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Simple Ideas for a Complex System

Axioms of Medical Care

Axioms for Workers' Compensation Medical Care

by Bill Zachry, SCIF Board Member

Axioms for Workers’ Compensation medical care:

Medical care is the first and most important benefit of workers’ compensation. It is also the most expensive.

Medical care in workers’ compensation should be focused on reducing pain, recovering function, and returning the patient to full duties.

The right medical care at the right time is always in the best interest of the injured worker. It results in an earlier return to work with less permanent residual disability as well as the lowest claims costs.

Evidence-based medicine is the right care for injured workers. There is a protocol and hierarchy on how to apply evidence-based medicine to the workers’ compensation system.

One of the best and most underrated treatments to achieve full recovery is returning to work. (Light-modified duties, transitional return to work duties, or full duties).

One of the best and most underrated tools to assist recovery and return to work is an accurate job description in the hands of the treating physician and the physical therapist.

A fee-for-service system has incentives that may result in physicians over-treating the injured worker. If the worker’s compensation system uses a fee for the service system, a medical utilization review is needed to make sure that the appropriate treatment is provided to the injured workers.

Pharmacy utilization is problematic because of the “Medicalization” of the general population. Medicalization is the direct advertising of symptoms and diagnoses to the general population by drug manufacturers, resulting in an overuse and/or misuse of some types of drugs and therapies.

There is a significant “off-label use” of drugs in the worker’s compensation system. (Off Label is the use of a drug for treatment that was not the reason for its approval from the FDA)

Medical decisions should be made by medical professionals.

Google is not a medical professional. Most Workers’ Compensation Judges, attorneys, and claims adjusters have little to no formal medical training and are also not medical professionals.

Poorly (inappropriate) placed financial incentives usually result in poor medical outcomes. There are several studies that have demonstrated that allowing physicians to do self-referrals for MRIs where they own the machine or to dispense pharmacy goods from their offices usually results in the provision of unnecessary services. Every patient looks like a good candidate for an MRI when there is an MRI machine in the doctor’s office.

There are currently enough treating physicians and specialty physicians in most urban areas; however, there are not enough physicians (treating, orthopedic, or neurosurgery, etc.) in many rural areas to meet the demand. The access problem will get worse as the population ages and more doctors retire.

Many surgeons & other physicians want to perform their craft (do surgery, provide injections, etc.). They truly believe that their surgery or injections will work even if the prior treatments have not been successful or if current evidence-based medicine says surgery is not appropriate.

Not every person with a surgical or potentially surgical condition is a good surgical candidate. While pre-surgical psychiatric evaluations are required for spinal cord stimulators (post-spine surgery) the same is not true for spine surgeries, or pain programs.

Patient advocacy is the application of appropriate treatment and patient encouragement that allows the patient to remain as functional and productive as possible.

Patient Advocacy does not always mean the pursuit of the treatment a patient desires. Patient advocacy may require the physician to decline to do the treatment sought by the patient when that treatment is inappropriate.

The patient’s confidence in their treating physician and their attitude toward their treatment and recovery is the primary determinant of success.

There are many (known and unknown) underlying non-industrial, psyche/social issues in workers’ compensation that may hinder or completely stop optimum medical recovery. Comorbidities and Adverse Childhood Experiences are some of the barriers to full recovery and return to work.

The wrong attorney and the wrong doctor are the primary determinants of system failure and poor medical outcomes.

Physical medicine is one of the biggest system cost drivers. Neither claims nor the treating doctors adequately focus on managing the pt homework which is needed to obtain optimum outcomes.

If the patient has a problem with pain during the first at-home exercise the subsequently assigned exercises will not be done even if they would not have caused any pain.

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