Orthopedic Doctors Reveal Latest on Shoulder Diagnoses, Treatments
Some of the latest protocols to treat shoulder injuries among Connecticut’s workers’ comp patients are drawing criticism from at least one expert. He says one of the new rules may save money initially but lead to poorer outcomes and more money in the long run.
The state’s revised rules took effect April 1. For acute traumatic or overuse/repetitive shoulder injury at less than four weeks, the state’s Workers’ Compensation Commission recommends X-rays if indicated by amount of trauma or medical suspicion but “no MRI or CT scan.”
“If you don’t get an MRI or ultrasound initially, you have the possibility of missing a full thickness rotator cuff tear, which is best repaired within 10 days of the injury,” said Dr. David Cooper, an orthopedic surgeon and founder of The Knee Center in Wilkes-Barre, Pa. “If you don’t make that diagnosis, not only are you doing a disservice to the worker, but also when he doesn’t get better and four weeks later an MRI shows a tear, it’s very hard to fix, and the guy will come back and blame workers’ comp for not getting a good result.”
While other experts may dispute that exact time frame, they agree the sooner a full thickness rotator cuff tear is repaired, the better chance for an optimal outcome.
Rotator Cuff Tears
Rotator cuff tears are one of the most common shoulder injuries, especially among injured workers. A partial tear involves damage to the soft tissue but does not completely sever it while a full-thickness tear splits the soft tissue into two pieces.
“A partial thickness tear is considered degenerative. You may not want to pick it up as a workers’ comp injury. It may not be your responsibility.”
Partial thickness tears are usually the result of wear and tear as part of the normal aging process. On the other hand, full thickness tears are often caused by traumatic injuries such as falls. Knowing the difference can help workers’ comp practitioners determine causation.
“Workers’ comp has a basis in treatment for an acute tear,” Cooper said. “A partial thickness tear is considered degenerative. You may not want to pick it up as a workers’ comp injury. It may not be your responsibility.”
That’s another reason Cooper suggests getting an early diagnosis of shoulder pain among workers. But he understands the reluctance to perform an MRI at the onset of shoulder pain, especially since they can cost upwards of $600.
“I sort of agree with having no MRI. But an ultrasound would be a good screening test. Studies have shown them equivalent to MRI results,” he said. “A good ultrasound costs about $150.”
Cooper and others point out that it’s important to use an occupational health facility that has experience with ultrasound.
“It can be abused but is very operator dependent,” said Dr. William Ritchie, an orthopedic surgeon who specializes in injuries and conditions of the shoulder and knee, occupational medicine, sports medicine, and trauma at New Mexico Orthopaedics. “MRI is still the gold standard.” However, Ritchie also says he would only do an MRI within the first four weeks if there was a high suspicion of a rotator cuff tear such as significant weakness in the setting of a traumatic injury to the shoulder
Ritchie says there are some additional diagnostic tests that may be overused for injured workers. “You seldom need, for instance, EMG and nerve studies, but I do see them done by physiatrists for shoulder pain,” Ritchie said. “[As far as] MRI scans, that’s a tough call. They probably are done somewhat more often than they need to be. On the other hand, in the workers’ comp population, there have been studies showing if they are done early and get diagnosis and treatment in the long term that can save money.”
Aside from rotator cuff tears, other injuries seen among workers include SLAP tears, or superior labral tear from anterior to posterior; essentially a pulling injury to the shoulder.
“The SLAP tear was much more commonly diagnosed by MRI scans in the past. We’re diagnosing and operating on fewer of these.”
“It’s more common in sports, but it can be from a fall if you try to catch yourself. But that’s changing over time,” Ritchie said. “The SLAP tear was much more commonly diagnosed by MRI scans in the past. We’re diagnosing and operating on fewer of these.”
An additional shoulder ailment seen occasionally among injured workers is instability from a current dislocation. Ritchie says that can occur from a fall, although it is more typical among athletes.
The treatment of shoulder injuries varies depending on the diagnosis. For example, there is debate about the effectiveness of surgery for full thickness rotator cuff tears. The American Academy of Orthopaedic Surgeons’ board of directors recently approved new appropriate use criteria to treat full thickness tears.
“We found that in many patient/treatment combinations nonsurgical treatments or lesser surgeries treatments — partial repair and/or débridement, or repair — might be appropriate,” said Dr. James O. Sanders, who served as section leader and moderator during the appropriate use criteria’s development. “Major surgery such as reconstruction was an option less frequently, and arthroplasty was rarely appropriate.”
In arthroplasty, the joint is replaced, remodeled, or realigned by cutting the bone. One change in recent years is the increased use of arthroscopic surgery versus open surgical procedures.
In terms of recovery from arthroscopic procedures, “there is a small but significant difference but a little less painful,” Ritchie said. “There is faster recovery for arthroscopic [surgery].”
In the future, there may be a variety of procedures to repair shoulder ailments. Included in the Connecticut protocol’s “nonconsensus modalities” are platelet rich injections, acupuncture, hyaluronic acid injections, and stem cell preparations.
Researchers Examine Workplace Cancer Links
Workplace exposures are among the environmental factors believed to be responsible for cancer, say researchers. They estimate between 3 and 6 percent of all cancers worldwide are caused by workplace exposures to carcinogens. That translates to as many as 762,000 new cancers each year from occupational exposure, which they say is likely an underestimate. In the U.S., scientists estimate there were between 43,695 and 87,399 new occupational-related cancers in 2010, the most recent year available.
“Cancers that occur as a result of exposures in the workplace are preventable, if exposures to known or suspected carcinogens can be reduced,” wrote researchers on a blog post for the National Institute for Occupational Safety and Health. The agency is doing studies to identify agents in the workplace associated with the development of cancer.
