Lighting Up Workers' Compensation through Research

Wednesday, November 5, 2014 | 0

Formal research helps us to better understand and reduce the burden of work injuries.  Sometimes formal research provokes change and sometimes it works in parallel with industry practice. As medical costs rose along with share of claims costs, the value of recruiting medical expertise in the provider community and claims organizations is evident. The situation has helped build a case that claims management is a complex, very demanding profession. 

Similar employers vary greatly in loss experience, as predicted from their worksite practices. 

It’s well-known anecdotally that employers apparently similar in many respects often have strikingly different track records in worker safety and workers’ compensation costs. In 1993, the Upjohn Institute in Kalamazoo proved that to be the case among nursing homes in Michigan[i], finding that worksite attributes largely explain variances in injury rates and duration of work injuries. These attributes include safety, diligence and proactive return to work.

Massachusetts introduced at about that time its Qualified Loss Management Program, which financially incented employers in the insurance assigned risk pool to adopt worksite practices that were similar to those shown in Michigan to be effective. Many insurers have provided premium credits for implementing some of these practices.

We can measure quality of care, and it surely makes its mark.

Only recently have carefully done studies shown that doctors vary quite a bit in how their work-injured patients recovered and how many medical dollars went into their care. The Louisiana Workers' Compensation Corporation teamed up with researchers at Johns Hopkins, led by Edward Bernacki, to study outcomes among several hundred doctors.  The results were first published in 2010, showing that a small number of doctors were accountable for relatively long durations of disability and high medical costs.[ii] 

Later, Johns Hopkins found similar results of high variances in outcomes when studying doctors in Michigan with the Accident Fund. The California Workers' Compensation Institute also came up with roughly the same findings.

Psycho-social issues greatly impact outcomes, and much information can be learned about them through simple questionnaires. 

During the past 15 years, a lot of research and piloting of programs has taken place in an effort to understand how much nonmedical personal factors affect claims outcomes.

Researchers at Liberty Mutual’s Center for Disability Research, at the insurer’s Research Institute for Safety, are responsible for numerous studies on this topic, which heretofore was the stuff of conjecture and old wives’ tales. In 2001, the researchers there identified as predictive of long disability durations “low workplace support, personal stress, shorter job tenure, prior episodes, heavier occupations with no modified duty, delayed reporting, severity of pain and functional impact, radicular findings and extreme symptom report."[iii]

A lot of initiatives sought to test and refine handy questionnaires that clinicians, adjusters and case managers could use to create predictive scores, or yellow flags, based on psycho-social factors.[iv] Kaiser’s occupational medicine program tested questionnaires with newly injured employees of Safeway. As with Kaiser’s program, high severity scores typically lead to more aggressive coaching and treatment. Kaiser and others have found this response pays off in fewer disability days. Early assessment of psycho-social factors has become an increasingly systematic practice. A good number of these screening tools are derived (sometimes without their users being aware of it) from the so-called Orebro musculoskeletal pain questionnaire, developed in Sweden.

Listen to injured workers. You’ll learn a lot.   

Rarely do researchers interview injured workers to find out about how they experience their injury and the workers’ compensation system. The Workers Compensation Research Institute published in 2014 a report on “Predictors of Worker Outcomes,” based on thousands of interviews with injured workers. The Institute explained this project by saying that “Better information about the predictors of poorer worker outcomes may allow payors and doctors to better target health care and return-to-work interventions to those most at risk.”

The interviews revealed that the worker’s trust in the workplace was an important predictor of the duration of disability. Workers who were strongly concerned about being fired after the injury experienced poorer return-to-work outcomes than workers without those concerns.

Australian researchers found though a review of the literature on workers’ compensation claimant experience that “the majority of interactions were negative and resulted in considerable psychosocial consequences for injured workers.”[v]

It’s hard to induce doctors to change.

A recent article in the New England Journal of Medicine about reducing “low value” (read: ineffective) care notes that “Unfortunately, little evidence exists on the effectiveness of [interventions with providers] in reducing low-value care.”[vi] Doctors don’t respond well to evidence-based medicine guidelines or incentives when they are stuck in their ways.

Some 600,000 major back surgeries are performed every year. David Hanscom, an orthopedic surgeon and author of an insightful guide to treating chronic pain, points to how back surgeons persist in the face of credible conflicting evidence.

Many surgeons use “provocative discography,” or injecting fluid near a disc, to assess whether spinal fusion should be performed on the disc, to remove pain. This practice persists despite a 2006 article in Spine Journal that disproves the technique for common low back pain.[vii] The article reported a low 23% success rate for spinal fusions when the surgeon went ahead to operate on the basis of provocative discographic findings. Evidently the test produces a huge number of false positives for the surgery.

