Adjuster X

Citizen Kane

By: | March 3, 2014 • 3 min read
This column is based on the experiences of a group of long-time claims adjusters. The situations they describe are real, but the names and key details are kept confidential. Michelle Kerr is the editor of this column and can be reached at [email protected]

Cynthia Kane, 58, allegedly suffered shortness of breath due to breathing in petroleum fumes over a prolonged period. Kane had already “lawyered up,” so a statement was out of the question. Her file during her 15 years with Union Manufacturing raised no suspicions. Kane was a nonsmoker, and she had never complained to the company nurse about pulmonary problems.

I arranged to tour Kane’s work location. It was separated from the machine shop, where the actual manufacturing took place, by a floor-to-ceiling wall with glass windows. The assembly area was not particularly dirty, and I verified that the HVAC system was up to specifications and maintained twice annually.

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Kane didn’t appear to be in any distress as she did her job.

Kane’s shift ended at 5 p.m., so I returned to the plant at 4:45 that afternoon and waited in the parking lot. I followed her as she made her way home in a fairly new two-door sports car. She stopped at a dry cleaner on the way. I parked and waited nearby for 10 minutes. When she didn’t come out, I decided to
go in.

This was a large operation with the cleaning machines in the back room. There were huge fans throughout the store, but even so there was an unmistakable kerosene-like smell from the solvents used in the dry cleaning process.

At the counter, I asked the clerk about dry-cleaning bedspreads while I strained to see into the back of the store. It was evident Kane was working.

I scratched my head. Why didn’t her attorneys name the shop as a co-defendant on the claims petition? It had far greater pulmonary exposure to airborne contaminants than Union Manufacturing.

The next day, I went back to the dry cleaner and asked to speak with Kane. The flustered counter person said they had no employee by that name. I went back to the dry cleaners three more times during the next two weeks, and each time, I saw Kane’s car there.

I arranged to have a disability evaluation by a pulmonologist, who confirmed that Kane had a mild pulmonary disability (5 percent PPD rating). After reading my report, the doctor concluded the condition was not due to her work at Union Manufacturing. Kane’s attorney had a disability report rating Kane at 25 percent PPD.

I couldn’t fault Kane for wanting a part-time job to help pay for living expenses (and her sports car), but she left me no choice but to deny the claim against Union.

I called her counsel and explained that we’d have to go to trial. He was incredulous, until I explained my findings.

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“Your client didn’t tell you about her ‘under the table’ deal at Salerno’s Dry Cleaning, did she?” I asked him. “I personally observed her working there on three different occasions, and noted the smell of the dry cleaning solvent was very strong.

“I am willing to bet that exposure is the proximate cause of any pulmonary disability she has, rather than from a clean and temperature-controlled environment at Union Manufacturing Co. My examining physician agrees.”

The attorney reluctantly agreed to withdraw the petition. Kane continued to work at Union, and whether she kept her night job at the dry cleaner wasn’t my concern. A good investigation paid off and the claim against Union Manufacturing hit a snag.

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2015 NWCDC Keynote Preview

Keynote Speaker Driven to Improve Health Care

The 2015 opening keynote speaker for NWCDC is known for captivating audiences with his passion for health care.
By: | August 31, 2015 • 3 min read
NWCDC Keynote

2014 NWCDC opening keynoter speaker Dr. L. Casey Chosewood, senior medical officer and director of the Office for Total Worker Health Coordination and Research at NIOSH.

Employers and workers’ compensation payers have grown increasingly interested in delivering quality health care that mitigates the rising costs of chronic health conditions, lengthy disabilities, and stubborn claims.

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Yet determining what defines quality health care remains a challenge.

That is why the National Workers’ Compensation and Disability Conference® & Expo selected Arthur M. Southam M.D. to deliver the opening keynote presentation at this year’s event scheduled for Nov. 11-13 at Mandalay Bay in Las Vegas.

Southam is executive VP health plan operations for Kaiser Foundation Health Plan Inc. and Kaiser Foundation Hospitals. He is known for driving measured improvements in medical care quality delivered by Kaiser, which serves 9.6 million health-plan members. As a speaker, Southam is also respected for captivating audiences with his passion for health care.

“Kaiser is an organization that has achieved multiple awards in terms of clinical excellence and the highest star rating from Medicare and medical group health programs,” said Denise Gillen-Algire, director, managed care and disability in corporate risk management for Albertsons Safeway Inc., and the conference’s program co-chair.

The keynote will focus on “leveraging what organizations have been able to do on the group health side and how we can use those tools in workers’ comp, and why that is important to employers.”

“So many organizations talk about either quality-focused networks or provider quality or quality outcomes, but how do you define ‘quality’ and how do you get there?” — Denise Gillen-Algire, director, managed care and disability in cor­porate risk management, Albertsons Safeway Inc.

Kaiser is the recipient of multiple awards from a variety of organizations, including the National Committee for Quality Assurance, U.S. News and World Report’s Top Hospitals, the Leapfrog Group, and J.D. Power and Associates.

“So many organizations talk about either quality-focused networks or provider quality or quality outcomes, but how do you define ‘quality’ and how do you get there,” Gillen-Algire said. “That’s how we came to Dr. Southam for the presentation.”

Several studies from leading workers’ comp research organizations have suggested that injured workers with comorbid conditions such as diabetes, obesity, and hypertension have higher costs per claim and longer disability durations. Thus, employers and other claims payers are increasingly interested in quality health care that can help improve claims outcomes when more injured workers suffer from those conditions.

“That’s the context. So if that’s the case, how do you check the quality of your providers, hospitals, your delivery system,” said Cyndy Larsen, area vice president for Kaiser On-the-Job, sales and account management. “Dr. Southam will discuss how did [Kaiser] get from where we were maybe 10 or 20 years ago to all these outside parties — like the NCQA, Leapfrog and J.D. Power and Associates — ranking us up there. What types of things had to be in place?”

Employers need to understand the importance of employees’ overall health and its impact on the workers’ comp system. Conference organizers say Southam’s experience on the group health side can demonstrate how workers’ comp can make similar improvements that lead to better outcomes.

“Really, group health is the bigger piece of the pie, and when you think of (the nation’s) total medical spend, workers’ comp is 2 or 3 percent,” Gillen-Algire said.

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As Gillen-Algire explained, injured workers should be viewed in terms of their overall health, not just the occupa­tional injury at hand.

“That’s absolutely a focus,” she said. “You can’t split a person into pieces. A person doesn’t come to you as a 2 percent problem over here and the rest over here in group health. [It’s important to] be able to tie what organizations are doing on the group health side and why that is important for workers’ comp in employee health outcomes.”

Southam will deliver the opening keynote address, Achieving Excellence in Medical Treatment, on Wednesday, Nov. 11 at Mandalay Bay.

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at [email protected]
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Sponsored Content by IPS

Managing Chronic Pain Requires a Holistic Strategy

To manage chronic pain and get the best possible outcomes for the payer and the injured worker, employ a holistic, start-to-finish process.
By: | August 3, 2015 • 5 min read
IPS_BrandedContent

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

IPS_BrandedContent“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

IPS_BrandedContentUnfortunately, 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

IPS_BrandedContentSoft 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_BrandedContentIPS’ 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.

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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.




Integrated Prescription Solutions (IPS) is a Pharmacy Benefit Management (PBM) and Ancillary Services partner to W/C and Auto (PIP) Insurance carriers, Self Insured Employers, and Third Party Administrators who specialize in Workers Compensation benefits management.
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