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Workplace Situations

Sentencing in the Long Island Railroad Disability Fraud Scheme

What is missing in this New York Times article is any reference to the consequences for those many claimants who engaged in the fraud, and the management and employees of the Long Island Rail Road, who clearly were aware that such fraudulent claims were the norm. Perhaps they were only counting the days until their own disability retirements. How many of those who Dr. Ajemian helped obtain benefits have been criminally charged for fraud and how much of the millions of dollars of ill-begotten compensation has been returned to the public from which it came?

What this doctor did, based upon the article, was reprehensible, but let’s not kid ourselves. The culture of disability is alive and well in the public and private sector. Well intended efforts to addresses excesses and distortions in the system may lead to personal attacks on those who try.

Industrial Accidents and Acts of Terrorism

Every once in a while an editorial catches our eye here at MCNTalk because it captures a certain aspect of the work that we do. This thoughtful New York Times op ed piece by Bruce Marchart does just that — reminds us both of  the human side of the injuries and disabilities we work with every day, and gives us pause to ponder how we view each life, each incident of “lost time” from work.

In Marchart’s past work in Houston he came across — and confesses to a larger fascination with — many industrial accidents.  He contemplates some of the moments of tragedy juxtaposed against the backdrop not just of the recent explosion at a fertilizer plant in West, Texas but also of the terrorist incident at the Boston Marathon, two incidents which resulted in over 200 injuries and multiple deaths.

Marchart muses, “We tend to discount that which is accidental as somehow less tragic, less interesting, less newsworthy than the mayhem of agency. Lives have been ‘lost’ in Texas, but in Boston, by God — lives have been ‘taken.’

“But this distinction means nothing to the victims or, I imagine, to their families. In Boston, in West, whether by sinister design or by accident, whether on a television-ready stage or hidden away in a rural factory, when people are hurt, when lives are lost, the essential human cost shouldn’t be lost on the living.”

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How Budget Conscious Doctors Can Lower Health Care Costs

When shopping, people tend to search for the best deal with the greatest value. But when it comes to receiving health care services, why is the price tag never a clear part of the discussion?

After TIME Magazine featured the report “Bitter Pill: Why Medical Bills Are Killing us,”  Cleveland Clinic CEO Dr. Toby Cosgrove argues that one potential cause of  out-of-control healthcare costs may be that doctors often have no idea how much medical procedures actually cost. He argues that by informing doctors about the specific costs of health care procedures, doctors may try to find more cost-effective alternatives.

And in a new study by Johns Hopkins published in the journal, JAMA Internal Medicine,  researchers showed that informing doctors of the cost of tests, services, and supplies they use actually can lead to hefty medical savings.

The researcher split physicians into two groups over the six-month experiment to see if showing the tests prices would change a physician’s decision about services.  One group was given the tests with prices on them, while the other group’s tests did not have a price.

The researchers compared the buying behavior of the physicians and found that showing the pricing information resulted in a 9% cut in use of the tests overall and a savings of over $400,000 over the six months. By comparison, there was a 6% increase in the use of the tests without pricing information over the same time period. Read More…

The researchers say the savings can be largely credited to the simple principles behind comparison shopping.

To challenge this theory, CEO Dr. Toby Cosgrove decided to make it a point to deconstruct the costs of their top three procedures, record the price of sutures, the number of instruments uses and record how long patient’s spend in post-anesthesia care.

“Take, for example, nitric oxide, a drug commonly used in heart, lung and chest surgeries to keep tissues well-supplied with oxygen during the operation. When it’s effective, it’s very effective, but it doesn’t help all patients. When we realized we were spending $2 million a year on the drug, we drilled down to see who was using it and why.

We found that doctors and OR staff did not have a standard protocol to guide them on when and how much to rely on nitric oxide; we had to educate them that if the drug didn’t work within a half hour of being administered, it won’t work at all, so repeated doses were wasteful. The result: nitric oxide use dropped by half, saving $1 million without any adverse effect on patient care,” Dr. Cosgrove said.

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When his team saw where they could easily cut costs, they made a goal to save $100 million in a year by focusing on what and how they use equipment and supplies they purchase. Within a year, they topped their $100 million goal and after three years have saved $155 million.

And while it’s crucial that quality of health care services always comes before price, it is equally important to realize that even the smallest cost saving practices create a monumental difference in our costly health care system.

Job Prospects for Radiology Graduates in Decline

A recent MCNTalk article describes changing perceptions and beliefs by U.S. doctors.

