Now on to the real stuff – deep research into issues of interest only to we real work comp geeks.

Dr Bogdan Savych started off this brief and information-stuffed session.

Across 15 states, 14 percent of workers with lost time injuries didn’t have a substantial and persistent return to work (this is PRELIMINARY and subject to change) – why?  what drives this?

Among the biggest drivers – workers who strongly agreed that they were afraid of being fired or laid off had “worse outcomes.”  As over a quarter of workers fell into that category, that’s a big issue. There are both literal interpretations of this – perhaps the worker was justified in fearing a layoff and broad interpretations of this – perhaps the work environment was low trust.  These workers were also more likely to hire an attorney.

Takeaway – the employee’s work environment, and interpretation of that environment, is a major driver of “permanent disability.”  So, think less about medical issues, and much more about these “other” drivers.

Glenn Pransky of Liberty Mutual was next up.  Dr Pransky is one of the industry’s leading researchers on disability issues (kudos to Liberty for continuing to support the Center for Disability Research and similar efforts.

Glenn noted that one driver was the patient’s communications with the payer.  Workers were sometimes thrown off by negative language used by the claims adjuster in the initial encounter or call.  If they feel their needs aren’t being taken into account or they are being treated unfairly they are more likely

The top return to work coordination skill – communications. That’s the result of research conducted in Canada about a decade ago, research that is very likely true today. In fact, Glenn and others conducted a study a few years back that evaluated the impact of improving the initial contact with the case manager, focusing the patient on problem solving and not using words like “claimant, investigation, liability, etc.

What’s interesting here is this is – in large part – old news, yet we still need to hear this.

More importantly, to paraphrase the previous White House, we need to STOP doing stupid stuff.

Clearly we KNOW this language, the style of communication, the employee’s workplace satisfaction are critically important to disability. Yet far too often we still talk to patients not as people but as “claimants”, and treat patients as legal claims, not as people.

Takeaway – treat patients as you would want to be treated.

Boston’s always beautiful in March – some days are even more beautiful than others. No better place for the annual gathering of the work comp geeks – myself included aka the WCRI Annual Issues & Research Conference.

The kickoff session featured two former denizens of Capitol Hill opining on the impact of the election on healthcare, labor, and work comp. Former Rep Henry Waxman (D CA) and former Sen Tom Coburn (R OK) took to the podium for a moderated discussion and audience Q&A.

WCRI CEO John Ruser started off asking about the Executive Orders issued by President Trump, specifically the drop 2 regulations for every one adopted. Waxman spoke briefly about the complexities, but focused on the lack of consensus among Republicans on healthcare reform and noted that, due to this lack of consensus, they are looking to the President for leadership.  But the President is not providing leadership on healthcare, so we’ve got a hot potato situation.

Coburn attributed problems to a lazy Congress passing large numbers of bills written by departmental Secretaries; elected officials aren’t developing the legislation but rather using language handed to them. He also believes Congress has abdicated and/or lost much of its rightful place as an equal player among the three branches of government.

ACA

Ruser led off with a hypothetical question about what parts of ACA should be kept if the law is repealed and replaced.  This was the wrong question, as it deals with a – in my view – highly unlikely hypothetical. Instead, the question should have been “what’s going to happen with ACA? Will it be repealed? What will pass if anything?”

Waxman doesn’t believe ACA will be repealed.  In contrast, Coburn thinks that all we have to do is publish prices for health services and outcomes and people will go to those providers with the best prices and outcomes.  I don’t know what planet he lives on, but parents with sick kids, individuals with mental health issues, or children of ailing and incompetent parents are never going to be able to make appropriate “Market based” decisions.  Oh, and insurers are never going to insure people with pre-existing conditions – and they’ll look to cancel policies for those who have the temerity to get sick.

This isn’t an economic decision folks, it’s your daughter or son.

Coburn promoted a bill that is under consideration – Burr Hatch Upton.  He believes this bill will be similar to what comes out of Congress.  Details on this here.

He also said there was no attempt by Democrats to involve the GOP in ACA – a statement that is patently false.

