Category Archives: Inspiration

Patient Engagement in Workers’ Compensation

This article was published on WorkCompCentral’s Work Comp World. Click here to link to the article.

The call to increase patient engagement to inform the development of standards and policies is gaining traction. The development of these standards ultimately helps improve health outcomes in workers’ compensation, and other health care influenced industries. Efforts to consistently collect and incorporate patient perspectives into the scientific process is becoming a priority for many. This is welcome news to all patients and patient advocates!

How important is patient input to ensuring the best possible health outcomes for ill or injured workers?

Understanding the importance of patient involvement in the composition of evidence-based Guideline Development Groups (GDG), The National Academies of Sciences, Engineering, Medicine (formerly the Institute of Medicine (IOM), included the requirement of patient input as one of its eight Standards for Developing Trustworthy Clinical Practice Guidelines in 2011. The standard directs guideline developers to incorporate patient involvement, at least, when formulating clinical questions and reviewing Clinical Practice Guideline (CPG) drafts. Former patients, patient advocates, or patient / consumer organization representatives qualify to participate in the GDGs under this requirement.

Accordingly, the requirement of patient involvement is included in AHRQ’s National Guideline Clearinghouse’s (NGC) assessment of submitted guidelines’ adherence to the academy’s standards of trustworthiness. Patient and public perspectives, along with multidisciplinary group participation and methodologist involvement, is measured by the NGC when grading the content developer’s GDG composition.

The newly energized push for patient engagement is prompting content developers aiming to align with National Academy standards to improve methods for soliciting, receiving, and incorporating patient and public input into the content development process. The American College of Occupational and Environment Medicine (ACOEM) accepts patient, and other stakeholder, input through an online portal to assist the development of its evidence-based medicine practice guidelines.

Patient Engagement beyond Content Development

Notable recent activity from the Food and Drug Administration (FDA) includes assembly of a Patient Engagement Advisory Committee (PEAC). A statement issued by the FDA explains the committee exists to support its efforts to broaden engagement with patients and deepen patient involvement in the administration’s regulatory activities.

More specifically, the initiative will seek patient perspectives for use across medical device design, clinical trial process, and post market evaluation. Additional guidance on patient preferences, such as tolerance of risk and patient point of view on benefits, will be used by the FDA to assess device benefit-risk profiles.

The administration can consider the systematically gathered patient preference information, in conjunction with its assessment of scientific evidence that demonstrates a device’s probable benefit outweighing its likely risks, to form its complete grouping of clinical and non-clinical testing.

Workers’ Compensation Continues its Efforts for Patient Engagement

Very few venues exist in workers’ compensation that facilitate direct engagement between industry vendors and patients. Perhaps the most visible platform today is WorkComp Central’s Comp Laude® Awards & Gala. Event participants advertise that Comp Laude’s most memorable moments typically occur when patients are involved in panel discussions. Event organizers have voiced their excitement about the overall positive impact patients have on the industry get-together.

Stemming from the mission and vision of the event’s late founder David DePaolo, Comp Laude® created a scholarship intended to create a path for direct engagement between the industry and its patients. The scholarship provides travel funds and covers lodging expenses along with conference registration for the patient and a guest. Several vendors, among them ReedGroup, are honored to have the opportunity to be sponsors of the scholarship fund.

Many have criticized the workers’ compensation industry for its numerous shortcomings, myself included. While it is important to acknowledge the industry has more work to do in the pursuit to increase patient engagement to improve health outcomes, it is equally important to acknowledge the progress gained by organizations whose corporate point of view regularly advocates for patients and their well-being. For this, the industry should be complimented.

Removing Friction from California’s Workers’ Compensation System

The California workers’ compensation system has been buzzing with activity since the passage of AB 1124 in 2015 requiring the Administrative Director of the Division of Workers’ Compensation to establish a drug formulary as part of the state’s Medical Treatment Utilization Schedule (MTUS). The addition of the formulary, in concert with the impending updates to various treatment guidelines (following the new expedited process set forth in SB 1160), in MTUS will improve the system by:

  • increasing the use of evidence based care administered to patients therefore reducing the inappropriate prescription of dangerous drugs and inappropriate medical treatment;
  • reducing system friction by providing a common standard to base medical decisions for injured workers at every step in the care and claim continuum.

California Code of Regulations and Presumptive Weight

Perhaps my day-to-day exposure to regulations and legislative text is what drives my “geeking out” on the code. I have actually heard highly influential people say, “no one pays attention to the labor code”, or “no one cares about what the regs state”. Comments such as these just don’t make any sense.

