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This Gordian knot of physical and psychological hurt is found in claims that account for half of the entire cost of workers' compensation claims.

It is extremely tempting for a claims payer to simulate a victory by isolating an attribute, for instance brand narcotic usage, and then rummaging around for some metric that appears to report an improvement, such as reducing treatment expenses.

Let's look at lumbar fusion surgery, performed to reduce the patient's pain symptoms by limiting range of motion. This surgery permanently fuses a section of the spine's lumbar vertebrae. Roughly half of back surgeries on injured workers are of this kind. And yet the research literature is very skeptical of it.

An effective approach would engage treatment guidelines, doctor coaching, patient coaching, and the courts.

Phil Denniston, president and CEO of the Work Loss Data Institute, tells me that the Official Disabilites Guidelines' summary recommendation on this treatment has not really changed much over the years. It is recommended only for uncommon back pain diagnoses. An article written by Trang Nguyen for the journal Spine, compares lumbar fusion outcomes with nonsurgical cases. She found that 76 percent of fusion patients continued to use opioids, at higher doses than before surgery, and they had much worse return-to-work rates than nonsurgical cases.

These kinds of findings fail to turn off most lumbar fusions for several reasons, as explained by David Deitz, medical director of Liberty Mutual. Some jurisdictions do not authorize utilization review and workers' compensation judges may not want to contradict the surgeon when a denial is appealed.

A challenge the medical directors run up against is that the patients often are not properly prescreened for surgery. Workers with prior back pain, Deitz said, those who are older, who have psychological problems, whose claim is litigated, and who use opioids, have a lower chance of a successful surgery.

Medical directors also typically try to have the worker, prior to surgery, referred to a program of conservative care, one that will address physical and psychological issues.

Finding these programs is difficult, but they may be the only setting to ensure that the patient is coached properly, medications are adjusted (probably downward) and a nonsurgical plan, recommended as best practice, has a real chance.

Chronic pain challenges us in ways we are unused to. We need to educate the medical community and to support the growth of superior medical practices. The long-term cost of reliance on large fee discount networks, which effectively discourage education and provider development, shows up in the high cost of chronic pain.

No medical professional group has the incentive, much less the resources, to articulate a vision of how chronic pain among injured workers should to be treated. And there is also the aggressive marketing by surgical implant manufacturers.

If many claims payers united to promote best practice, and if state regulators strongly endorsed such a campaign, then we'd be in better shape.

PETER ROUSMANIERE is an expert on the workers' compensation industry.

October 15, 2010

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