Cost shifting

Waxman responded to Ruser’s question about the potential for healthcare changes on case or cost shifting to work comp.  He talked about Medicaid changes that may well reduce enrollment in Medicaid – didn’t speak to workers comp.  Not surprising as he isn’t a work comp guy.

Coburn is a practicing physician, he discussed unfunded liabilities, asserting $105 trillion in future unfunded liability for medicare medicaid etc, noting that we are hurting Millennials as they will have to pay for this.  This is somewhat interesting as he voted against requiring the feds to negotiate pricing for drugs for Medicare.

Unfortunately these two gentlemen weren’t really equipped to address the question – no fault of their own as this is an esoteric topic.

Federal oversight of work comp

Waxman doesn’t see the new Administration moving to increase federal oversight of workers comp, as there’s been no indication from the nominee or administration about this.  that and there are too many other issues re far more important.  Coburn agreed with Waxman and cited lack of Constitutional support for federal involvement in workers comp.

Coburn discussed the expansion of the definition of disability under SSDI, and the subsequent increase in beneficiaries.  He sees SSDI as a social safety net.  All the data supports his case that SSDI enrollment has increased and there are now 25 million Americans are on ssdi – a number that isn’t right.  The actual figure is 4.8% of the population – or 15 million people.

An audience member asked if the Grand Bargain is being dismantled.  Coburn noted that there’s no requirement that SSDI factor in the cause of the disability; SSDI is responsible for disability regardless of the cause.  He said the real question is should work comp cover the entire cost of the disability?  

That’s an excellent question – I believe the answer has been, and still is, yes.

 

 

 

Could hypertension be an occupational disease?

That’s the question addressed in an excellent article in HealthAffairs.

The short answer is there are many factors that contribute to or mitigate risk for hypertension, however the physical and psychological hazards associated with the worksite do correlate with hypertension risk.

Specifically, psychological demands such as how often one is required to work fast  and without errors are correlated with blood pressure while more freedom for workers to make independent decisions is associated with lower blood pressure.

The research looked at about 14,000 Alcoa blue-collar workers over a 16-year period and included surveys as well as medical billing data.  While other external factors are indeed important, the researchers concluded:

workplace environmental exposures may as a whole contribute substantially to hypertension among US blue-collar workers. We found evidence for this across multiple exposures in the categories of psychological hazards and the plant social environment.

Note that this study resulted from a partnership between a very large employer and researchers.  I’d hazard a guess that a study involving less paternalistic employers would show stronger correlations with greater impact.

What does this mean for you?

Employers have long known the worksite is a factor in employee health and productivity; this research clearly indicates hypertension could be characterized as an occupational disease specifically associated with employment.

Note – HealthAffairs has been doing really good work of late on workplace health and exposures.  Put their site on your reading list.

Back claims account for around a quarter of all workers’ comp claims.  They are also among the toughest to handle; what appears to be a simple strain at first report may end up a long-term, permanent disability claim.

Three recent studies on back pain, the treatment thereof, and how treatment varies from place to place are well worth your consideration.

Here’s the quick summary of each – followed by what it means for work comp patients, providers, and payers.

First up, a comprehensive study of management of nonspecific back pain treatment options will begin shortly, funded by the Patient-Centered Outcomes Research Institute (PCORI).

The Comparison of Surgical and Nonsurgical Options for Management of Chronic Nonspecific Low Back Pain will assess outcomes for patients receiving surgery (lumbar fusion) vs non-surgical treatment. This is a randomized control trial, so the results will be instructive indeed for work comp regulators, payers, and providers.

HOWEVER, a decade ago a very similar study was conducted which indicated similar outcomes for surgical and non-surgical patients – but this result was not deemed conclusive because lots of patients who were put in the “surgery” group chose not to have surgery and vice versa.

Implications for work comp – a valid study will greatly help regulators determine the approval process and standards for back surgery.

Whether or not you get back surgery appears to depend more on where you live than what your symptoms are.  That’s the conclusion from a recent Dartmouth analysis of Medicare data.  The other major takeaway –  – despite the lack of credible evidence that surgery produces better outcomes.

maps below are from Dartmouth Diffusion project.

Notice how surgery rates didn’t move much at all in New England, but dramatically increased in the southeast and Rocky Mountain regions.

