Treating the Whole Person
Recent research from Gallup and Healthways Inc. shows what claims payers already know: The percentage of obese Americans continues to increase. In their May 2015 report, Gallup and Healthways stated that the nation’s obesity rate rose again in 2014, reaching 27.7 percent, up from 27.1 percent in 2013.
Even more unsettling — and perhaps surprising to some — is that research indicates changes in diet and exercise are not enough to reverse the trend.
What’s needed, according to the studies, is a more holistic engagement that boosts a person’s sense of purpose and strengthens their community and social relationships; even their financial health.
Professionals that help injured workers address biopsychosocial issues say they agree with that assessment. They also say it is increasingly a factor in their work with employers and other workers’ compensation and disability claims payers.
Biopsychosocial issues refer to psychosocial factors impacting a person’s medical problems, said Michael Coupland, CEO and network medical director at Integrated Medical Case Solutions Group, which provides biopsychosocial assessments and interventions.
Most biopsychosocial approaches take into account that factors such as emotions, behaviors, social environments and culture all impact human medical conditions and performance.
Services addressing biopsychosocial problems are being applied more often when medical treatment alone fails to mend injured workers. They can help with depression, pain medication misuse and obesity, which can delay or even thwart successful return to work.
About 75 percent of the workers’ comp and disability claimants referred to his group are obese or morbidly obese, IMCS’s Coupland said. They are referred by claims payers, treating physicians, self-insured employers and others.
“They are the people that tend to have psychosocial factors that are delaying their recovery,” Coupland said.
IMCS Group specialists offer their patients cognitive-behavioral techniques for taking control of their health and wellness, Coupland said. The techniques include meditation, mindfulness and biofeedback.
Those practices can help, for example, with decreasing muscle discomfort so recovering workers are able to go for walks and reap the benefits of exercise.
Darrell Bruga, founder and CEO, LifeTEAM Health, agrees with the Gallup and Healthways findings that factors such as social interactions, financial well-being and a sense of purpose must be addressed.
Bruga said many of the injured and disabled workers his company sees are obese, although his organization does not directly treat obesity. LifeTEAM professionals provide services for reducing psychosocial and return-to-work obstacles.
Interventions that help people develop a sense of purpose, achieve financial well-being and develop community interactions “are exactly the sort of things we are focused on in helping people re-engage,” Bruga said.
“It makes sense that if you are having challenges from a psychosocial standpoint in life as a whole, that is certainly going to impact your well-being and potentially your body composition,” he said.
But it’s important to recognize that returning to work is part of the solution — it can help meet the needs the researchers outline because work is social and it also improves peoples’ financial position, Bruga added.
“It makes sense that if you are having challenges from a psychosocial standpoint in life as a whole, that is certainly going to impact your well-being and potentially your body composition.” — Darrell Bruga, founder and CEO, LifeTEAM Health
Bruga will speak on mitigating psychosocial risk factors with biopsychosocial measures during the National Workers’ Compensation and Disability Conference® & Expo to be held at Mandalay Bay in Las Vegas November 11-13.
Dr. John T. Harbaugh, occupational medicine physician director at Southern California Permanente, will join Bruga and share results from helping his organization’s injured employees overcome psychosocial risks with a biopsychosocial strategy.
What’s important to keep in mind in managing the biopsychosocial aspect of work injury and return-to-work is that any injury creates stress for both the employer and the employee. The mere fact that a once-productive employee is leaving work creates a host of issues.
“There is a stigma to going out of work. Nobody wants to go out on leave,” said Rebecca Moya, a behavioral health manager with Sun Life Financial.
“So if we can battle that, have employers manage that piece in a more empathetic, supportive and understanding way, that’s one less hurdle that insurers or benefit analysts or vocational rehabilitation consultants have to jump over to get there,” Moya said.
There is also psychological trauma that lives within a worker who associates pain and injury with their workplace.
“It’s hard to revisit and go back to that place,” Moya said.
“We’ve worked with employers to ask, ‘Are there other sites? Is it possible to have this person work at a different site?’ Because they’re ready to come back — it’s just that the emotional and psychological aspect of returning to the site of their injury is very challenging,” she said.
There are also the injuries to self-esteem and the sense of self-worth that a physical injury can bring about.
Even without obesity or some other comorbidity dogging them, a worker who faithfully performed a task for decades can suffer a loss of confidence or suffer depression when a work injury means they will never be as strong or able again.
“That’s hard for people. They don’t always want to go back and do something different. Even with accommodations, it’s hard for people to accept that’s going to be the way things are going to be going forward,” Moya said.
Overcoming those fears and that damage to self-esteem means focusing on the positive, Moya said.
“If an analyst starts off a relationship with an injured worker with a positive, ‘We’re going to work on your abilities, not your disabilities, and we are going to get you back to work,’ then people are really receptive to that.
