Workers' Compensation: The Difficult Ten Percent

Clinical Corner

July 2014

Studies have shown that only 10% of the Workers’ Compensation cases account for almost 90% of the cost. Thus, dealing with the difficult ten percent more effectively could really result in substantial cost savings. These difficult ten percent are not the people with the most severe injuries. Rather, this small but significant population consists of people who continue to feel pain after their tissues have healed. In the U.S., 550 million sick days are lost annually due to dysfunctional pain syndromes among the working population.

Changing the usual approach, and using a model of disease management that recognizes psychosocial issues, even during the initial evaluation of injured workers, can greatly improve outcome and satisfaction with care in these cases.

Patients, who have subjective complaints out of proportion to objective findings, are suspected of malingering. However, it is more appropriate to view these persistent complaints as a maladaptive reaction to what has happened to this person, in which the patient uses an injury as a solution to a problem.

All disease and injury are disruptions not only on a physical or cellular level, but also on a personal and social one. The purely biological model of disease that is typically used has not served well.

For many years, low back pain has been treated as a predominantly physical problem caused by the physical demands of the job such as heavy lifting and repetitive bending. Industry has responded by introducing ergonomic improvements and educating employees about proper lifting techniques. Despite this, low back disability has increased at a higher rate than other disabling conditions. This suggests that low back disability is not due solely to the physical factors in the workplace, but is instead a more complex problem that is influenced by job satisfaction, economic factors, psychosocial reasons, and labor management issues.

There is evidence that some people are prewired to develop a dysfunctional way of dealing with injury and pain. When we are born, the connections (synapses) between the neurons in our brain are not fixed. The density of synaptic connections increases during infancy, and reaches its maximum by the age of two. At that point, it is 50% higher than in adults. Between the ages of five and sixteen, synaptic activity declines. The connections that persist are the ones that are activated and stimulated by our experiences.

Individual who have a lot of painful experiences at an early age develop very entrenched pain pathways. Later on in life, they actually feel more pain with a given stimulus than someone who does not have as many entrenched pain pathways. They are not wimps or malingerers. They really do feel pain out of proportion to what those of us who do not have such entrenched pain pathways would feel with the same injury.

How all the players in the Workers’ Compensation system treat these patients has a great impact on prognosis. The physician has a major influence on how patients understand their problem. Being aware of that, the physician should intervene when a patient starts to show dysfunctional ways of dealing with an injury. With a change in management strategies, the physician can help the patient move forward instead of heading down the slippery slope to chronic pain.

To do this, the physician has to give up the role of “healer” and become a “rehabilitator.” The doctor has to accept the fact that he or she is not going to “fix” the patient. It is that person’s way of dealing with pain and not tissue injury that is the problem.

The physician has to focus on function and not on pain. He/she must focus on what and how much the patient is doing and not how much an injury is hurting. It is also important for employers, supervisors, and insurance adjusters not to look on this patient’s pain as a moral failing. It only makes the situation worse to compare the injured worker who is not getting better as quickly as anticipated with others who got better faster following a similar injury. It is tremendously helpful for the employer and the treating physician to communicate, and to work together so as to get these workers to a healing plateau as expeditiously as possible.

As frustrating as this difficult 10 percent can be for physicians, employers and insurance carriers, they just happen to be the group where appropriate management strategies can have the greatest impact on decreasing the costs of Workers’ Compensation injuries. If we meet the challenge of handling these problematical cases well, it can be a win-win-win situation for everyone.

Maja Jurisic, MD, is the Medical Director for National Accounts at Concentra.

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A Strong Partnership

President's Message

March 2014
Although I’ve only been Pinnacol Assurance’s new president and CEO for a few months, I’m already certain of two things: Pinnacol has a long history as Colorado’s leading provider of workers’ compensation insurance, and I am humbled and proud to be leading a company that is doing so much for Colorado employers and their employees. I'm also pleased to know that we have such a strong network of medical providers who help ensure that the nearly 40,000 injured workers Pinnacol serves annually receive compassionate care for their workplace injuries.

As you know, the world is changing at lightning speed, and all of us must anticipate and adapt to changes as they come. One of my most important roles as CEO is to identify where Pinnacol needs to be in the future so we can continue to grow and thrive as a company. One area I have identified is to create a new position - vice president of medical operations and healthcare strategy.

Nearly 46 percent of the cost of each claim – about $180 million last year - is spent on injured worker medical care. Hiring a new executive leader with specific strategic and medical operations experience will help strengthen our partnership with you – our valued medical provider partners. It will also help ensure the well-being of injured workers and provide us a competitive advantage as well as the opportunity to be on the front end of trends that are affecting our industry. We will do a national search for this position and I will keep you apprised of its progress.