Admittedly, regulation text can miss the mark if stakeholder input is not considered. Real-world experience and wisdom must inform the process that is expected to turn the gears of the workers’ compensation industry. Absent sound and constructive input from the marketplace, regulations run the risk of being detached from the day-to-day needs of the system and all of its stakeholders.

In California, the Division of Workers Compensation’s Administrative Rules emphasize the state’s commitment to injured workers and their employers by defining what may well be the most critical of expectations – that the best available evidence be used to guide clinical decision-making. The state’s commitment to injured workers and their employers is again emphasized by the thorough analysis that was conducted to inform their selection of the content source that powers the MTUS’ treatment guidelines and drug formulary.

The outcome of the state’s thorough analysis of multiple treatment guidelines and drug formularies lends great weight to the state’s assignment of the MTUS (and the platform that provides the foundation for the MTUS, the ACOEM Practice Guidelines and Drug Formulary) as being the “go-to” source when treating ill or injured workers in the California market:

§ 9792.21 Medical Treatment Utilization Schedule.

(c) The recommended guidelines set forth in the MTUS are presumptively correct on the issue of extent and scope of medical treatment. The MTUS constitutes the standard for the provision of medical care in accordance with Labor Code section 4600 for all injured workers diagnosed with industrial conditions because it provides a framework for the most effective treatment of work-related illness or injury to achieve functional improvement, return-to-work, and disability prevention. The MTUS shall be the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers.

Assigning this weight to the MTUS prioritizes the use of its treatment guidelines and drug formulary above all other sources. In doing so, MTUS becomes California’s primary language of communication for all workers’ compensation system stakeholders. Understanding that on occasion secondary sources may be needed to form a comprehensive foundation for evidence base care, California’s Division of Workers’ Compensation defines a very clear path (through its Medical Evidence Search Sequence) for introducing standards not found in the MTUS. This path should only be taken after the MTUS is considered (see charts below).

More Than Claims and UR Tools

California’s endeavor to establish the tools contained in MTUS as the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers is based in the realization that in order to meaningfully improve the friction in the workers’ compensation system, MTUS must be the guiding source for treatment from day-one.

The treating physician’s initial interaction with the injured worker is paramount to accomplishing favorable health outcomes. The dialog between doctor and patient not only sets appropriate (or inappropriate) medical expectations, it ultimately shapes the trajectory of the claim – smooth going, or friction-filled. This is the point where evidence based care is most effective and necessary.

Retrospective efforts to get a run-a-way claim train back on track are perceived as detrimental to employee benefits by employee advocacy groups. Deviating from or challenging a doctor’s orders, even when informed by the highest-grade of evidence-based medicine, can be an invitation for friction. Disparate standards of care introduced outside of the established path (Medical Evidence Search Sequence) further widens the gap among stakeholders and adds friction to the process.

Opponents of Sound Patient-Centric Medicine

Sound patient-centric medicine will always have opponents – opponents by commission and opponents by omission.

Misaligned interests are present in numerous verticals of the industry. Opponents by commission are identifiable by their persistent off-center messaging in the marketplace. Their message intends to deemphasize what the State has created as a standard; they work to obfuscate what is otherwise a clear path to scientifically based standards for optimal care. Their interest is driven by personal gain, forgetting that a conflict-free, good working system that produces optimal health outcomes benefits everyone.

In some cases, opponents do not see themselves on the opposing side of sound medicine. Opponents by omission are parties that remain neutral when confusion is intentionally sown into the marketplace by the aforementioned. I often question, are opponents of sound patient-centric medicine unware, or are they indifferent to the friction they invite by their lack of action?

California’s success in removing friction from its workers’ compensation system hinges on all of the state’s stakeholders committing to work from the same standards and speaking the same language. Anything short of this type of cooperation is both counter-productive and an affront toward the collective effort to produce improved health outcomes for California’s injured workers.

Aides from Dr. Raymond Meister, CA DWC Medical Director

*Complete presentation deck is available at http://ccwcworkcomp.org/ccwc/assets/File/2017%20Conference/PPT%20Presentations/4_1%20Implementation%20of%20SB1160.pdf.

MTUS Online Education

http://www.dir.ca.gov/dwc/CaliforniaDWCCME.htm

Inspiración en el Sistema de Compensación de Trabajadores Lesionados

La inspiración lleva a la gente a hacer cosas increíbles, a veces cosas atípicas. En raras ocasiones, la inspiración mueve a la gente en su núcleo y activa el comportamiento y la creencia, que no es característico para ellos. Cada cuatro años, la inspiración moviliza a millones de ciudadanos en esta nación para que se reúnan detrás de unas cuantas personas que ellos creen que los van a inspirar.

