Managed Care in the Workers' Compensation Environment -- Part IV

Over the years, I have seen what makes a good utilization management program. It should be able to assure medically necessary treatment while optimizing cost savings. It should be clear that the earlier observations of the workers' compensation environment require a special set of skills and a specific program design to properly and cost-effectively manage these cases. Because the chiropractic care "system" is really not a well-defined system of standards, the quality of care received in any given case is often a matter of chance. The organization of a true system, or network, of selectively contracted, quality objective providers (often referred to as Preferred Provider Organizations, or PPOs) can greatly benefit workers, employers, and insurers. Clearly, workers' compensation payers should not be denied the benefits of receiving the discounts and preferential arrangements offered to other payers.

Causality Determination

The key initial step that is often overlooked in the management of a workers' compensation case is the causal relationship between the inciting incident and the illness or injury. A description of the incident may sound plausible on the surface but may not be chiropractically/medically reasonable. Many falls or bending incidents I have seen could not have caused the injuries that were alleged, or could not have caused symptoms years later, as alleged. The first step is a national, federally-funded research program concerning the whole issue of causality, which would include repetitive movements, macrotrauma, and microtrauma. The issue of ergonomics is still not fully understood. The surface of causality has just been scratched.

Standards of Care

The second key step in workers' compensation management is identification of protocols or standards of care. This is an area that is sorely lacking in our profession. We now have a loose-knit, eclectic approach to standards and protocols. The standards that we do have come from the Chiropractic Council on Education (CCE) colleges, our national organizations, our malpractice carriers, and/or other recognized authorities. They are available to anyone who wants to go digging to find them. Why can't we have a more uniform, one-voice standard of care? The end result of a "hidden" protocol is a practitioner who is "at risk" every time he fills out an insurance claim form. Typically, what defines a new practitioner's practice habits are: the chiropractor he initially associated with (and who knows where they got their practice habits), some practice management guru (who may not have your or the workers' compensation system's best interests at heart), trial and error, and just plain economics. This creates frustration, confusion, and adversity. When we have a standard of care that is published, when all the players in the game know all the rules of the game, everyone wins. If a practitioner chooses to step outside the rules, he then knows why a claim has been questioned.

The cornerstone of a managed workers' compensation program is the protocols or standards of care. These standards would be used to review cases and determine the justification for the diagnosis and treatment. There is a tremendous variation in practice patterns in the workers' compensation environment. Variation is an a priori definition of poor quality. The symptoms of variation, overuse, and marginally confirmed diagnosis demand specific and up-to-date standards for both cost containment and quality assurance.

Certification and Management

An effective utilization management organization (UMO) will use the standards of care to certify tests and procedures. Most workers compensation care is orthopedic/chiropractic in nature. A UMO should have the expertise to clinically discuss the most appropriate tests and procedures if those suggested by the attending physician are not the most current or the most efficient. Once certification has been granted, there should be frequent review of the need for further care, further tests, or further procedures. A program that statistically averages length of care and then recontacts the provider the day before "discharge" may allow excessive treatment if the patient recovers more rapidly. Those same averaged programs may also permit non-causally related procedures through lack of attention of the unique workers' compensation needs.

Quality Assurance

All chiropractic review programs should have a structured quality assurance and quality improvement program in place that monitors record timeliness and completeness, as well as the clinical quality of decisions made by staff case assistants, nurse reviewers, chiropractic physician advisors, and network physicians. Regular training sessions should be held to assure that the reviewers have the latest and most accurate information on which to base their decisions. A database should be maintained and statistically analyzed to monitor the practice patterns of both review personnel and treating physicians. This data would be used to improve the quality of review and care.

Outcome Assessment

Reviewers should periodically and selectively contact patients and providers after discharge from care to determine whether they have improved as a result of their treatment. In addition, random chart audits and work performance checks provide important outcome assessment information. This data should be integrated into the database.

Peer to Peer Arbitration

A peer review panel is an extension of the standards of care. Differences between attending physicians should be arbitrated on a peer to peer basis. A variation on the peer to peer issue might be review of chiropractic treatment proposed by a practitioner of one technique by a practitioner of another technique. One technique may be better suited for a particular condition than another technique. There are so many wonderful techniques available to us now. If we truly care about our patients' health and progress, why must we insist that "our" technique is the only one that works (or will get them well)? Let's put egos and pettiness aside. Our profession is growing so fast and in so many directions; no one person can have all the tools for all conditions of all people. Let us refer to a colleague who has a technique or expertise that is better suited to a patients' problems. Let's not deride our colleague for using a technique or procedure that is different from our own (as long as it is an accepted standard). We try to fix all of humanity with "our" technique. That is like an MD latching on to one drug and prescribing it to every one of his patients. It may be successful on some, but not on all patients. A wise man once said, "To the man that owns a hammer, everything looks like a nail."