On behalf of everyone at Pinnacol, I want to thank you for your continuing support. I’m looking forward to finding new ways to make our partnership even stronger and I hope that you will share your thoughts and ideas with me in the days and months ahead so we can all work together to make Colorado the best place to live, work and grow a business.

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Clinics Achieve Summit Elite Designation

Featured Story

March 2014
Two Thirds of the 5-Star Rated Clinics Achieve Summit Elite Designation
At the conclusion of the fifth Clinic Performance Initiative (CPI) appeals period, updated star ratings were posted in the SelectNet directory, viewable by external customers. Pinnacol’s medical operations team is pleased to announce the primary care physicians (PCP) clinics awarded the highest performance rating available — five stars — in CPI.

Results obtained from the data set published on December 3, 2013 show that 10 of the 15 PCP clinics that achieved the five-star rating qualified for the Summit Elite Designation.

The Summit Elite Designation recognizes those clinics that maintain a five-star rating for two consecutive rating periods. The Summit Elite are:

Aviation & Occupational Medicine, Denver
CCOM Canon City, Canon City
Colorado Occupational Medicine, Denver
Exempla Green Mountain, Lakewood
Exempla Northwest, Westminster
High Country Healthcare, Silverthorne
OnSite Injury Care Inc., Colorado Springs
PVMG Occ Health, Fort Collins
Union Medical PC, Lakewood
Workwell Occupational Medicine, Fort Collins

In addition to the Summit Elite members, the following clinics reached a five-star rating for the metric period ending June 30, 2013:

CCOM North Denver, Westminster
CCOM South Denver, Littleton
Colorado Mountain Medical, Edwards
Colorado Mountain Medical, Vail
Integrity Urgent Care PC, Colorado Springs

We congratulate each of these outstanding clinics, and we thank you for your hard work and commitment to provide excellent care and service to our mutual customers.

CPI achievements allow injured workers to experience an improved service environment, policyholders to make informed designated medical provider selections, and high-performing medical clinics to take advantage of performance rewards and marketing opportunities. For a complete list of PCP clinic ratings and performance information, visit the online SelectNet provider directory.

If you have any questions regarding the CPI program, please contact Pinnacol’s medical operations team at 303.361.4945, and speak to the provider relations specialist assigned to your geographic region of Colorado.

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Save the Date for the 2014 SelectNet Conference

Corporate News

March 2014
2014 SelectNet Conference: Managing Workplace Injuries
Pinnacol Assurance is offering two medical conferences in 2014 – in Denver on Friday, June 27, and in Grand Junction on Wednesday July 23.

These conferences are free to invited SelectNet providers, and participants will receive continuing medical education (CME) credits.

Online registration opens on May 5. Watch your email for details. Registration is first come, first served, as space is limited for both locations.

Please contact your provider relations specialist with any questions.

We look forward to seeing you at one of the conferences!

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Keep Up To Date on Legislative Issues

Corporate News

March 2014
With Colorado's 2014 legislature in session, the Workers' Compensation News and Issues Network (WCNIN) website is your go-to resource for information about any bills affecting workers' comp, along with Pinnacol's position on those bills. Please take a few minutes to visit the site, learn more about its content and subscribe to receive alerts.

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Electromyography (EMGs) as a Diagnostic Tool

Clinical Corner

March 2014
Contributed by William H. Cooper, M.D.
Diplomat American Board of Electrodiagnostic Medicine
Durango Neurology, P.C.
Board Certified Neurologist
The advantage of properly evaluating neuromuscular disorders is that an appropriate diagnosis can be determined without having to resort to more invasive studies. The most important evaluation begins with the history and a physical of a patient. Another technique that is extremely helpful when used correctly is electromyography (EMG). Unfortunately, EMG is frequently ordered in isolation (i.e., an EMG of an arm or a leg for numbness/weakness) which may not be useful and quite costly. The best practice for ordering an EMG is to already have a diagnosis in mind and only use the EMG to confirm clinical suspicions.

Weakness can originate in the muscle, the nerve or the neuromuscular junction. It may not represent a peripheral problem. It could be on a metabolic basis or misinterpreted spasticity, such as from a myelopathy or hemiparesis. It may be a manifestation of a totally unrelated problem. For instance, I admitted a fifteen-year-old straight from the EMG lab to a psychiatric unit because her foot drop was a result of her anorexia and loss of the fat pad from marked weight loss. If the referring physician had looked at the entire patient and not just her foot drop, her treatment could have been initiated earlier.