Las instituciones religiosas, organizaciones no comercial (educativas, basadas en las salud, políticas, etc.) y empresas de comercialización del sector privado con éxito usan como arma la influencia de la inspiración para reclutar el apoyo y la inversión necesarios para cumplir sus misiones definidas. Efectivamente, las organizaciones de ventas más exitosas construyen sus imperios sobre una base de inspiración, inyectando a sus representantes copiosas cantidades de la euforia adictiva.

Si la inspiración es de hecho un tan poderoso conducto de acción, ¿existe una parte constructiva que pueda desempeñar en el mundo de el sistema de compensación de los trabajadores lesionados? Un mundo sostenido por cuerpos rotos, muchas veces oscurados por la moral derrotada, y en casos raros, confiscados por un carácter en bancarrota.

Estudio tras estudio, pilas sobre pilas de datos científicos, se ha verificado la realidad de que los elementos no fisiológicos (psicosociales) tienen un impacto significativo en el retorno a la función de lesión / enfermedad fisiológica. Mientras que los pagadores, proveedores, reguladores, empleadores y abogados debaten sobre la conveniencia, y la necesidad médica de los protocolos de tratamiento diseñados para abordar los elementos fisiológicos, los psicosociales muchas veces no se observan mientras que conducen al paciente por un camino rico en sedación, pero pobre con mejoría funcional.

Sentado en un centro de convenciones lleno de gente, con 2,000 otros trajes, me inspiró recientemente un panel formado por un presidente americano de dos períodos, un proveedor / líder del cuidado de la salud de Baltimore, y dos adictos en recuperación de medicamentos recetados. Su peregrinación a la salud provocó una fuerte creencia de una realidad alternativa del systema de compensación de los trabajadores lesionados; una realidad donde los esfuerzos colectivos de las partes interesadas / accionistas en el sistema realmente podrían ayudar a las personas heridas o enfermas volver a la función severed y esfuerzo productivo y revertir una epidemia que demuestra ser más proficientes en matar que los accidentes de vehículos de motor y armas de fuego.

Me pregunto a mí mismo, ¿podría este mismo tipo de inspiración ayudar a impulsar al famélico de motivación, el quien esta roto en cuerpo y en la mente, regresar a una vida productiva después de una lesión o la enfermedad en el lugar de trabajo?

¿Cómo respondería a la inspiración el arduo ensamblador de gabinetes, padre de cuatro hijos, ganador primario de su hogar, con tres dedos cortados (el que experimenta dolor constante porque se niega a ingerir los narcóticos recetados)?

Tal vez estoy exageradamente sensacional; tal vez no…

Why Standards Matter

I had the privilege of attending the AASCIF conference for the first time, hosted in Oklahoma City this year. I was honored to have so many in the state compensation insurance fund community express support of our organization’s efforts to elevate evidence-based medicine (EBM) and advocate for the improvement of the quality of medical care to injured workers.

One conversation left a lasting impression. A well-known workers’ compensation veteran verbalized discomfort with some of my topical write-ups on EBM, trustworthy clinical guidelines, and my willingness to name certain commercial guidelines publishers in hopes of encouraging accountability. They echoed the conflict-free mantra, “There is enough room for all EBM treatment guidelines in workers’ compensation.”

A thought immediately consumed me:  My point of view is based on standards that are not defined by me, or my employer (also a commercial guidelines publisher), but standards that were developed independently by a non-interested not for profit entity at the request of the U.S. Congress looking to establish best methods used in developing clinical practice guidelines. The goal was to ensure such guidelines have information on approaches that are objective, transparent, scientifically valid, and consistent – the ideal basis of accountability for the clinical guidelines industry.

What is at Stake?

The statistics are sobering. Treating providers experience challenges in the clinic. A 10-year study conducted by a medical consultation firm found that nearly a fifth (~21%) of medical diagnoses in workers’ compensation claims involve errors costing the injured worker prolonged disability and household financial distress.

Workers’ compensation only covers a portion of the earned income and there is usually a ceiling, typically 66% of pre-tax earnings up to the state’s average weekly wage. Lost time from work for the injured worker due to injury or illness means loss of income. According to a study by the Washington State Department of Labor and Industries (2015), injured workers with less than 3 months of lost time lose an average of 3.5% of earning capacity over a 10-year period. Conversely, lost time of 3 to 12 months produces losses of income of approximately 11.6%; 28% loss in earnings is experienced after a 3-year absence due to workplace injury or illness.