A study published by Johns Hopkins in early 2014 reported that only 37% of surgeons order presurgical psychological screenings, despite being recommended for routine application.[viii]

Aggressive care can speed recovery.

Medical treatment of injured workers is often slow, fragmented and ineffective. Claims payers hunt with wide variation in success to find experts who diagnose and treat correctly in a determined manner. Many believe, and rely on anecdotes to show, that when expert  clinicians and case managers get involved, clinical and vocational outcomes can be superior.  Two studies, while by no means conclusive, suggest that superior outcomes are achievable by aggressive application of medical expertise whether or not the course of care complies with evidence-based guidelines.

Harbor Health provides for claims payers services to organize and oversee medical provider networks. The firm has been studying the performance of clinicians in California for some time. It did a study of the timing of ACL repairs, arthroscopic menisectomy of the knee, rotator cuff repair and endoscopic or open carpal tunnel release. The study showed that scheduling surgery prior to the recommended end of conservative care resulted on average in lower duration of disability, higher medical cost and a substantially lower total incurred cost.[ix] 

Paradigm is a well-known catastrophic case-management firm, which has been case managing worker injuries costing upwards of several million dollars in incurred costs on behalf of claims payers. Milliman consultants compared catastrophic injury cases managed by Paradigm with non-Paradigm managed cases taken from Milliman’s files. They found that the Paradigm cases showed a 41% return to work compared with 8% in the benchmarked cases. Paradigm cases were 36% less expensive.[x]

Use the gold standard to determine causality.

English epidemiologist and statistician Bradford Hill wrote a famous article in 1965 in which he laid out a protocol for determining the cause of a health condition. He also pioneered the use of random clinical trials and helped to confirm the causal relationship between smoking and lung cancer.[xi]

Opioids can kill.

Opioid prescribing climbed in frequency and dosage from the late 1990s through about 2011. It appears that in recent years the trends have flattened or declined somewhat. One doctor can be credited with sounding the alarm in the workers’ compensation community.  Gary Franklin, medical director of Washington State’s Department of Labor and Industries, reported alarming problems early. By the mid 2000s, he and colleagues had carefully documented that the deaths of injured workers involved their use of prescribed opioids.

Using Franklin’s census of opioid-related deaths of claimants, I estimated that it was more dangerous for an injured worker to be prescribed opioids for a long period of time than is was for a worker to be engaged in the most dangerous jobs, such as logging. 

In 2011, Franklin and colleagues reported that an opioid-dosing guideline they crafted in 2007 led to substantial declines in high prescription doses and patient deaths.[xii]

Footnotes:

[i] Allan Hunt et al. The Michigan Disability Prevention Study: Research Highlights. 1993.  Working Paper No. 93-18. W.E. Upjohn Institute for Employment Research.

[ii] Edward Bernacki et al. The Impact of Cost Intensive Physicians on Workers' Compensation. J Occup Environ Med. 2010 52 (1): 22-28.

[iii] William Shaw et al. Early Prognosis for Low Back Disability: Intervention Strategies for Health Care Providers. Disabil Rehabil. 2001 23(18): 815-28.

[iv] William Shaw et al. The Back Disability Risk Questionnaire for Work-Related, Acute Back Pain: Prediction of Unresolved Problems at 3-Month Follow-Up. J Occup Environ Med 2009 51(2): 185-94.

[v] Elizabeth Kilgore et al. Interactions between Injured Workers and Insurers in Workers’ Compensation Systems: A Systematic Review of Qualitative Research Literature. J Occ Rehabil. 2014 Epub ahead of print.

[vi] Carrie Colla. Swimming against the Current — What Might Work to Reduce Low-Value Care? N Engl J Med 2014 371:1280-1283.

[vii] Eugene Carragee el al. A Gold Standard Evaluation of “Discogenic Pain” Diagnosis as Determined by Provocative Discography. SPINE 2006 31(18): 2115–2123.

[viii] Arthur Young. Assessment of Presurgical Psychological Screening in Patients Undergoing Spine Surgery: Use and Clinical Impact. Jrn Spinal Disorders. 2014 27(2): 76-79.

[ix] Theodore Blatt et al. Impact of Aggressive Care in Workers’ Compensation. Harbor Health. September 2013.

[x] Paradigm. Managing the Impossible: Getting Better Results in Returning Catastrophically Injured People to Work. 2008.

[xi] Austin Bradford Hill. The Environment and Disease: Association or Causation? Proceedings of the Royal Society of Medicine. 1965 58: 295-300.

[xii] Gary Franklin et al. Bending the Prescription Opioid Dosing and Mortality Curves: Impact of the Washington State Opioid Dosing Guideline. Am J Ind Med, first published online December 2011.