Motor neuron disease, myopathies, and movement disorders (such as Parkinson's) are often missed by the referring doctor because these are relatively uncommon entities. In motor neuron disease, if suspected, a minimum of at least three extremities should be reviewed for acute and chronic changes in the setting of increased reflexes or multiple blocks in multifocal motor neuropathy. In myopathies, the changes can be subtle and easily missed if the proximal muscles are not studied carefully. Entities such as inclusion body myositis can have both myopathic and neuropathic changes, simultaneously. Peripheral neuropathies cannot be reliably diagnosed if only a few nerves are studied. While radiculopathies and entrapment neuropathies can present with pain or numbness, multiple other processes such as problems in the joints, soft tissues, immune system, metabolic disorders, and even mechanical or overuse syndromes can present in a similar manner.

Limited techniques such as nerve conductions or surface EMGs have been marketed to primary care doctors, therapists and others to assist in screening for “abnormalities.” These studies have no value in untrained hands and result in unnecessary procedures which may lead to critical delays in diagnosis. Random information can be more confusing than helpful. For example, MRIs may detect multiple abnormalities and create confusion rather than point to a correct diagnosis. Often, the initial MRI is of the wrong area and the patient has to undergo yet another procedure.

In summary, EMG is useful in the evaluation of peripheral nerve and muscle disorders but only when used as a piece of the entire evaluation. An EMG that is applied appropriately can be not only clinically expedient but also cost-effective.

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Psychological Evaluation Referrals

Workers' Comp Coordination

March 2014
Contributed by Daniel Bruns, Psy.D., and Dawn Jewell, Psy.D.
When Are Psychological Evaluation Referrals Appropriate?

Colorado's workers’ compensation system uses the biopsychosocial model for the assessment and treatment of injured workers. This model has increased in popularity over recent years by providing what is believed to be better care for less cost. Chronic pain treatment guidelines developed by both Colorado1 and the American College of Occupational and Environmental Medicine (ACOEM)2 make clear recommendations about when these evaluations should be made.

Colorado’s workers’ compensation guidelines recommend a psychological evaluation for all patients with chronic pain or delayed recovery, as well as prior to lumbar fusion, back surgery if Waddell signs > 2, artificial disk surgery, spinal cord stimulation, discography, facet rhizotomy, IDET, some cervical and shoulder surgeries, chronic opioid therapy, and biofeedback.

It might be helpful to consider the role of psychological evaluations in two different scenarios: lumbar fusion and chronic opioid therapy. In a study of lumbar fusion patients, although successful fusion occurred in 84% of the patients, half of the patients were dissatisfied with surgical outcome, and 38% were totally disabled at follow-up.3 Thus, in many cases, surgical outcome can be simultaneously an orthopedic success and a behavioral failure. Even when fusion occurs, patients may report continued dissatisfaction with outcome (verbal behavior), and exhibit pain behaviors and disability (overt behavior).

Due to the close relationship between psychological variables and surgical consequences, it is not surprising that psychological assessment is more accurate than MRIs in predicting surgical outcome.4 An added valuable reason to make a referral is to save money; in contrast to fusion surgery or a spinal cord stimulator, behavioral treatments for pain are vastly less expensive, have lower risk, and in many cases have very similar outcomes.5

Another indication for psychological evaluation is prior to chronic opioid therapy. Empirical studies have determined that more Americans die from unintentional prescription opioid overdose than from heroin and cocaine use combined6, and that psychiatric disorders are a primary predictor of opioid abuse.7 Almost all guidelines recommend psychological evaluation prior to prescribing opioids long-term, as identifying patients at risk for opioid overuse early in treatment can reduce the risk of severe problems later on.7

It may also be helpful to explore psychological referrals from an intuitive perspective. Much of the time, making a referral for a psychological evaluation can come down to your clinical impression that the symptoms do not make sense medically. When there is no objective medical explanation, there is often a psychosocial explanation. When you suspect that nonmedical factors (such as depression, somatic preoccupation, or a strained workplace environment) are influencing the progress/outcome of the case, a psychological evaluation might help to determine what is interfering with recovery, and help you develop a plan for addressing the problem.

While select patients require surgical intervention, and following surgery, opioids are the consensus treatment, selecting the best treatments for a patient with a chronic condition is one of the physician’s most challenging tasks. A psychological evaluation can provide you with a better understanding of your patient’s risk factors, and knowing a patient’s psychiatric vulnerabilities can reduce the risk of iatrogenic complications down the road.


