Hospital Employee Safety and Workers’ Compensation Seminar – March 31, 2016

Minh Q. Nguyen, DO, FACOEM

VP of Medical, West – US HealthWorks

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“Anyone can practice occupational medicine, but not everyone can practice

occupational medicine right.”

CA Cost of Workers’ Compensation• In 2014, $5 billion, or 60% of total loss payments,

were for medical services.

2015 Workers’ Compensation Insurance Rating Bureau of California

Distribution of Medical Losses Paid by Physician Specialty

Estimated Average Indemnity Cost per Indemnity Claim by Accident Year

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Paid Indemnity Benefits for Calendar Year 2013 and 2014

2015 Workers’ Compensation Insurance Rating Bureau of California

Estimated Average Medical Cost per Indemnity Claim by Accident Year

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Total Paid Cost of Medical Cost Containment by Calendar Year

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WCIRB’s 2015 State of the System Report• California has the highest premium rates in the country.

California’s high rates are largely driven by the highest frequency of permanent disability claims in the country, high medical costs per claim driven by a more prolonged pattern of medical treatments, and much higher-than-average costs of handling claims and delivering benefits.

• In both 2013 and 2014, 83% of total system costs were for indemnity and medical benefits incurred on behalf of injured workers and the cost of delivering those benefits.

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WCIRB’s 2015 State of the System Report• The high cost of medical benefits in California relative

to other states is not driven by treatment costs early in the life of a claim, but rather by the length of time a claim remains open and medical benefits are paid.

• Senate Bill 863 impacts have generally been emerging consistent with initial WCIRB projections with potentially greater-than-projected savings in medical cost reductions offset in part by less-than-projected savings in reduced frictional costs.

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“Best‐in‐Class Physicians”• Clinical Outcomes

• Behavioral Outcomes

• Quality of Office Interactions

• Fulfilling Regulatory Requirements

Clinical Outcomes• Statistical Measures of Claims and Paid Data

• Claim Duration• Incurred Total Expense• TTD Days• Litigation Rates• Recidivism (re-opened claims)

Behavioral Outcomes• Communication

• Claim Examiner Satisfaction • Clear work status• Respond to questions when necessary• Request authorization when

appropriate prior to treatment or services

• Stay within the specific designated network for medical services

Behavioral Outcomes• Communication

• Patient Satisfaction• IW’s perception of the providers’ demeanor • Overcome perception of being the

“company’s doctor” mentality• Explain extent of injury and treatment plan• Defuse any anxiety of the IW toward

employer because of the injury• Gain the trust and confidence of the IW as

it pertains to treatment

Quality of Office Interaction• Staff communication with examiners

• Ease of making an appointment for IW

• Ease of checking IW in for the visit

• Physical condition of the office• Professional, healthy environment• Perception of quality

Meeting Regulatory Requirements• Reports

• Meet the requirements for submission• Complete address of all injured body parts• Must address causation in initial report and upon

request of claim examiner (AOE)• Must document physical findings on examination to

justify the work status • Subjective and objective information consistent with

work restrictions

Case Stagnation• Diagnostic studies remain pending at next visit

• No change in work status for two consecutive weeks

• No clear indication of maximum medical improvement (MMI) or plan for case progression

• Therapy sessions in excess of 24

• Refill of medication with no follow up appointment

• Temporary total disability (TTD) > 1 month

It is the responsibility of the providers to effectively manage the cases.

Requires a collaborative approach with all stakeholders.

Case Management• Be very specific regarding work restrictions in

writing and make functional work status recommendations

• Assure IW that the provider is their physician advocate for helping them to return to work

• Assure that returning to work does not mean that he/she is released from medical care

Case Management• Explain that return to work (RTW) does not mean

the claim is closed

• Put specific work restrictions in writing and assure the IW if he/she is skeptical what action to take

• Clinically-based recommendations and communicating with employer regarding their ability to accommodate restrictions

Communication (Cont.)• Occupational Medicine providers should be proactively involved in the case management

• Calls to Case Managers/Adjustors• Re-open claims/cases• Discuss needs for emergent/urgent services• Discuss denials and delays• Discuss potential concerns with employers• Alert to potential issues of litigation• Alert when subjective complaints not consistent with

objective findings

Case Study #1• 60 y/o female U/S tech presented with one month of pain to

left forearm with radiating pain to upper extremity; 30-year employee and increased work load and use of keyboard over the past four years, but progressively worse over the past month and not better with OTC meds

• Treated conservatively with meds, splints and therapy recommended for left forearm strain and lateral condylitis; patient remained on full duty

• DOI #3 – better with pain 5/10

• DOI #19 – pain remained the same and patient was started on PT

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Case Study #1• DOI #24 – no change in symptoms, reached plateau and

orthopedic evaluation was recommended

• DOI #32 – PT completed and acupuncture was recommended to help with persistent pain (acupuncture was non-certified)

• DOI #51 – initial consultation with hand orthopedics confirmed diagnosis of forearm myositis and recommended acupuncture; patient remains on full duty

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Case Study #2• 35 y/o baggage handler with back pain after pushing a cart

• DOI +5 – improving with less pain, consider full duty at next visit; up for promotion to supervisor position

• DOI +8 – 90% better and returned to full duty

• DOI +13 - 90% worse – no specific aggravating factor, started on Norco and placed on TTD

• DOI +16 – not better and MRI and orthopedic consult requested

Case Study #2• DOI +21 – chiro x6 done and not better, start PT, more

narcotics and TTD

• DOI +28 – not better, needs to travel; PM&R requested, TTD and narcotics refilled

• DOI +29 – MRI shows 5-6mm HNP with right L2 nerve involvement and also 2 mm HNP L3-4

• DOI +37 – PM&R consult and diagnosed with lumbar strain and trigger point injected and started on steroids; completed 6 PT; remains TTD and on narcotics

Case Study #2• Biopsychosocial issues?

• Clinically-based decision for TTD recommendation

• Subjective vs. objective findings

• Role of narcotics and impact on disability and cost

• Study the use patterns and claim cost impact of prescription opioids and benzodiazepines in workers’ compensation

• A cohort of 11,394 lost time claims filed with the Louisiana Workers’ Compensation Corporation from 1999 to 2002 was observed for seven years post-injury

• Results: Researchers found that benzodiazepines are almost always prescribed in combination with opioids. The odds ratios of benzodiazepines used alone, with short-acting opioids and with long-acting opioids for claims ≥$100,000, were 2.74, 4.69, and 14.24, respectively (after controlling for gender, low back pain, marital status, attorney involvement, and each other)

• Average benzodiazepine daily dose increased to year three post-injury and plateaued thereafter, whereas the average opioid dose escalated each year post-injury

• Conclusions: The addition of benzodiazepines to an opioid treatment regimen significantly increases workers’ compensation costs

Minh Q. Nguyen, DO, FACOEM, MPH, MHA, MGH

Understanding occupational medicine and working together is crucial in providing optimal outcomes for

injured workers, keeping a healthy work force and keeping workers’ compensation costs low.

Take Away Points• Use occupational medicine specialists –

accountability and ownership of the claim

• Partner with your occupational medicine provider

• Early intervention and communication

• Be proactive to ensure disability days are managed

• Be engaged with your employee – Caring Goes a Long Way

• Communication among all stakeholders – share similar goals

Questions?

Thank you

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Minh Q. Nguyen, DO, FACOEMVice President of Medical, West DivisionUS HealthWorks(619) 297-9610Minh.Nguyen@USHWorks.com