“It’s all about the foundation you lay at the start of a claim,” Moya said.
IMCS Group’s Coupland agrees that helping people return to work and reclaim their sense of purpose is a key piece of the well-being issue that the Gallup and Healthways researchers raise.
“We get so much of our purpose from work,” Coupland said.
Data Drives Down Skepticism
Growing acceptance of paying for biopsychosocial approaches to wellness is being helped along by a significant shift that occurred in 2009, Coupland added.
Health providers in psychology gained the ability to provide health and behavior treatments under Current Procedural Terminology codes for physical medicine rather than having to provide them as treatments under psychiatric codes, he said.
Now, workers’ comp payers are much more accepting of the treatments, Coupland said.
Even so, some workers’ comp claims payers are skeptical about a concept calling for treating the “whole person” and are still reluctant to pay for providing injured workers with biopsychosocial treatment approaches.
But increasingly, sophisticated claims payers are funding such programs and their numbers will continue to rise, said Debra Levy, senior VP of workers’ comp product management and national workers’ comp practice leader for York Risk Services Group.
Payers funding those programs are doing so because their data shows a positive return on investment, Levy said.
“The earlier you can recognize those are factors and offer solutions or guided care … you see a positive impact as opposed to throwing away money,” she said.
An Unnecessary Death
Brandon Clark’s demise and his family’s victory in a legal battle for death benefits makes one wonder whether remedies among the expanding list of workers’ compensation claims services might have saved his life.
It’s an important question because the carpenter left behind a grieving family, including children. It also offers a chance to weigh the potential value those services might provide disabled workers, their devastated families and claims payers.
In the case of South Coast Framing v. Workers’ Compensation Appeals Board, the California Supreme Court laid out the lessons to be gleaned from the case, finding in favor of providing death benefits.
The court addressed issues expected to arise across more states, mirroring the industry’s concerns that too many injured workers have been prescribed an abundance of harmful drugs, including opioids.
Clark was 36 when he fell from a height of 10 feet in 2008, suffering a concussion and neck and back injuries that caused progressive pain until he died 10 months later of an overdose of prescription medications.
His family presented arguments about causation and the degree to which drugs prescribed by workers’ comp doctors and his personal doctor played a role in Clark’s death.
The court said the family met a standard that only required proving industrial causation is reasonably probable. There was evidence that Ambien, prescribed for pain-induced sleep problems, was causally related to his work injury while drugs prescribed by a workers’ comp doctor for depression and pain played at least some role in the death.
When you hear about the magnitude of a family’s loss, it makes one think that the value of all those workers’ comp services must be considered in more than just financial terms.
California claims payers now face a lower causation standard than they perhaps expected when multiple factors contribute to a worker’s death, including prescription combinations.
Since Clark’s 2008 injury, workers’ comp has seen an expanding list of services increasingly applied to address a rise in challenging disabilities, prescription misuse and increased medical expenses. I’m thinking of the growth in pharmacy benefit reviews, nurse case management and predictive analytics, to name just a few.
It’s always prudent to question the value of those services and whether inefficient application or overuse might drive unnecessary expenses.
But Clark’s death, among numerous other cases, also raises the question of whether a pharmacy benefit manager’s review of his prescriptions might have raised a warning. Or whether a nurse case manager’s discussions with Clark might have provided life-saving pain-treatment alternatives.
The court records don’t show whether Clark received such services, and my attempt to reach his family through their attorney failed. But considering several factors, including the accident year and his employment as a carpenter, I suspect there is a possibility he didn’t.
The attorney did tell me, though, that Clark’s family was his life’s focus and that they struggled to understand his demise.
When you hear about the magnitude of a family’s loss, it makes one think that the value of all those workers’ comp services must be considered in more than just financial terms. It’s not just a question of whether they reduce claims costs, eliminate litigation or improve worker productivity.
There are also families needing someone to deliver the right care that will spare them the painful financial and emotional devastation that comes with prolonged disabilities and the loss of a loved one.
Managing Chronic Pain Requires a Holistic Strategy
Chronic, intractable pain within workers’ compensation is a serious problem.
The National Center for Biotechnology Information, part of the National Institutes of Health, reports that when chronic pain occurs in the context of workers’ comp, greater clinical complexity is almost sure to follow.
At the same time, Workers’ Compensation Research Institute (WCRI) studies show that 75 percent of injured workers get opioids, but don’t get opioid management services. The result is an epidemic of debilitating addiction within the workers’ compensation landscape.
As CEO and founder of Integrated Prescription Solutions Inc. (IPS), Greg Todd understands how pain is a serious challenge for workers’ compensation-related medical care. Todd sees a related, and alarming, trend as well – the incidence rate for injured workers seeking permanent or partial disability because of chronic pain continues to rise.
