A four-point strategy drawn from successes nationwide.

Medical cost inflation solved
Published in Risk & Insurance Magazine June 2011 in slightly modified form.

I have seen the future, and it works: a future in which we lick the demon of excessive medical cost inflation. Four essential strategies, visible in at least one state and among a handful of claims payers, cry out for adoption by many.

Pain treatment costs drive claims costs today. Poor treatment also drives up indemnity costs. Every major claims payer, every team engaged in claims analysis, every lobbying arm of the business and insurance community needs to focus on executing these four strategies.

First, use state regulation and claims payer collaboration to solve the public health crisis of over-use of opioid (narcotic) pain medication. State regulation covering all over-prescribing in workers comp and healthcare is needed.

A leading architect of this strategy, Gary Franklin MD, is medical director of Labor and Industries, Washington’s state fund. His state has orchestrated a policy of education and control over over-prescribing. Part of the strategy is to mandate physician oversight where prescriptions exceed a threshold.

Other states are in effect trying to replicate this policy, but Franklin is uniquely informed about how it plays out in the workers comp community.

Workers comp payers with large market shares in states need to use their moral authority at the CEO level and their claims resources to move regulation ahead and execute the policy on a claim by claim basis.

Second, claims payers can to a lot more to document and make public the deleterious effects of a very small share of physicians in aggressive use of opioids and controversial treatment.

Alex Swedlow and his team at the California Workers Compensation Institute recently released a study with nuclear force about opioid prescribing in his state. Edward Bernacki MD of Johns Hopkins led with Larry Yuspeh of the Louisiana Workers Compensation Corporation a similar study of extreme outliers in medical treatment.

This kind of analysis, while resource-intensive, should be done. We need to document how much a very small number of outliers drive a huge share of medical cost severity, by throwing drugs, injections and surgeries onto hapless workers with no documented benefit on outcomes. Claims departments not aware of this skewing.

Third, claims payers need finally to invest in medical intelligence to develop a "supply chain" of preferred clinicians to address chronic pain issues, along the spectrum of cases ranging from early intervention to old open claims. I estimate that very roughly there today is about one truly trustworthy provider of chronic pain services to workers per million of state population – 300 in the country. Broad scale discount networks are clueless about who these people are. They also are incapable of tripling that number to where it needs to be.

Superior treaters of workers with chronic pain vary in their treatment models. While some standardization is desirable, it is not necessary. A claims payer should use physician/nurse teams to compensate for gaps in service and to link providers.

It is a rare insurer that knows these providers, systematically monitors them, and follows a proper approach for referral and compensation (this is an area of care very amenable to global fees).

Fourth, claims payers have to buy in to very close monitoring, intervention and referral. Predictive modeling is valuable in forging within the claims payer a habit of timely intervention and referral. This is a vital step to severely cuting down on unnecessary surgeries -- half of them can be eliminated -- and injection-happy doctoring.

Safeway, the grocery chain, the Kaiser’s occupational medicine program is ready to share its early intervention predictive modeling protocol, which has proven very successful. In fact, predictive models should be open source, public domain tools.

Claims payers that adopt these four strategies in their states will solve the problem of excessive medical severity.

This is a call to action.

Posted by Peter Rousmaniere at 8:30 AM | Permalink | Comments (0)

The rise and fall of leading occupational conditions.

How major change happens in workers comp
published in Risk & Insurance September 2011

In the past hundred years expansion of the concept of work injury or disease comes in surges that extend over roughly fifteen to twenty years, mobilizing advocates among medicine, law, safety and the public.

A spotlight shines upon a troublesome health condition. New safety and medical interventions promise if not to conquer, at least to greatly ameliorate the problem.

Scientific advances in understanding occupational risk and medicine cannot alone propagate and explain these surges. More influential is the full impact of popular beliefs, the peculiar rage for certainty in the workers compensation system, medical entrepreneurism, and social values.

Back pain has been around for millennia. Workers compensation law, work safety reforms and medicine in the early 20th Century enabled the rise of the concept of work-related back injury.

As the states introduced workers compensation laws, injury statistics improved greatly, uncovering for the first time minor impairments many of which were back conditions. Safety professionals began to focus upon the notion that heavy lifting was responsible. The science supporting work causality was weak and hotly disputed. Yet occupational back injuries took on the force of an epidemic.

In the late 1920s x-ray technology was introduced, and not many years thereafter the proposition was made that many vertebral disks shown by x-ray to be irregular were traumatically “ruptured” or “herniated.” This was a welcomed solution to workers compensation courts looking for a plausible explanation of how back pain could be caused at work, especially from an identifiable incident.

The orthopedic profession was ready to correct the traumatic condition. Back surgery flourished starting in the mid 1930s. Workers compensation-funded surgery remains today as a frequent intervention for persistent back pain, even though its benefits are disputed.

In the 1970s cumulative trauma disorders of the wrist and hand attracted attention of industrial unions, safety professionals and occupational doctors. After several years of moderate growth in recorded incidence, these conditions exploded in number in the mid 1980s through early 1990s. Did they fit into the legal definition of work injuries, though? Unions and many doctors adapted the term “cumulative trauma syndrome,” or CTS, as workers compensation courts began to recognize these conditions as compensable.

Testing for cumulative trauma, such as by nerve conduction studies, expanded as workers compensation insurers began demanding gold standard-like evidence.

Cumulative trauma and back injury have never lacked critics on the question of their work causality. The confluence of work and non-work factors is a perpetual Gordian knot. That has not prevented the safety profession from focusing on prevention, lawyers from litigating, and doctors from proposing the next path breaking solution.

These surges draw their sustenance in part from broad societal trends. The Depression helped to broaden concern about the plight of the injured worker. Labor disputes, mainly in the meat processing industry, publicized the extent and severity of cumulative trauma in the 1970s and 1980s.

And societal forces have been strikingly important in propagating a third surge that is today reaching its apex: the emergence of chronic pain as a second-order risk of injury.

A fundamental change in the medical paradigm for pain relief joined with drug innovation and medical consumerism to create a vast expansion of pain management for injured workers. Long-term benefit of treatment is questionable. Workers compensation courts do not have objective measures to determine the level and causality of pain. And yet treatment for pain has soared in the past decade.

This latest surge has essentially nothing to do with work, but is paid for by workers comp premiums. It reveals how much the workers compensation system is tangled up within the culture of medicine today.

Posted by Peter Rousmaniere at 9:57 AM | Permalink | Comments (0)