1. Colorado Division of Workers' Compensation. Rule 17, Exhibit 9: Chronic Pain Disorder Medical Treatment Guidelines. Colorado Department of Labor and Employment: Division of Worker Compensation 2012.
2. American College of Occupational and Environmental Medicine. Chronic pain treatment guidelines. 2nd ed. Beverly Farms, Mass.: OEM Press; 2008.
3. LaCaille RA, DeBerard MS, Masters KS, Colledge AL, Bacon W. Presurgical biopsychosocial factors predict multidimensional patient: outcomes of interbody cage lumbar fusion. Spine J. Jan-Feb 2005;5(1):71-78.
4. Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J. Jan-Feb 2005;5(1):24-35.
5. Bruns D, Disorbio JM. Assessment of biopsychosocial risk factors for medical treatment: a collaborative approach. J Clin Psychol Med Settings. Jun 2009;16(2):127-147.
6. Centers for Disease Control and Prevention. CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic. Morbidity and Mortality Weekly Report (MMWR) 2012; Accessed August 9, 2012.
7. Nuckols TK, Anderson L, Popescu I, et al. Opioid Prescribing: A Systematic Review and Critical Appraisal of Guidelines for Chronic Pain. Ann Intern Med. Nov 12 2013.

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Winter Injuries: Get the Whole Story

Featured Story

October 2013
Thorough medical reports are the best tools for evaluating and treating injuries.
With winter just around the corner, medical providers — as well as Pinnacol Assurance’s claims and medical staff — can expect to see more common winter injuries and ensuing workers’ compensation claims.

Typically, these include:

Certainly, all of these injuries can and do occur on the job. But winter — especially here in Colorado — can create hazardous conditions anywhere: home driveways, sidewalks, supermarket parking lots and more. Additionally, many of the outdoor winter activities that so many Coloradans enjoy are inherently risky, including skiing, snowboarding and snowmobiling.

Ascertaining the mechanism of injury
As in all injuries, winter injuries require a methodical examination approach to determine not just the severity of the injury and appropriate course of treatment. Confirming the mechanism of injury — i.e., what actually happened — is critical for knowing if an injury is work-related, pre-existing or an exacerbation of a previous condition.

Pinnacol Nurse Specialist Audra Cruz explains that Pinnacol’s staff relies on thorough, detailed medical reports in determining the mechanism (and severity) of any injury, as well as treatment guidelines.

“We rely on all sides of the story, particularly the observations and expertise of our medical providers,” said Cruz. “It’s essential to know as much as possible about the injury and the injured worker’s medical history to manage the claim and treatment effectively.”

Here are some things for providers to keep in mind for preparing thorough medical reports:

Does it all add up?
In the end, does the mechanism of injury match the diagnosis? Sometimes, an unlikely story (e.g., a knee injury suffered by simply “walking up stairs”) might have a more probable explanation, such as a recent weekend of hard skiing.

In all cases, include all relevant information in your reports, and be sure to highlight and/or explain any areas of interest so your points are clear to Pinnacol staff.

“This information is used for so many claims decisions, from treatment protocols to potential work restrictions and establishing financial reserves to cover potential claims costs,” said Pinnacol Claims Specialist Kathy Duncan. “Our goal is always to evaluate claims fairly and accurately. The more detailed information providers can give us, the better we can do our jobs.”

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Addressing Prescription Drug Abuse

From Pinnacol's Medical Director

October 2013
Pinnacol Assurance supports and is participating in the launch and one-year strategic plan development of the Colorado Consortium for Prescription Drug Abuse Prevention. The kick-off meeting of the Consortium took place Sept. 24, 2013, at the University of Colorado Skaggs School of Pharmacy. As we are unfortunately aware, Colorado is ranked as the second-worst state in the United States for prescription drug abuse, with more than 255,000 residents misusing prescription drugs. Deaths due to prescription drug misuse have increased fourfold between 2000 and 2011.

In response to this drug misuse epidemic, Colorado established the Consortium to provide a framework for cooperation among health care providers, professional organizations, academic institutions and state agencies to develop and implement a one-year strategic plan that includes public awareness, prescriber and provider education, improved effectiveness of the Prescription Drug Monitoring Program safe drug disposal and treatment. In fact, the coordination and collaboration that Colorado has developed to address prescription drug abuse have been presented to the National Governors Association and is a key component of Gov. Hickenlooper’s Colorado Plan to Reduce Prescription Drug Abuse.

The Consortium has been tasked with lowering the current 6 percent prevalence rate of drug misuse to 2.5 percent by the year 2016. This reduction would prevent 92,000 Coloradans from misusing prescription drugs. The Consortium will be working to meet specific quarterly goals in each of the six work group areas and produce a specific Colorado Plan in one year. As Pinnacol’s medical director, I serve on the Provider Education work group, which is tasked with developing a plan for effective dissemination of information regarding best practices around prescription drug management. One of the six work groups created by the Consortium, the Provider Education work group has 16 members comprising representatives of the Colorado Medical Society, Colorado health agencies, providers, academic organizations and insurers. During the first quarter of 2014, the work group is expected to create an evaluation plan of the progress in provider education.

I again want to express my appreciation to SelectNet providers who work with great professional skill to care for injured workers and manage their pain medication requirements according to the best medical practices.

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