Another study published in January 2017 looked at ~1.9 million short-term disability and workers’ compensation claims investigating for absences where prescribed opioids were contrary to a leading EBM drug formulary’s recommendations. The study estimated 57,000 (~3%) claims were found to have had an opioid prescribed that was either moderately or strongly not recommended in the formulary. The study also discovered approximately 133,000 (~7%) claims where prescribed opioids were contrary to the formulary recommendations for disorders of the peripheral nervous system including ulnar nerve lesions and carpal tunnel syndrome.

The challenges experienced in the care and claim continuum are plentiful and very difficult to navigate. Employees, employers, insurers, and medical providers deserve content measured and deemed trustworthy according to non-bias standards to guide injured workers through these challenges and on to recovery.

Thought-Leaders Stand Up

With the deep knowledge base and hands on experience of how quickly a workers’ compensation claim can go into free fall toward catastrophic health and recovery outcomes for the injured worker, why aren’t more “thought-leaders” taking a closer look at the status quo to identify inadvertent, or unintended, consequences and voice opportunities for improvement in their respective areas of expertise? Why is accountability viewed as a negative for industry report and the cost to the individual worker is almost intentionally ignored?

There may be enough room for all EBM treatment guidelines in workers’ compensation. However, there should never be room for vendors to profit from poorly constructed products that are dangerous to the well-being of injured workers and subsequently cost employers a lot more time and money.

Leading “comp-sters” have a duty to encourage accountability in the spirit of preserving the heart of the Grand Bargain, where the employee and the employer are center of the discussion. In cases where benefits and quality of medical care suffer from intendedshortcuts, or vendors falsely representing the basis of their products, accountability should not be viewed as bad for the industry rather it should be viewed through the eyes of an injured worker trusting they will get better.

Weekend Read: Catching Feelings

Being an emotional person by nature (as many are) and knowing this about myself, I consciously work to keep my personal feelers (my 3 year-old daughter’s word for feelings) and views from being the only filter I see the business world through. A college mentor once made a very strong and lasting impression on me when explaining her view about how to show you care in a business context:  Showing you care in your business life is not as different as you might think [as in your personal life].

A big overlap in both settings that I’ve experienced is that verbal affirmation is not enough. In other words, don’t just speak about it; be about it.

Speaking the words “I care” must be followed by action and commitment. In my day-to-day business life, honesty, trustworthiness, reliability have all been great staples of ways to show my colleagues that I care about them and their contributions to the business community. It has only recently become very real to me that QUALITY and ACCOUNTABILITY are such great, tangible ways to say, “I care” to my internal and external customers.

QUALITY

It is easy to let a corporate marketing department do all of the talking about the quality offered by your firm. Most large organizations have very robust marketing operations to reach the masses at multiple levels; massive marketing efforts don’t just happen at the mainstream level, some of the best marketing happens at the grass roots level (individual email/phone campaigns, etc.).

When you “get down to nitty-gritty” (in my best Nacho Libre voice), does the service or product your offer measure-up to clearly defined quality measures? Can someone who is an expert in your line of work look “under the hood” of your vehicle and see the time (and financial) investment you’ve made to provide a best in class value/experience?

If you answered these questions with a resounding YES, invite deep dives and thorough analysis of your process and final product. Meeting and exceeding your industry’s highest quality measures is a great way of saying, “I care” to internal and external clients alike. Passing the test of quality is truly speaking with your actions and not just your words.

ACCOUNTABILITY

Being subject to the test of quality also says, “I care” through accountability.

Even in an industry founded in the spirit of fairness and cooperation like Workers’ Compensation, the industry’s evolution has given birth to a host of interests that routinely clash due to misaligning goals/incentives (or the perception of misaligned goals/incentives). Communication is as valuable as an oil gusher spewing crude richness hundreds of feet in the air from a Texan well and as scarce as volcanic lightning. Accountability is the great equalizer desperately needed to create balance among system vendors, whose inception (some may say) can be attributed to the apparent chaos and disconnect, to ensure the wellbeing and recovery of injured workers remains the epicenter of their efforts.

Can an industry say, “I care” any better way than to keep its shareholders and stakeholders honest and focused on the participants it was designed to protect through accountability?

Accepting accountability is the actionable way of saying, “If I can do it a better way, I want to do it better way.” Settling for the status quo or resisting growth and progress is detrimental to the success of the industry as a whole and a major obstacle for accomplishing its primary objective(s).

Please hear what I’m saying, I’m not opposed to growing profits or implementing efficiencies wherever possible. When profits and efficiencies come at the cost of quality, it is not worth the effort and could derail already established success.

Investment in quality and being open to accountability are ideal tangible ways to say, “I care” in business terms. People in the business world may not always care how you feel, but they will always respect and appreciate the quality you offer and your openness to accountability.