Recent findings include:
Lung cancer among non-metal miners in which “risk was significantly associated with diesel exhaust exposure.” The results of that study were part of a decision by the International Agency for Research on Cancer to designate diesel exhaust as a Group 1 — known human — carcinogen.
Highly elevated incidence of bladder cancer among rubber manufacturing workers that was strongly associated with workplace ortho-toluidine exposure. The findings influenced the IARC’s recent determination of ortho-toluidine to be a Group 1 carcinogen.
Higher than expected rates of cancers, especially mesothelioma and cancers of the respiratory and digestive tract, among firefighters in Chicago, Philadelphia, and San Francisco. “Recent findings about mesothelioma and lung cancer related to asbestos exposure have shed new light on the importance of size and shape on the carcinogenicity of that well studied agent,” NIOSH said. “These findings may have important implications for future risk assessments of the hazards associated with asbestos exposure.”
The research has helped influence the development of risk-based exposure limit recommendations by national and international organizations. The agency is seeking input from stakeholders on priorities for future epidemiological research of potential occupational carcinogens.
Global Program Premium Allocation: Why It Matters More Than You Think
Ten years after starting her medium-sized Greek yogurt manufacturing and distribution business in Chicago, Nancy is looking to open new facilities in Frankfurt, Germany and Seoul, South Korea. She has determined the company needs to have separate insurance policies for each location. Enter “premium allocation,” the process through which insurance premiums, fees and other charges are properly allocated among participants and geographies.
Experts say that the ideal premium allocation strategy is about balance. On one hand, it needs to appropriately reflect the risk being insured. On the other, it must satisfy the client’s objectives, as well as those of regulators, local subsidiaries, insurers and brokers., Ensuring that premium allocation is done appropriately and on a timely basis can make a multinational program run much smoother for everyone.
At first blush, premium allocation for a global insurance program is hardly buzzworthy. But as with our expanding hypothetical company, accurate, equitable premium allocation is a critical starting point. All parties have a vested interest in seeing that the allocation is done correctly and efficiently.
“This rather prosaic topic affects everyone … brokers, clients and carriers. Many risk managers with global experience understand how critical it is to get the premium allocation right. But for those new to foreign markets, they may not understand the intricacies of why it matters.”
– Marty Scherzer, President of Global Risk Solutions, AIG
Basic goals of key players include:
- Buyer – corporate office: Wants to ensure that the organization is adequately covered while engineering an optimal financial structure. The optimized structure is dependent on balancing local regulatory, tax and market conditions while providing for the appropriate premium to cover the risk.
- Buyer – local offices: Needs to have justification that the internal allocations of the premium expense fairly represent the local office’s risk exposure.
- Broker: The resources that are assigned to manage the program in a local country need to be appropriately compensated. Their compensation is often determined by the premium allocated to their country. A premium allocation that does not effectively correlate to the needs of the local office has the potential to under- or over-compensate these resources.
- Insurer: Needs to satisfy regulators that oversee the insurer’s local insurance operations that the premiums are fair, reasonable and commensurate with the risks being covered.
According to Marty Scherzer, President of Global Risk Solutions at AIG, as globalization continues to drive U.S. companies of varying sizes to expand their markets beyond domestic borders, premium allocation “needs to be done appropriately and timely; delay or get it wrong and it could prove costly.”
“This rather prosaic topic affects everyone … brokers, clients and carriers,” Scherzer says. “Many risk managers with global experience understand how critical it is to get the premium allocation right. But for those new to foreign markets, they may not understand the intricacies of why it matters.”
There are four critical challenges that need to be balanced if an allocation is to satisfy all parties, he says:
Across the globe, tax rates for insurance premiums vary widely. While a company will want to structure allocations to attain its financial objectives, the methodology employed needs to be reasonable and appropriate in the eyes of the carrier, broker, insured and regulator. Similarly, and in conjunction with tax and transfer pricing considerations, companies need to make sure that their premiums properly reflect the risk in each country. Even companies with the best intentions to allocate premiums appropriately are facing greater scrutiny. To properly address this issue, Scherzer recommends that companies maintain a well documented and justifiable rationale for their premium allocation in the event of a regulatory inquiry.
Insurance regulators worldwide seek to ensure that the carriers in their countries have both the capital and the ability to pay losses. Accordingly, they don’t want a premium being allocated to their country to be too low relative to the corresponding level of risk.
Without accurate data, premium allocation can be difficult, at best. Choosing to allocate premium based on sales in a given country or in a given time period, for example, can work. But if you don’t have that data for every subsidiary in a given country, the allocation will not be accurate. The key to appropriately allocating premium is to gather the required data well in advance of the program’s inception and scrub it for accuracy.
When creating an optimal multinational insurance program, premium allocation needs to be done quickly, but accurately. Without careful attention and planning, the process can easily become derailed.
Scherzer compares it to getting a little bit off course at the beginning of a long journey. A small deviation at the outset will have a magnified effect later on, landing you even farther away from your intended destination.
Figuring it all out
AIG has created the award-winning Multinational Program Design Tool to help companies decide whether (and where) to place local policies. The tool uses information that covers more than 200 countries, and provides results after answers to a few basic questions.
This interactive tool — iPad and PC-ready — requires just 10-15 minutes to complete in one of four languages (English, Spanish, Chinese and Japanese). The tool evaluates user feedback on exposures, geographies, risk sensitivities, preferences and needs against AIG’s knowledge of local regulatory, business and market factors and trends to produce a detailed report that can be used in the next level of discussion with brokers and AIG on a global insurance strategy, including premium allocation.
“The hope is that decision-makers partner with their broker and carrier to get premium allocation done early, accurately and right the first time,” Scherzer says.
For more information about AIG and its award-winning application, visit aig.com/multinational.