The impact of a well-designed UMO can be profound due to the evidence of unnecessary diagnostic tests, unnecessary treatment, and prolonged lengths of care. Such results not only improve the experience relative to clinical outcomes and chiropractic benefits cost, but also improve the indemnity experience as time lost from work is impacted.

The future looks bright for us only if we accept the challenge of policing ourselves in a responsible and prudent manner. Let our patients always have the benefit of chiropractic care.

References

1. Ryan, Kevin M., president of the National Council of Compensation Insurers. "Business Insurance," feature article, April 1988.

    

2. "Business Insurance." October 23, 1989, p.23.

    

3. "WCRI Research Reports." June 1986.

    

4. Hyman, D.A., and Williamson, J.V. "Fraud and Abuse: Setting the Limits on Physician Entrepreneurship." New England Journal of Medicine 1989; 320(19): 1275-1278.

    

5. Hyman, D.A., and Williamson, J.V., op. cit.

    

6. Federspiel, C.F.; Guy, D,; Kane, D.; and Spengler, D.M. "Expenditures for Non-specific Injuries in the Workplace." Submitted for publication 1989.

    

7. Spengler, D.M., et al. "Back Injuries in Industry: A Retrospective Study I. Overview and Cost Analysis." Spine 1981; 11(3): 241-245.

    

8. "WCRI Research Reports," June 1986.

    

9. Hyman, D.A., and Williamson, J.V., op. cit.

    

10. See, for example, Spityer, W.O., et al. "Scientific Approach to the Assessment and Management of Activity Related Spinal Disorders." Spine 1987; 12(75). Chassin, M.R., et al. "Indications for Selected Medical and Surgical Procedures: A Literature Review and Ratings of Appropriateness." Santa Monica: RAND 1986; and many works by Robert Brook and by Avedis Donabedian.

     

11. National Council on Compensation Insurance, Issues Report, 1988. New York: National Council on Compensation Insurance, 1989.

     

12. National Council on Compensation Insurance, op. cit.

     

13. National Council on Compensation Insurance, op. cit.

     

14. National Council on compensation insurance, op. cit.

     

15. Kassirer, J.P. "Our Stubborn Quest for Diagnostic Certainty." New England Journal of Medicine 1989; 320(22): 1489-1491.

     

16. Spitzer, W.O., op. cit.

     

17. Witt, I.; Vestergaard, A.; Rosenklint, A. "A Comparative Analysis of X-ray Findings of the Lumbar Spine in Patients with and without Lumbar Pain." Spine 1984; 9: 298.

     

18. Wiesel, S.W.; Tsourmas, N.; Feffer, H.L.; Citrin, C.M.; Patronas, N. "A Study of Computer Assisted Tomography. 1. The Incidence of Positive CT Scans in an Asymptomatic Group of Patients." Spine 1984; 9: 549.

     

19. Hitselberger, W.E.; Witten R.M. "Abnormal Myelograms in Asymptomatic Patients." Journal of Neurosurgery 1968; 28: 204.

     

20. Kent, D.L.; Larsen, E.B. "Magnetic Resonance Imaging of the Brain and Spine: Is Clinical Efficacy Established After the First Decade?" Annals of Internal Medicine 1988; 108: 402.

     

21. Kassirer, J.P., op. cit.

     

22. Haddad, G.H. "Analysis of 2932 Workers' compensation Back Injury Cases: The Impact of Costs to the System." Spine 1987; 12: 765-769.

     

23. Frymoyer, J.W. and Cats-Barril, W. "Predictors of Low Back Pain Disability." Clinical Orthopedics and Related Res. 1987; 221: 89-98.

     

24. Anderson, G.B.; Svenson, H.; Aden, A. "The Intensity of Work Recovery in Low Back Pain." Spine 1983; 8: 880-884.

     

25. Kelsey, J.L., and White, A.A. "The Epidemiology and Impact of Low Back Pain." Spine 1980; 5: 133-142.

     

26. Trief, P., and Stein, N. "Pending Litigation and Rehabilitation Outcome of Chronic Back Pain." Archives of Physical Medicine and Rehabilitation 1985; 66: 95.

     

27. Edwards, L.S. "Workers' Compensation Insurance." Orthop. Clin. North Am. 1983; 14(3): 661-669.