Preventing Poor Results & Prolonged Case Durations for Injured Employees

September 17, 2020

Original article by Jim Heaney Jr. entitled “It’s Never Too Late To Recover”:

This article discusses how to avoid prolonged case durations, and, in the event, claims remain open for future medical care, options that could help both the injured employee and employer. Not all injured employees secure the desired outcome. There can be several reasons driving poor outcomes.

The employee is not compliant with recommended treatment.
They receive care that does not benefit them.
In a subset of claims, the framework benefitting a majority is inadequate for a few.
If the parties cannot come to a full and final settlement, these claims are monitored regarding future medical care needs.

That’s why, for injured workers: It’s never too late to recover.

Resistance to Medical Treatment

Our country continues to face a pain crisis. Over 100 million Americans report they suffer from chronic pain. There are a myriad of studies and theories on what can cause chronic pain. Several studies show that pain that continuing beyond six weeks will become chronic in nature. The workers’ compensation framework helps the majority of those injured, but this subset of individuals can end up going down a “rabbit hole” of treatment and medicals that do not help. This leads to the injured employee becoming hopeless, blaming the employer or carrier, seeking legal representation complicating an already complex situation.

Efficacy of Surgery

Surgery is an example of medical treatment that can deemed as reasonable and necessary through the Utilization Review process, but not always efficacious for those injured on the job. Dr. Hazlewood, Pain Management Specialist based in Nashville noted, “several studies show that opioid use continues and, in some cases, increases after lumbar surgery. This makes it difficult for those injured to return to work. In some cases, further surgery is required.” So, as an industry, why do we continue to provide care that has shown to be ineffective? Are we missing an opportunity to provide the employee with a different more effective path?

Stop it Before it Starts

It is possible to stop it before it starts. Dr. Hazlewood adds, “we need to stop cases from turning into high medicalization with unsustainable costs and poor outcomes. In some cases, we are harming patients with multiple injections, unnecessary surgeries, chronic opioid utilization leading to inadvertent overdoses.” Further, “this care fosters a dependent state which leads to deconditioning, weight gain, depression, hopelessness and anxiety. So, how do we stop it before it starts? Dr. Hazlewood provides us with the below tips:

Engage the injured worker in the process discussing goals and expectations regarding how to recover.
Ensure the patient is referred to the appropriate specialist early to avoid unnecessary imaging which can lead to false-negative findings and possible surgery.
Early identification of poor prognostic indicators is important and can help all stakeholders take the appropriate actions to benefit the injured employee.
It is important to recognize pre-existing conditions as well as apply the science of causation analysis to determine appropriate expectations around when the employee will achieve a maximum medical improvement.
Avoid inappropriate delays in defining the cessation of injury related pain.
Therapy should be diagnosis-specific and not performed as a cook-book approach. This is important when working to resolve ongoing pain.
Consider proper injections early to help the injured employee be more successful in tolerating critical manual manipulations by the therapist.
The physician and injured worker should have timely discussions around the appropriate use of opioids and that the expectation should never be prolonged utilization and instead that opioids are a temporary mechanism to assist in their recovery.
Understand when it is appropriate to order imaging studies and being able to anatomically correlate findings clinically to avoid treatment of irrelevant pain generators.
Identify the few cases where there is a significant emotional overlay that inhibits recovery and appropriately order cognitive behavioral therapy when needed.
Attempt to separate out on-going injury related pain versus age-related degenerative pain.
Don’t always use the traditional path and consider alternative treatments in chronic pain per evidence-based medicine guidelines including an electrotherapy H-Wave unit, cognitive behavioral therapy and acupuncture rather than opioids and polypharmacy which in turn leads to healthier and better long-term outcomes.
And above all, secure and use a good history and physical examination, with less reliance on diagnostic testing, listen to the patient, counsel and educate them gaining their trust and engagement.

Challenges of COVID-19

Regional orders to stay at home and the cessation of elective surgeries could possibly lead to an increase in opioid utilization. As cases of Covid-19 surge, access to medical care is limited and inconsistent from region to region. One saving grace has been the use of telemedicine which has allowed physicians and practitioners to refill prescriptions and provide virtual physical therapy. Additionally, physicians are beginning to realize the value of other alternative non-invasive treatments supported by medical based guidelines such as the Official Disability Guidelines. Dr. Hazlewood treats many injured employees and has found the benefit of prescribing H‑Wave units rather than physical therapy, injections and opioids. Dr. Hazlewood states, “H-Wave has helped improve the effectiveness of his approach to telemedicine during this unprecedented time.”

Injured Employees Resistant to Medical Care

There are many patients in chronic pain clinics that are completely resistant to traditional medical care. Yet, these individuals continue to receive injection after injection, ineffective spinal cord stimulators, receiving pill after pill, opioid after opioid, going to higher and higher dosages. In most cases, their pain level remains high with the individual being completely non-functional, “living in their state of mind” which is miserable in day to day life. Dr. Hazlewood identified items to check when dealing with patients resistant to medical care. They include:

Psychological factors including depression, anxiety and hopelessness.
Personality inventories finding dependency and disorders.
Assessing the patient’s support systems.
Gauging their trust in the system and physician.
The number of opioids the patient is on, the higher the dose, the harder the task sometimes requiring in-patient multi-disciplinary programs to wean.

It’s Never Too Late to Change the Course

When we encounter an injured worker that is resistant to medical care, it is never too late to change the course. However, it seems some physician are reluctant. It’s hard work to switch gears for both the injured employee and physician to stop dangerous opioids and explore more effective alternatives.

These alternatives are proven per evidence-based medicine to produce better outcomes and are much safer for the injured worker. Additionally, these costs are more static than when surgery and opioid utilization are involved. These alternatives include:

Cognitive Behavioral Therapy teaching coping skills, helping fear avoidance and catastrophizing behavior, explaining the need for exercise and breathing techniques.
H-Wave Units are much more cost effective than polypharmacy, opioids, the resulting monthly follow up visits, the multiple yearly urine drug screens, and the possibility of further treatment. They are non-invasive and have better success rates than spinal cord stimulators. They can lead to weaning off opioids and other medications, improvement in pain to the point of resuming an exercise program as well as psychological improvement.
Acupuncture can work in some patients per evidence-based medicine.

Conclusion

We have to switch gears in the way we’re treating injured workers the appear resistant to medical treatment. We can’t let the mistakes of the past prevent changes in the future. We must become less reliant on the diagnostic process and instead use good history and physical examinations to guide the diagnosis and treatment plan. Multiple studies demonstrate the low efficacy of surgical intervention in workers’ compensation cases, especially involving the spine. These injured workers end up using more opioids absent the surgery. When faced with these cases, let’s start exploring effective alternatives, proven by evidence-based medicine to secure a different outcome. There is always the ability to change the current path and do the right thing by the injured worker. Remember, it is never too late to recover.

To see the original post of this article, click here.