Orlando, FL (WorkersCompenstion.com) – There are roughly 3,000 board certified occupational physicians in the country. With an estimated 2.8 million annual injuries, that means most of the care of injured workers is left to physicians who have little if any training – or interest – in occupational medicine.
“Nobody learns about occupational medicine in medical school.,” said Jill Rosenthal, M.D., chief Medical Officer for Zenith Insurance Company. “Students to this day think occupational medicine is occupational therapy.”
The short supply of physicians who understand concepts such as ‘mechanism of injury’ and ‘return-to-work,’ coupled with consolidated healthcare facilities with mandates that don’t necessarily steer injured workers to the most appropriate providers, and the use of telemedicine in ways that may sometimes impede best treatment is creating challenges in the workers’ compensation system. Several industry medical experts outlined their concerns and provided insights during a presentation at the NCCI Annual Issues Symposium.
The Right Physician
Getting the best outcomes for injured workers is dependent on using the right medical provider. “It really comes down to who’s the physician that gets somebody back to work,” said Will Gaines Jr, M.D., from the Department of Occupational and Environmental Medicine at Baylor Scott & White Health. “That’s the bottom line, what we’re here for and what we’re trying to do.”
Gaines, who works side by side with group health physicians, said the focus of occupational physicians is different and their approaches don’t necessarily coincide with one another. For example, his group uses an opioid risk assessment tool before ever prescribing the drugs.
Physicians who are not attuned to the benefits of RTW – for the injured worker as well as the payer – can do a great disservice. A study from Johns Hopkins that looked at high-cost workers’ compensation claims over a 5-year period, for example, found a significant impact on outcomes when physical therapy goes beyond a certain timeframe.
“If PT stays within the guidelines, 10 visits or less, it did not have a huge impact,” said Edward Bernacki, M.D., Executive Director of Health Solutions at the University of Texas at Austin, and a co-author of the study. “ But once you get up into the 15 plus [visits] range, there’s a huge cost impact of 6 times. And the lost time is really great, as bad as a person with a comorbid psychosocial condition.”
Many treating physicians don’t understand the effects on patients who are out of work for extended periods of time, the panelists explained. They don’t see the medical benefits of work.
“The last thing I want is for the patient to feel they are disabled and can’t work. I’ve seen that too much,” Bernacki said. “Doctors get that message to people too often. That leads to really big problems for families. So I always have to keep that in mind.. I’m trying to get them back at work so they feel good about themselves. So value based medicine, to me, is value to the patient.”
But sometimes providing value to the patient by getting them the right medical provider is thwarted by requirements for treating physicians to refer patients to other providers within their parent healthcare systems, even though they may not be the best fit for the injured worker. Rosenthal related a story about a Florida physician whose practice had been acquired and faced a dilemma in dealing with an injured worker with a traumatic injury. The physician wanted to send the patient to a specific rehabilitation facility that was the most appropriate for the worker.
“The hospital system that had acquired the practice had one stipulation; to only refer to their rehab facility. But [the physician] had identified that it did not have the best outcomes,” she said. “They called me and asked what to do. So these things are going on. They were not willing to do what is right for the patient, their hands were tied.”
Technology can play a vital role in getting an injured worker to the right physician; at least, in some respects. “Absolutely technology is important,” Rosenthal said. “If you can use data analytics [to determine] who is giving us the best outcomes, and who is the best to treat a particular body part … knowing the data exists to see where somebody excels or not, which facility [is best], and you can put it all together, wow! That’s the right combination for treatment.”
However, the physicians also cautioned about using technology to the exclusion of the human involvement. “The spoken word at the first visit is critical,” Gaines said. “You set that expectation with the injured worker.”
Bernacki questioned whether using telemedicine for triaging injured workers is the right approach; at least, telephonically. “I’m not so sure an interaction, electronically or by phone, when a person gets injured is really going to help in the long run,” he said. “As an occupational physician I want to see this person first and set expectation for that person to return to work as fast as possible because it’s in their best interest. So that interaction is really important. Later, down the road, checking up on them, technology is fine.”
Gaines added that there have been instances when injured workers who’ve been triaged via phone have shown up weeks later saying their care was impeded and they are angry.
“Many have been told by somebody who has never seen them, ‘this is what is wrong with you.’ And in many cases we find, no, this isn’t what’s going on,” he said. “I can go to telemedicine to help someone return to work. But on the front end, it’s a technology that has yet to be proven.”