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By DAN REYNOLDS, senior editor of Risk & Insurance®.

Would it be an assault on the sensibilities of modern workers' compensation professionals if one were to assert that workers' compensation claims management is more art than science?

Take the plumbing of the human mind, for example. In assessing the psychological state of an injured worker, is it a physician's conversation with an injured patient that is going to produce the best outcome or a claims manager's interpretation of traits that the individual exhibits under treatment? How bound are we by ethics and the law when it comes to interpreting data based on psychological analysis, be it abbreviated or in-depth, and in making decisions that will lead to the best outcomes for injured workers?

Cost is often a focus in managing workers' compensation claims, but for the purposes of this discussion, let's not focus on cost; instead, focus on outcomes and allow ourselves the leap of faith that cost reductions will follow if we produce humane and thoroughly adept outcomes.

"Certainly, if you are in the business of support and you are in the business of providing opiate analgesics, you will have one perspective," said Dr. Joe Pachman, a regional medical director for Liberty Mutual.

"We are in the business of returning people to work," Pachman said.

That is a fair and noble goal as stated.

With all the energy that smart people expend in monitoring and treating injured workers, it remains that analysis of the psychological piece--why a worker reacts to pain and medications in the way that she does--seems to be in an immature state within the profession.

Some simple questions asked by a physician might go a long way toward determining whether someone is an addict and might be heading down a dark tunnel were they to be prescribed opioids.

Those questions, said Dr. Phil Walls, senior vice president of pharmacy operations for Tampa-based myMatrixx, a pharmacy benefit manager, would be. "Do you drink? Do you smoke? Do you gamble?"

"Those are very basic questions, but the answer can give the physician a general idea if that person is prone to addiction," he said.

But the problem is that, as simple as those questions are, they rarely get asked, he believes.

"I don't think it is very common at all unfortunately," Walls said.

Why is that? Is it truly the nature of occupational medicine to be so narrowly focused that physicians look only at the specific injury that has sparked the claim and not at the psychological state of the person that has suffered the injury?

Bill Shaw, principal research scientist for the Liberty Mutual Research Institute for Safety in Hopkinton, Mass., said that the traditional, narrow focus of occupational physicians may be one reason that psychological testing or screening of an injured worker doesn't happen with the frequency or precision that it might.

"They are really tasked with looking at the specific work injury, and they are not really going to go looking too far for other sorts," Shaw said.

"The person may have a whole list of chronic health issues, but they are really going to look at a pretty narrow window to look at just this work injury because that is what they are being tasked with," he said.

"So I think in occupational medicine, in particular, we have a pretty focused way of looking at patients," he said.

"I think part of the barrier is that the clinicians just don't want to spend the time I think, or we don't have a system that encourages them to spend this extra bit of time," he added.

Is it that physicians don't have time to screen patients? Is it that they aren't trained in that and shouldn't be dabbling in it?

If that's true, then who does the task of analyzing the mind-body connection fall to in workers' compensation?

Maureen McCarthy, senior vice president of workers' compensation claims and managed care for Liberty Mutual, said managers in her organization have access to reams of data on patients that exhibit the yellow and red flags that signal potential addiction or an attitude about pain, a pain belief, if you will, that is outside the normal range of reactions.

You can take two people with the same injury, McCarthy said, and one can have a fatalistic, brave approach. In essence, "I will heal and I will get through this and get back to work."

And then there is another type, the type that catastrophises.

"I just don't know what I'm going to do," this person says, when afflicted with a workplace injury.

Patient No. 2 represents a yellow flag according to McCarthy and her associates. This is the person who might be having an exaggerated reaction to pain, might be seeking to avoid pain at all costs, and could be a danger either for a prolonged absence from work or an excessive appetite for pain medications.

Either way, someone to watch, interact with and guide, McCarthy said.

"It is more about securing information and being able to recognize information as it is coming into the claim that some of these catastrophising beliefs exist in the injured worker," McCarthy said.

"It may be as simple as putting a nurse on the case and getting out there and having good dialogue with the injured worker."

"Or even getting to their provider and saying, 'This person seems to be having some issues dealing with the realities of their workers' comp claim,' " she said.

Liberty Mutual's Shaw and his colleagues have studied the variations that can exist in an injured workers' state of mind and the implications of that state of mind on workers' compensation issues like opioid addiction and speed of returning to work.

Using a 16-item questionnaire, Shaw and his team concluded that 90 percent of low scorers on the questionnaire returned to work within a month.

Among high scorers on the questionnaire, only about 40 percent returned to work within a month.

These traits--things like catastophising pain and extreme pain-avoidance behavior--can be tracked.

What remains to be done, Shaw said, is to find a way to communicate these traits to the caregivers in a way that will stick.

"So we are at a point now in the research of trying to translate this large body of research into useful tools, and though it sounds like on the medical clinician side it would be a relatively easy thing to do, it is surprisingly difficult to imbed this kind of psycho-social line of questioning with our traditional bio-medical evaluation of things like low-back pain," he said.

This is exactly what must be done, and it is where pharmacy benefit managers and others are going to be able to provide the true value to their clients going forward, said Jim Andrews, senior vice president of pharmacy solutions for Atlanta-based Healthcare Solutions.

Andrews' company can track opioid use and give a client the heads up that an injured worker is consuming a questionable amount of painkillers.

"I'm not playing policeman. I'm not playing 'gotcha.' I am just saying that, if you have a lot of claims files in front of you and I send you an alert, this would require you to create some teamwork with our medical management team," Andrews said.

Andrews introduces another nuance in the effort to understand the link between psychology and pharmacy use and return to work issues in workers' compensation. He calls it "pseudo-addiction," drug-seeking behavior that centers around mere possession of the drug. This can take the form of hoarding and buying medications from various sources to make sure there is a mind-comforting stockpile nearby.

"I don't think everybody truly understands that this is not a sign of a physiological addiction. It is more of a sign that you are very concerned psychologically that somebody is going to deprive you of the necessary medications in the future," Andrews said.

Like Shaw, Andrews believes plenty of work needs to be done to create a better connection between what a pharmacy benefit manager like him sees in his data and how a treating physician is looking at a patient.

"What we don't have is a good bridge on something that requires someone to personalize this, to reach out to a provider and make sure everyone is on track to make sure that what they are seeing is what you are seeing," Andrews said.

September 1, 2011

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