Palliative Care: The Cure to Workers’ Compensation Blues? (A

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Palliative Care: The Cure to Workers’ Compensation Blues? (A

Postby davidd on Mon Dec 20, 2010 11:47 am

Palliative Care: The Cure to Workers’ Compensation Blues?
by David J. DePaolo

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

The Los Angeles Times paper edition published a front page story Sunday, December 19, 2010 on palliative care (http://www.latimes.com/news/local/la-me ... 1231.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/publicat ... ndex.shtml). Mental disorders are the leading cause of disability in the U.S. 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 DePaolo is the president, CEO and publisher of WorkCompCentral.
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Re: Palliative Care: The Cure to Workers’ Compensation Blues? (A

Postby nan version on Tue Dec 21, 2010 5:57 pm

Dear David -

I really appreciated your message regarding this important issue. I have not posted on the forum for some time as I have been busy working as a therapist with clients experiencing a variety of mental health concerns. I entirely agree with the concept that injured workers need to be able to have their medical providers listen to them. For fifteen years I was a work comp adjuster in CA. It was my experience that being able to listen, validate, and brainstorm solutions with the IW could be very healing. Over the years I heard heartbreaking stories and did the best I could to be of help. I was struck by how many of my clients were having problems with depression, anxiety, PTSD, etc. and that so little attention or help was provided to them.

When I left the work comp industry (having filed my own WC claim for stress. Denied of course), I pursued and received my B.S. in psychology and then obtained a master's degree in mental health counseling. I now work at a community mental health facility and do counseling full time with a variety of clients. So many of them have virtually no one who will listen to them and their concerns so the very act of being listened to and understood is powerful in and of itself. They all struggle with various mental health issues and I have seen a lot of progress and growth in many. Counseling is my passion, and it was working with IW that lead me on that amazing path.

Thank you for reminding me of why I am a counselor. Happy holidays to all -
Ann (nan version)
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Re: Palliative Care: The Cure to Workers’ Compensation Blues? (A

Postby davidd on Thu Dec 30, 2010 3:39 pm

From Forum member Stew:

Dave,

Here's a link to a book about sleep which I have published at my expense. It is copyrighted by the students' team, the "Robo-Medics," but can be reproduced free of charge with the understanding it is to be provided for the use of gradeschool students in the classroom.

http://dl.dropbox.com/u/14822048/Let%27 ... %20ed..pdf

(The book needs to be rotated counter clockwise in Adobe to be read online.)

It was produced as part of a robotics competition as the inside cover and Introduction explains. Their team won a preliminary match in the California's central valley with 10 teams participating, and placed 8th out of 96 central valley teams a couple of weeks ago in Clovis.

While the book is copyrighted, there is no sales price. It was designed for use in the classroom by grades K through 3rd. The authors were 4th, 5th and 6th grade students...including my grandson, Alex S. The idea is the time to teach the importance of something so commonplace as sleep is as soon as possible in someone's life, before they learn bad habits. This was the team's "unique solution."

Note the "Dedication." The team had a hard time understanding the $50 billion annual cost of sleep loss in the U.S., so I tried to give a more concrete example. The cost is 1.89 times around the planet earth. . . with $100 bills! That was a shocker for me.

It occurs to me a lot of injured workers have problems with sleep deprivation, not only as a cause of accidents in the first place, but afterwards, delaying recovery. These problems include of course pain, but also emotional problems as well and problems caused by claims persons and physicians with their own sleep problems!

I don't know if it would be useful or not to post the above as a response to your recent "Letter to the Editor" dealing with pallatiave care, listening to injured workers and comorbidity. Over the past couple of months I've read many thousands of words about sleep deprivation and its effects. I have come to realize its importance is only recently being understood and publicized.

The photo of the kids and their coach, Doug Urabe, is at Kaiser Permanente in Fresno. The kids are wearing devices designed to help persons with sleep apnea. One of the kids' father wears such a device when sleeping. The mother of another was in the audience, listening to a presentation by Kaiser's Sleep Lab staff and the symptoms shocked her! The last I heard she was undergoing testing, since she had many of the symptoms e.g., high pulse rate in the early a.m. Sleep apnea was something her doctors had not previously considered.

In "comp" most of us are either on the employee's or employer's "side of the fence." This influences how we look at things, e.g., the glass of water, half empty or half full?

The importance of sleep? If you are a claims rep, employer, defense attorney or "their" physician, you see "sleep" as a ploy to possibly increase case value by "the other side," resulting in a knee-jerk denial of testing, etc., just as you pointed out with counseling.

If you are a person claiming an injury, their attorney, or a physician "sympathetic" with injured people you may view "sleep" as a way to increase settlement value under, e.g., the AMA Guides or increase your own "accounts receivable."

What does the future hold? Hopefully, this little book will help raise awareness of the problems caused by sleep deprivation by reaching and having a positive influence on younger grade school students before they learn the bad sleep habits of many teenagers and adults.

Feel free to add this e-mail to the thread on "Pallitive Care" in the Forums if you think it relevant. If so, you could also do the same with WCC.com in other jurisdictions? Our "target audience" will not be your subscribers, but hopefully their parents, friends, teachers, doctors, etc., will be and they can pass the word by printing and giving a copy of this book to younger grade school students?

Stew
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