This New York Times posting “Job Prospects are Dimming for Radiology Trainees,” describes major disruption in the field of radiology – once one of the most coveted specialties from a compensation and lifestyle standpoint.

Recent radiology graduates with huge medical school debts are having trouble finding work, let alone the $400,000-and-up dream jobs that beckoned as they signed on for five to seven years of relatively low-paid labor as trainees….

“The times of graduating from medical school and driving a Porsche are done,’ said Dr. Dana Lowenthal, a first-year radiology resident and fourth-generation doctor. “It was never easy, but there was light at the end of the tunnel. This is new territory.” Read More…

A reader may feel a certain disconnect when noting that the 10% decline in average radiologist income still places them in the top echelons of the nation and are double that of primary care doctors. But it would appear, as we are seeing a similar trend with new law school graduates, that the prospects for new radiology trainees are far less promising. And that technology and payer behaviors, especially Medicare, are having a very disruptive impact on the profession.

Many U.S. Doctors Appear Alienated From Their Profession

By Brian L. Grant MD

The AMA News reports that many physicians are reducing their hours treating patients and in some cases, leaving or considering leaving the profession altogether.

Some decreased productivity is a result of being employed rather than independent. Morale in many physicians is said to be suffering. The causes can be debated, but the phenomenon is real.

When I entered the profession in the early ’80s, physicians prided themselves on autonomy and enjoyed a great deal of respect. Little did my colleagues and I know that U.S. healthcare was in the twilight of an era of professional control.

We have shifted to a world where the “system” is under challenge by many factors: runaway costs, massive engagement by market driven businesses in the technology, device, and pharmaceutical industries, consolidation of hospital groups, buying of physician practices and many other forces.

Physicians no longer enjoy, by and large, the sense of control and respect that once was their domain. To a degree we may have brought in on ourselves and there have been some decent trade-offs made by some. For example, work-life balance for many has become more important than professional power and pride.

The large number of women who have entered the profession (48% of current medical school graduates) have encouraged new models for women and men in balancing work and family. But to the degree this means fewer hours worked, it is equivalent to less care being provided per doctor working. (For more information on women in medicine, see http://www.catalyst.org/knowledge/women-medicine.)
In order to address the growing physician shortage, many solutions are being considered. This includes leveraging the talents of other professionals, altered delivery models, encouraging more medical immigration (to the detriment of the countries who have trained professionals only to see them leave), and striving towards new delivery models using technology and innovation.

In the end, medicine as we knew it may be history.

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The practice changes physicians are planning in 2012

Practice plan Physicians agree
Continue as I am 49.8%
Cut back on hours 22.0%
Retire 13.4%
Relocate to another practice or community 10.9%
Seek nonclinical job in health care 9.9%
Cut back on patients seen 9.6%
Switch to cash/concierge practice 6.8%
Work part time 6.5%
Work locum tenens 6.4%
Seek job outside health care 6.4%
Seek hospital employment 5.6%
Close practice to new patients 4.0%
Other 5.5%

 

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.

Electronic Medical Records: Promise vs. Reality – A Work in Progress

Electronic medical records were fervently promoted as a panacea to medical inefficiencies, medical errors, and cost.

The reality has been to date, anything but. The New York Times article, “In Second Look, Few Savings from Digital Health Records,” outlines some of the disappointments that the technology has delivered to date.

Clearly systems relying upon handwritten and typed notes and reports, repositories of paper, and lack of portability are not worthy of the future. Quality systems should be secure, interoperable on any platform via a common set of data standards, and should not permit meaningless content and boilerplate or inflation of fees and improper billing.

Given our ability to put a variety of data on the web, one must wonder why the move towards electronic medical records has been so disappointing to date and has failed to deliver as promised.

There is no turning back but we are still in version 1.0 it would appear. Perhaps Apple or Google should take it on? Could it be that because it is “medical” it has been made needlessly complicated?

MCNTalk thanks Richard Bensinger, MD for referring this article to us.

Nurses Fired for Refusing Flu Vaccine

An Indiana hospital fired eight nurses last month after they refused to meet the deadline for receiving a mandatory flu vaccination themselves.

The ABC News article, “Nurses Fired for Refusing Flu Shot,” speaks for itself.

MCNTalk would like to hear from you, our readers, what you think about this topic and this particular case. Vaccination refusal is a hot button issue that pits individual beliefs against the public interest.

— Note that we are not stating that the beliefs are accurate or the public interest well-founded (though be assured we do have our own view on both).

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.

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