If you want to know why, there’s this from the NYTimes article: “physician beliefs about the benefits of surgery were associated with surgical variations.”

Implications for work comp – Regulators, use NATIONAL guidelines, and don’t rely on local providers to drive your guideline selection.

Supporting this research is this – drugs don’t seem to help resolve back pain any quicker. A guideline was just released by the American College of Physicians advocating non-pharmaceutical approaches for treatment of back pain.

Implications for work comp – I’d be repeating myself…

I (virtually) sat down with WCRI CEO John Ruser PhD last week to catch up on his first year at the Institute and get a preview of next month’s WCRI Conference. (Registration is here)

MCM – Talk about the last year and WCRI’s accomplishments.

Dr Ruser – We are working to maintain and build on the momentum Rick [Victor, former CEO] created – a rigorous approach to our research agenda, addressing a series of issues in workers’ compensation. One we are focused on is the worker outcome surveys. This can add considerable value to the industry; it addresses access to care, satisfaction with care, Return to Work, Return to Functionality, and earning history post-injury.

We are excited about what’s coming up. We want to provide information in a more readily accessible fashion. We will be launching a new website; the current one is functional but it’s time to refresh. We will go live soon with a site that is visually appealing; the new website allows us to experiment with a blog and video and provides more readily accessible content that is easier to search.

MCM – Can you expand on that [making information more accessible]?

Dr Ruser – Our work is very scholarly; it is hard to digest sometimes, so we are focusing on producing new products to reach a broader set of stakeholders that aren’t researchers. These will be written in layman’s terms that are more approachable.

MCM – The annual conference is set – what are you most looking forward to?

Dr Ruser – The theme is Persistent Challenges and New Opportunities: Using Research to Accelerate the Dialogue. There have been lots of challenges and questioning of workers’ comp over the last few years. Is workers’ comp fulfilling its obligation to injured workers? We will address some of those issues, as well as discuss what the election means for healthcare in general, labor regulations and workers’ comp. We’ve invited veteran politicians and other experts to talk about what they see down the road.

We’ve been talking about opioids for years. Are we making progress, defined as reducing new pts and reducing duration? Our people have looked at this and we see lots of variation across states, but in many states there have been fairly dramatic declines in opioid dispensing (pharmacy and physician) even back in 2014.

We will also be focusing on alternatives to opioids, a variety of solutions to control pain aside from opioids – excited about this – research on marijuana and pain and biochemistry of that. Apart from sharing our latest opioid research, we will have a panel that talks about about a variety of different approaches, including mindfulness, and we have some policymakers will discuss medical marijuana and complexities involved [in dealing with marijuana].

There is a session on grand bargain and we are really excited about it.  Among the speakers are Dr. David Michaels now at GWU, who was behind record keeping changes and is the former head of OSHA is there, Northeastern’s Prof. Emily Spieler, Dr. David Deitz, and former AIA Workers’ Compensation executive Bruce Wood.

MCM – What’s been the biggest surprise in your first year?

Ruser – [The] amount of support and respect that WCRI gets from the industry and our broad base of stakeholders, the recognition of the value and independence of our work, [we are] filling a void, [stakeholders have been] very supportive in general. Some disagree, but when they do they are respectful due to WCRI’s reputation.

That’s Los Angeles, not Louisiana.

I ask that question, dear reader, because the latest report from the fine folk at CWCI raises yet another question about why LA is so different from the rest of California.

The latest information (available here for purchase; free to CWCI members) indicates cumulative trauma claims happen way more frequently in the LA Basin than elsewhere in the Golden State.

Whaaaat?

Are there millions of Angelenos doing manual data entry and getting carpal tunnel?

Getting wrist injuries from turning keys like those guards at the Illinois prison?

Hurting their hands clapping for all the Hollywood crowd?

Twisting their necks from constantly looking up at the gorgeous blue sky? (no, that can’t be it)

Too many botox injections? (that’s kinda cumulative trauma, right?)

Too much yoga?

It can’t be crooked physicians…right?

 

 

Geek alert!

For work comp wonks, in this post I’m reporting on what transpired at this morning’s meeting at DOL on Work comp; a summary and perspective will be the subject of a post tomorrow.