Challenges aside, managing chronic pain so both the payer and the injured worker can get the best possible outcomes is doable, Todd said, but it requires a holistic, start-to-finish process.
Todd explained that there are several critical components to managing chronic pain, involving both prospective and retrospective solutions.
Prospective View: Fast, Early Action
“Having the wrong treatment protocol on day one can contribute significantly to bad outcomes with injured workers,” Todd said. “Referred to as outliers, many of these ’red flag’ cases never return to work.”
Best practice care begins with the use of evidence-based UR recommendations such as ODG. Using a proven pharmacological safety and monitoring opioid management program is a top priority, but needs to be combined with an evidence-based medical treatment and rehabilitative process-focused plan. That means coordinating every aspect of care, including programs such as quality network diagnostics, in-network physical therapy, appropriate durable medical equipment (DME) and in more severe cases work hardening, which uses work (real or simulated) as a treatment modality.
Todd emphasized working closely with the primary treating physician, getting the doctor on board as soon as possible with plans for proven programs such as opioid Safety and Monitoring, EB PT facilities, patient progress monitoring and return-to-work or modified work duty recommendations.
“It comes down to doing the right thing for the right reasons for the right injury at the right time. To manage chronic pain successfully – mitigating disability and maximizing return-to-work – you have to offer a comprehensive approach.”
— Greg Todd, CEO and founder, Integrated Prescription Solutions Inc. (IPS)
Alternative Pain Management Strategies
Unfortunately, pain management today is practically an automatic move to a narcotic approach, versus a non-invasive, non-narcotic option. To manage that scenario, IPS’ pain management is in line with ODG as the most effective, polymodal approach to treatment. That includes N-drug formularies, adherence to therapy regiment guidelines and inclusive of appropriate alternative physical modalities (electrotherapy, hot/cold therapy, massage, exercise and acupuncture) that may help the claimant mitigate the pain while maximizing their ongoing overall recovery plan.
IPS encourages physicians to consider the least narcotic and non-invasive approach to treatment first and then work up the ladder in strength – versus the other way around.
“You can’t expect that you can give someone Percocet or Oxycontin for two months and then tell them to try Tramadol with NSAIDS or a TENS unit to see which one worked better; it makes no sense,” Todd explained.
He added that in many cases, using a “bottom up” treatment strategy alone can help injured workers return to work in accordance with best practice guidelines. They won’t need to be weaned off a long-acting opioid, which many times they’re prohibited to use while on the job anyway.
Chronic Pain: An Elusive Condition
Soft tissue injuries – whether a tear, sprain or strain – end up with some level of chronic pain. Often, it turns out that it’s due to a vascular component to the pain – not the original cause of the pain resulting from the injury. For example, it can be due to collagen (scar tissue) build up and improper blood flow in the area, particularly in post-surgical cases.
“Pain exists even though the surgery was successful,” Todd said.
The challenge here is simply managing the pain while helping the claimant get back to work. Sometimes the systemic effect of oral opioid-based drugs prohibits the person from going to work by its highly addictive nature. In a 2014 report, “A Nation in Pain,” St. Louis-based Express Scripts found that nearly half of those who took opioid medications for more than a month in their first year of treatment then refilled their prescriptions for three years or longer. Many studies confirm that chronic opioid use has led to declining functionality with reduced ability to recover.
This can be challenging if certain pain killers are being used to manage the pain but are prohibitive in performing work duties. This is where topical compound prescriptions – controversial due to high cost and a lack of control – may be used. IPS works with a reputable, highly cost-effective network of compound prescription providers, with costs about 30-50 percent less than the traditional compound prescription
In particular compounded Non-Systemic Transdermal (NST) pain creams are proving to be an effective treatment for chronic pain syndromes. There is much that is poorly understood about this treatment modality with the science and outcomes now emerging.
Retrospective Strategies: Staying on Top of the Claim
IPS’ retrospective approach includes components such as periodic letters of medical necessity sent to the physician, peer-to-peer and pharmacological reviews when necessary, toxicology monitoring and reporting, and even addiction rehab programs specifically tailored toward injured workers.
Todd said that the most effective WC pharmacy benefit manager (PBM) provides much more than just drug benefits, but rather combines pharmacy benefits with a comprehensive ancillary suite of services in a single portal assisting all medical care from onset of injury to RTW. IPS puts the tools at the adjustor fingertips and automates initial recommendations as soon as the claim in entered into its system through dashboard alerts. Claimant scheduling and progress reporting is made available to clients 24/7/365.
“It comes down to doing the right thing for the right reasons for the right injury at the right time,” Todd said, “To manage chronic pain successfully – mitigating disability and maximizing return-to-work – you have to offer a comprehensive approach,” he said.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with IPS. The editorial staff of Risk & Insurance had no role in its preparation.