those who suffer legitimate injury and we believe they deserve proper care and assistance as they recover. However, with every workers’ compensation claim, we believe the goal should be for an employee to receive the most effective treatment so they can return to work in due time.

Unfortunately, situations and people like this cast a pall on legitimate claims and claimants.

Read More…

CMS Drops Coverage for TENS to Treat Chronic Lower Back Pain

After a systematic review of studies, the Centers for Medicare and Medicaid Services (CMS) concluded that it would drop coverage for the use of Transcutaneous Electrical Nerve Stimulation (TENS) for chronic low back pain. In a memo sent out in June, CMS stated, ““TENS is not reasonable and necessary for the treatment of [chronic low back pain].”

Before the decision, Medicare paid for FDA-approved TENS equipment when prescribed by a physician and reimbursed physicians and physical therapists for evaluating patients’ suitability for the treatment. The TENS units are usually small, portable battery operated devices that deliver electrical currents to the skin through electrodes. While TENS treatment is widespread, its efficacy is debated due to inadequate reporting and methodology in early studies.

With CMS nixing the viability of TENS, Medicare will no longer cover most TENS treatments except for patients enrolled in new clinical studies of the treatment.

The move could not ony set a precedent for denial of coverage of non-pharmacologic pain treatments, it might also have a large impact on Workers’ Compensations and Auto Insurance markets. Read More…

Ohio Workers’ Comp Agency Battles Painkiller Epidemic

By Vanessa Radatus

Prescription painkiller overdoses killed nearly 15,000 people in the US in 2008. In 2010, about 12 million Americans (age 12 or older) reported nonmedical use of prescription painkillers in the past year, according to the CDC. Illustration by Bryan Christie.

Though prescription drug abuse is not a new problem, it is one that deserves renewed attention. In 2010,  12 million Americans reported using prescription drugs non-medically. Among the most abused painkillers, Oxycontin, Vicodin, and Xanax, are so powerful that even when those with injury or disability are prescribed medically, a staggering number of them become addicted. It goes without saying that prescription drugs can be indispensable allies to those who really need it, but they also pose serious health risks such as lifetime addiction and death.

Fortunately, several states are taking initiative to control this problem and have even managed to find appropriate and safer treatment options given to injured workers. The Ohio Bureau of Workers’ Compensation (BWC) is effectively reducing painkiller abuse trends through formulary and pharmacy management initiatives in an effort to address Ohio’s opiate epidemic. Read More…
From February to April, the number of patients who received powerful narcotic painkillers saw a 12 percent drop as the agency strictly regulates the drugs that physicians can prescribe for the initial pain of  injured workers. In a WorkCompWire article,  BWC Administrator and CEO Steve Buehrer, said, “Ohio’s new formulary is proving an effective way to help manage care and ensure we are getting injured workers the right prescriptions for the right conditions at the right time. While narcotics can be a legitimate part of the treatment process, we owe it to Ohio’s workers to ensure their road to recovery doesn’t descend down the dark path of addiction.”
The initiative has driven down the number of narcotics prescribed to injured workers by 12 percent, or 1.1 million doses. This equals a 12-percent reduction in the number of doses and a 15-percent, or $2.1 million, reduction in costs, according to the BWC. It’s initiatives like these that will help ensure injured workers are receiving the right prescriptions for the right conditions at the right time,” said Steve Buehrer.
The painkiller epidemic  is an issue that must be addressed wisely. While it is a life saver to those who need it for short-term pain or legitimate reasons, it is also the silent killer of thousands of people who abuse it. The Ohio BWC initiative is step in the right direction but a collective effort from the U.S. government, our state legislature, health insurers, healthcare providers and patients must be made to end this nationwide epidemic.
Here are some key findings from the Center for Disease Control and Prevention (CDC):
  • Overdoses from prescription painkillers — including oxycodone, methadone and hydrocodone (Vicodin) — killed 15,000 people last year. That’s more than 40 per day.
  • In fact, painkillers now cause more deaths in America than cocaine and heroin combined. And if the numbers keep rising, they’ll soon outpace car crashes as the nation’s leading cause of fatal injury.
  • In 2010, 1 in 20 people in the United States (age 12 or older) reported using prescription painkillers for non-medical reasons in the past year.
  • Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for a month.
  • Nonmedical use of prescription painkillers costs health insurers up to $72.5 billion annually in direct health care costs.