OSHA’s Director led off this morning’s presentation at the Department of Labor with a quick summary of the history of work comp, noting the death rate for WC declined from 37 per day to 12 per day over the last 40+ years despite a doubling of the number of people employed.

(note the statements below are paraphrased, some may not be entirely accurate due to lack of transcript available at the time of posting)

The written report is here for download. 

He also stated many injuries are NOT reported, saying workers’ comp is the ONLY element of the social net without federal oversight.  

Key paraphrased quotes:

• Costs are shifted away from employers, and to workers, their families, and other social insurance programs.
• The race to the bottom for workers comp among states has continued.
• Potential policy initiatives are here.

NASI CEO Bill Arnone’s comments included:

• workers’ compensation is a social insurance system that “needs work”
• today’s work place is very different from 1908…
• 3 million injuries and illnesses reported in 2014 – 1/3 represented time away from work
• lack of uniform reporting of state experience
• goal of workers comp- adequate wage replacement and medical care at reasonable cost – balance adequacy and affordability

Social Security’s Commissioner Carolyn Colvin was up next; notable statements follow:

• 9 million disabled workers receive income from Social Security – plus 2 million of their dependents; averaging under $1,200 per month
• for 1/3 of these workers, SS Disability Income (DI) income is their ONLY income.
• if the full cost of workers injuries aren’t covered by workers comp, someone else is paying for those costs
• recent changes in some states’ work comp laws may be shifting costs to SS DI and Medicare

The Commissioner was quite clear that Social Security is very interested in worker disability as shifting of expense to SS DI increases Social Security’s ultimate cost.

Secretary of Labor Tom Perez then took the podium.  Perez gave a detailed and passionate review of the formative years of workers’ compensation.  The Secretary noted that today, just as 80 years ago, state workers’ comp systems vary widely, AND, the Feds have “leverage” at the federal level for other social insurance programs including unemployment insurance.

Perez linked today’s work comp systems with those that led to the National Commission in the last century, starting with Texas opt-out as problematic due to low benefits. The Secretary also said:

• you’ve got to win the geographic lottery to be taken care of due to differences among states
• taxpayers are unfairly subsidizing a workers’ comp system that is not doing enough
• DOL doesn’t have statutory authority to protect workers but we do have the bully pulpit.

A panel discussion began; speakers included John Burton, PhD, Professor Emeritus at Rutgers and former Chair of the Commission; Gary Franklin MD, Medical Director of Washington’s State WC Fund L&I; Christopher McLaren PhD of NASI, Emily Spieler, Professor and Labor Attorney, former Commissioner of WC in West Virginia.

Burton was asked for his views…at which time the broadcast went down for a few minutes. When we were reconnected, Burton provided a background of the Commission’s work, suggesting the standards represented a “floor” for benefits and other aspects of workers comp, and the decline in benefits was largely driven by state’s unfounded fear that employers would leave for more friendly locales.

Burton does not believe there is any chance federal standards will be enacted over the next 20 years, and can’t be developed because the world has changed so much.  Burton believes there is a “race to the bottom” once again, and this has resulted in states reducing benefits.

In a later segment, Burton noted there is a discrepancy between the NASI data and the Bureau of Labor Statistics’ data on employers’ workers’ comp costs; BLS data indicates employer costs are not going up, in contrast to NASI’s findings.

He also panned the AMA Disability Rating Guidelines, claiming among other things that they are completely non-evidence based, and suggesting the Institute of Medicine come up with a disability rating guide…I wholeheartedly disagree w Burton’s assertions about and denigration of the Guides.

Dr McLaren hit the highlights of the new NASI work comp report – copy here. Later, he noted that costs are going up now due in large part to the ongoing recovery from the Great Recession; costs tend to go up before the benefits paid catches up to the new workers’ new injuries. 

