Pallative Care: The Cure to Workers' Compensation Blues?

Thursday, December 23, 2010 | 0

I feel like a number
I'm not a number
I'm not a number
Dammit I'm a man
I said I'm a man
Bob Segar - Feel Like a Number

By David J. DePaolo
WorkCompCentral

The Los Angeles Times published a front page story Dec. 19 on palliative care (http://www.latimes.com/news/local/la-me-1219-end-of-life-doctor-20101219,0,5461231.story). Palliative care is the medical specialty focused on improving overall quality of life for patients and families facing serious illness. Emphasis is placed on intensive communication, pain and symptom management, and coordination of care (http://www.getpalliativecare.org/whatis). Note the emphasis on “intensive communication.”

What struck me about this article, besides the heart wrenching choices faced by both patients and physicians highlighted by the author, is the observation that in general health care there is very little communication going on. In workers’ compensation there is even less communication. Sure, there is reporting in fact I would argue there is too much reporting in workers’ compensation. But that is NOT communication.

Communication requires listening. And in workers’ compensation, there are very few that actually LISTEN to the injured worker.

Workers’ compensation is all about numbers. Injured workers generate a huge amount of numbers statistical, clinical, financial … and they are given numbers claim numbers, case numbers, etc.

Yet, the research clearly is demonstrating that the vast majority of troublesome issues (including troublesome numbers) are related to the fact that injured workers ARE treated only like numbers, and not as human beings. There is a failure in workers’ compensation systems to deal with the underlying mental health of the injured worker and this has serious implications.

Coventry Workers’ Comp Services, in a white paper released this month (http://www.coventrywcs.com/C056716), discusses its own research affirming other studies implicating comorbid conditions as contributing significantly to higher (sometimes dramatically) treatment costs:

“When a comorbid condition was found on a workers’ compensation claim, CWCS’ study confirmed what other research has indicated: the medical experience was significantly more costly.”

Comorbidity is either the presence of one or more disorders (or diseases) in addition to a primary disease or disorder, or the effect of such additional disorders or diseases (http://en.wikipedia.org/wiki/Comorbidity).

The Coventry research reviewed five overall comorbid conditions: smoking, hypertension, diabetes, obesity and depression. The single most troublesome comorbid condition found by the Conventry researchers is depression, clearly adding huge sums to the 12-month medical cost comparison. Coventry notes that claims with a comorbidty of depression had 33% more bills than the next most costly comorbid condition obesity. And when one combines comorbidity of depression with other comorbid conditions the impact is much more dramatic.

The researchers are careful to note that their research did not address whether injured workers entered into the workers’ compensation arena with preexisting depression, or whether the plight of an injured worker in the workers’ compensation system caused or contributed to depression and that is irrelevant to this discussion anyhow.

There are many other studies internationally that attribute comorbidity to an increase in duration and extent of disability.

What is relevant is that there is a failure in the workers’ compensation system to deal with an injured worker’s mental health despite the clear impact mental health has on the cost of care, the length and ultimate outcome in disability, and the return-to-work status of the worker.

According to the National Institute of Mental Health one in four adults has some diagnosable mental disorder in any given year (http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml). Mental disorders are the leading cause of disability in the United States and Canada. Major depression is the single leading cause of disability in the U.S. for ages 15-44.

What this really means is that one in four workers’ compensation claimants has a mental health related comorbid condition. If comobidity is to be factored into the nature, extent and length of treatment and disability then this industry is not only losing a whole lot of money, time and resources by failing to deal with mental issues affecting workers’ compensation injury claimants, this industry is fighting a losing battle that can never be won.

There is no incentive for carriers or employers to provide mental health services to injured workers, and in fact the laws in all of the state’s workers’ compensation systems are such that there is a complete disincentive any attempt by a carrier/employer to provide mental health services in conjunction with treatment for the underlying physical injury opens a Pandora's box of liability that the carrier/employer is just not willing to risk.

Which leads me back to the LA Times article and this observation:

"'Healthcare reimbursement tends to favor high-tech and procedure orientations like surgery and endoscopy over the less dramatic like spending time talking,' says Thomas Strouse, a colleague of [David, M.D.] Wallenstien's at UCLA. It is a situation, Strouse believes, reflective of 'a society not quite knowing what to do with the activity of sitting with a patient and family and identifying goals of care.'"

Strouse’s quote is reflective of workers’ compensation as well. The incentive in workers’ compensation certainly tends towards cattle call practices. The medical provider community finds it difficult, with all of the attendant overhead expenses of a workers’ compensation case, to make money treating injured workers without engaging in high volume, low impact services unless surgical intervention can be justified even then the focus is on the procedure, not compassionate, understanding, care of the patient.

Precious few resources are actually devoted to compassionate understanding of the injured worker’s overall condition despite the wealth of international scientific research demonstrating that the psychological condition of the injured worker is nearly more important than the actual physical condition being treated! If there is a billing component for such “touchy-feely” professional services, I’m not aware of it, or physicians aren’t aware of it, or maybe it isn’t substantial enough to provide incentive for physicians to actually care to use it.

Maybe, though, there is a way to encourage mental health intervention without creating a liability for the employer/carrier for the underlying condition; perhaps the short term cure is regulatory comprise billing components that encourage palliative care of the injured worker. Actually PAY the doctor to TALK with the injured worker and LISTEN, show some compassion, some empathy, some understanding, offer some advise take the TIME that demonstrates that an injured worker IS a human being with thoughts, emotions, problems, issues that may interfere with the good health progression of the underlying work injury.

Until this industry is willing to tackle an injured worker’s mental health as a part of the treatment plan for a work injury, attempts to control medical costs will simply result in the further demoralization of those responsible for delivering care, and the further demoralization of the injured worker, which in consequence will just result in higher medical care costs.

So, the bottom line I propose regulatory adjustments to fee schedules to provide reimbursement for quality patient/doctor relationships as a first step towards ultimately changing the laws such that carriers/employers can provide mental health services in conjunction with physical treatment of injured workers without incurring additional liability.

Until we can deal with an injured worker’s mental health, regardless of its origin, attempts to control medical and indemnity costs will be futile.

David J. DePaolo is chief executive officer and editor-in-chief of workcompcentral.com Inc.