Physicians, A Patient’s Ultimate Advocate

The healthcare landscape has experienced significant evolution over the past few years. Group Health, Occupational Health, and everything in between has been materially affected by rules and regulations where the patient is not always the central focus of the implemented standards; other stakeholders’/shareholders’financial interests take precedence over patient recovery and preserving the importance of the physician’s role as the patient advocate becomes an afterthought. Healthcare as a whole, must return to a place where clinicians are the drivers of clinical decisions for their patients.

An excerpt of Dr. Linda Girgis’s (MD, FAAFP/Family Physician; New Jersey) book, The Healthcare Apocalypse (CreateSpace Independent Publishing Platform (April 7, 2016), included in her blog “Patients, Stand Up for your Right!” speaks to the weakening of physician participation in determining the outcome of patient recovery (http://drlinda-md.com/2016/05/standupforyour-rights/). Dr. Girgis brings up two examples that translate well into Workers’ Compensation:

  1. Being prescribed a medication for a specific condition only to be denied by the pharmacist and told that the insurance company does not cover that particular drug.
  2. Ordering an MRI only “if the patient needs it” and challenged downstream by an insurance adjuster using a “predetermined set of guidelines” as the basis for the challenge.

Both scenarios above are frequent occurrences in the world of Workers’ Compensation; both scenarios encounter show stoppers (the pharmacist and the adjuster) that have never seen or even spoken to the patient. Their influence on the outcome of the patient’s recovery now supersedes the physician’s influence.

The shift of influence is a byproduct of over-zealous entities placing claim on thefinancial value of healthcare and on the other side of the spectrum, sincerely concerned stakeholders are over compensating to regulate bad-acting physicians (think of the doctors who are overprescribing opioids and rampant over-utilization of other treatment/diagnostic testing) while stifling patient-centric practitioners. The answer lies somewhere in between with physicians marrying their expertise with scientific evidence to deliver the highest quality care to their patients and SPEAKING UP when show stoppers misappropriate credible evidence.

Doctors are in a unique position to advocate on behalf of patients, and they must.” (Linda Girgis, MD, FAAFP)

A physician’s clinical expertise and direct line to the patient are the ideal foundation to build on. Provided with the right tools at the point of care and a patient-centric focus, a provider is the only party involved in the process with all of the pieces in hand to make sound, informed treatment decisions to usher the patient back to health.

A physician can be, and must be, a patient’s greatest advocate.

Weekend Read: Celebrate Every Win

The 2016 Annual Issues Symposium by NCCI was a great experience in a number of ways. There were many memorable moments and important themes were discussed by a great cast of presenters; there was an abundance of soundbites generously dispersed by speakers to appeal to every personality type.

A memorable moment for me was hearing Bill Donnell, President & CEO of NCCI, kick off the conference and challenging attendees to be more vocal and make known the good happenings in Workers’ Compensation – bring more awareness to the things that are working well and fulfilling the goals of the Grand Bargain. Essentially, celebrate every win.

I was impressed and encouraged by the examples of companies that have experienced significant improvements in their Workers’ Compensation outcomes as a result of vigorous focus on Safety/Injury Prevention as well as compassion-driven, patient-centric Workers’ Compensation processes.

Iron Mountain, the nation’s leading data and document management company, improved its cost output in Comp claims from $14M in 2008 to $9M in 2014. The numbers in and of themselves are impressive. However, the metric is more impressive when you realize that the material impact is a combination of prevented injuries and injuries that occurred, but were handled optimally and returning the employee to health much faster than in prior years.

“Our system can, and does, achieve the goals of the Grand Bargain,” Donnell asserted.

A recent write up pointed out that Workers’ Compensation has “lots of caring, dedicated people who want to make a difference” and are, in fact, making a difference. Sharing these success stories will motivate, and hopefully mobilize, other members of the Workers’ Compensation eco-system to strive toward progress and challenge the status quo for the benefit of the people served by the system.

Donnell correctly stated, “We remain a system under the lens of a microscope.” Opponents of Workers’ Compensation don’t have to go far to hear a contradicting point of view about the effectiveness of the system. And while I don’t argue that the timing is right to revamp, and somewhat modernize, the Grand Bargain, I do not believe it is entirely dead or irrelevant.

A good parallel can be drawn here: We spend the majority of our time working/toiling with complex claims that represent a small percentage of the overall claim volume. Similarly, we consume the majority of our time dwelling on the things that are wrong with the system paying very little attention/time to the things that are right (and significantly outnumber the former).

I agree with Bill Donnell: We need to do better at celebrating every win. Every win should represent a person’s health restored.