Dr Spieler was asked to identify the key problems in state workers’ comp systems. She agreed with John Burton that a major problem is states seeking to compete with other states, and:

• many injured workers don’t apply for benefits and therefore don’t appear in NASI or other reports
• some apply for benefits but don’t get them due to payer contesting the claim due to requirement that workplace was major contributing cause to the impairment.
• are cash benefits adequate – there have been cutbacks in length of time patients can receive benefits, citing Oklahoma
• patients exist in a “Kafka-esque” system, alarmingly complex and stigmatizing.
• there’ve been statutory efforts to “cut back” on medical benefits
• the goal of replacing 2/3 of pre-injury wages was and should remain a goal.
• Oklahoma opt-out was mentioned multiple times

Gary Franklin MD PhD spoke about medical care in the system (note – Gary is a  friend and colleague)

Gary noted that unlike some states, Washington is in a race to the top.  He also said many payers don’t even have senior medical staff to help guide policy. For those who know Dr Franklin, it will come as no surprise that he used the term “evidence-based” multiple times in referring to formularies, lumbar fusion and other surgery, and disability.

A lot of the contribution to long term disability is due to baad medical care; workers’ comp medical care is among the worst medical care in the country,  Gary cited 32 deaths of workers comp patients who had low back sprains, got opioids, and were dying due to their prescriptions.  WA focuses on preventing disability three ways:

• develop validated methods, tools, and instruments that docs can use to identify patients at risk for extended disability
• using evidence based methods to develop treatment guidelines to prevent them from being injured
• develop delivery systems to reorganize care to allow better care for injured workers, the Centers for Occupational health and Education – 50% of patients are going thru these Centers, which have helped reduce preventable disability by over a third.

Net – paying much more attention to technology assessments, evidence-based clinical guidelines, and preventable disability are all helping workers avoid bad care and prevent extended disability.  Gary talked about the horrible effects of lumbar fusion surgery and opioids – “a huge percentage of injured workers that are now on SSDI are on opioids, and that started in the workers comp system.”

The discussion went on from there, with a discussion of illnesses and how the system doesn’t adequately address occupational injuries, DOL’s views on work comp and the Gig economy, and the need for more research on occ injuries and illnesses sustained by Gig economy workers.

The issue of misclassification, and how states handle independent contractors, problems in the construction industry with labor cheating was raised by Burton – valid points all.

A comment by David Deitz MD on last week’s post is well worth your read.  Referring to ProPublica, Dr Deitz said:

describing the use of guidelines and other evidence-based tools as a cut in benefits is not just misleading, it gets to the root of one of the central problems with much WC care

As Dr Deitz notes, what PP doesn’t grasp is this; evidence-based guidelines promote better medical care, and when work comp patients get sub-standard care, everyone suffers. .

Not just a few patients highlighted in a couple of headline-grabbing stories, but thousands victimized by lousy medical treatment. Today, many states do not allow or support the use of evidence-based clinical guidelines (which PP describes as a “cut in benefits”), and as a result many patients get crappy medical care.

Want evidence?

• Workers’ comp accounts for 1.25% of total US medical spend, but 13% of opioid spend. Opioid prescribing and dispensing is a major contributor to death, extended disability, ruined families, and ruined lives.
• The Drobots and their ilk – carving up workers’ comp patients to implant faulty devices to generate huge profits for a select few doctors.
• Physician dispensing of drugs extends disability, runs up medical costs, and keeps patients from returning to work.
• Physician-owned toxicology labs.

Data and the analysis thereof identifies these issues.

Outcomes data such as return to work, disability duration, functionality, sustained re-employment, re-injury rates differentiates good medical care, and providers who deliver that care, from providers who don’t.

Alerts based on potentially problematic treatment such as prescription of opioids without trauma or surgery, high incidence of surgery for patients with soft-tissue injury diagnoses, physical therapy scripts for patients without musculoskeletal injuries are based on data collection and analysis.

Dull stuff, huh?

Anecdotes are easy to grasp, get lots of attention, generate excitement, start politicians squawking. Data is, well, boring. Thinking based on data requires focus, concentration, effort, and a desire to understand.  Anecdote is quick, easy, and triggers emotions that often lead to simplistic and misguided conclusions.

That’s the briefest explanation I could come up with as to why work comp reform efforts are far too often sidetracked by issues/stories that, while concerning or even troubling, do NOT represent what happens the vast majority of the time.

What does this mean for you?

Make decisions based on data, not on anecdote.