ProviderPulse

Obesity and Workers' Compensation

From Pinnacol's Medical Director

November 2014
Contributed by Edward Leary, MD Medical Operations, Pinnacol Assurance

A well-known national epidemic, obesity, has an adverse impact on workers and the workers’ compensation system in Colorado. The National Institute for Occupational Safety and Health has been devoting increased attention to the overall health of workers as an essential component of health promotion and health protection. Obesity reduction by improved nutrition and increased physical activity is a priority for workers, employers and the workers’ compensation system.

A peer-reviewed article on this topic was authored by Duke University Medical Center. Obesity has long been recognized in general health insurance as a risk factor contributing to overall mortality and chronic diseases such as cancer, diabetes, cardiovascular disease, and musculoskeletal disease. However, data which addresses the impact of obesity on workers’ compensation rate of claims, lost work days, medical claims costs, and indemnity claims costs has not been as widely available. It has been documented in general health insurance that obese patients have 21 percent higher health care costs compared to patients with recommended weight, but what does data reveal from workers’ compensation?

A Duke University study obtained body mass index (BMI) data from a worker’s initial health assessment and divided the cohort into five categories: underweight (BMI <18.5), recommended weight (BMI 18.5-24.9), overweight (BMI 25-29.9), obese class I (BMI 30.0- 34.9), obese class II (BMI 35-39.9) and obese class III (BMI > 40.0). The study then went on to compile medical costs, indemnity costs, body part affected, nature of the injury, and cause of the injury. There was a clear linear relationship which demonstrated marked adverse outcomes which became progressively worse with the increasing obesity associated with each successively heavier cohort. The claims rate metric being twice as great for the heaviest cohort compared to the rate for recommended weight employees.

The Duke University study demonstrated that the relationship between BMI and other metrics was even stronger; number of lost work days being 13 times greater, medical costs 7 times greater and indemnity costs 11 times greater when comparing the BMI obesity class III to recommended weight employees. In addition, there was a correlation between the heavier BMI cohorts and injuries to the back, arm, neck, shoulder, and lower extremity. Claims caused by lifting, falls or exertion were also greater as the BMI category increased to greater obesity. This study shows a linear relationship between obesity and adverse outcomes in all metrics related to a worker’s injury.

Is research uncovering any new insights? In the June issue of the Journal of Occupational and Environmental Medicine, an article was published which studied cohorts of progressively severe obesity and the perception of poor health in firefighters. The results of this national study showed a strong association between greater levels of obesity and a firefighter’s conviction of being in poor health. Further, this correlation was not linear but rather a “J” shaped curve with the higher levels of obesity producing disproportionately larger belief in their poor health by firefighters. Overall, obesity produces greater injury rates, poor clinical recovery and cost metrics, and it also is a contributor to poor outcomes due to the underlying belief that the workers are in poor health.

Continued research on the physical and psychological impact of obesity as well as closer integration of general health care and workers compensation care is necessary to achieve improved health for Colorado workers.

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X-STOP or Laminectomy for Spinal Stenosis?

Featured Story

November 2014
Contributed by Dr. Sanjay Jatana

Spinal stenosis is a narrowing of the space for the nerves and/or the spinal cord. It can occur developmentally and as part of the aging process of the spine. When it occurs in the lower (lumbar) part of the spine, the symptoms of spinal stenosis can include pain radiating to the legs (sciatica), a heavy feeling in the legs when walking, numbness and tingling sensations. Patients often say that it becomes more difficult to walk longer distances. Sitting can help the symptoms temporarily and leaning over slightly helps them to walk further.

We can establish a diagnosis of spinal stenosis if the patient has a history of these leg symptoms. Even if a physical examination appears totally normal, imaging such as x-rays, an MRI or a CAT scan can help us confirm the diagnosis. Sometimes non-surgical treatment options like modifying physical activity, taking anti-inflammatory medications such as Advil or Aleve or spinal injections can help. Depending on the degree of stenosis (mild, moderate or severe), the success rates of these non-surgical options can vary. In other words, if one has moderate to severe spinal stenosis and symptoms are progressing, then the non-surgical options will likely only provide temporary relief.

When surgery is necessary, the standard operation is a laminectomy, where we remove the bone and the ligaments of the spine from the back. Recently, we have seen some new, less invasive options developed to address symptomatic spinal stenosis. These include the X-STOP and other competitive devices. The concept is to place a spacer in the back of the spinal column. The spacer indirectly wedges open space between the vertebrae and makes more space for the nerves and the channels, helping to decrease or eliminate the symptoms of spinal stenosis.

A recent study comparing the success of the laminectomy as compared to the new surgical procedures showed mixed results. Patients with either procedure improved significantly and in a similar fashion, but more X-STOP procedure patients (26 percent) needed additional surgery when compared to the group that had the decompression alone (6 percent). The study also found that in 22 percent of the X-STOP patients, the symptoms did not improve. They required removal of the implant and conversion of the decompression.

While the X-STOP procedure is less invasive, patients should be aware of the high probability of repeat surgery.

Sanjay Jatana, MD
Board Certified Orthopaedic Surgeon
Fellowship Trained in Spine
jatanaspine.com

jatanaspine is a partnership in Denver Spine Surgeons, LLC
Main: 303.697.7463 I Fax: 303.783.1200

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Useful Functional Capacity Evaluation

Workers' Comp Coordination

November 2014
Contributed by Mary Hamilton, OTR Return to Work Specialist, Pinnacol Assurance

A Functional Capacity Evaluation (FCE) is a systematic process of assessing an individual’s physical capacities and functional abilities, and it is used to establish the physical level of work an individual can perform. The treating provider often requests an FCE when an injured worker reaches the conclusion of medical treatment and relies on the information in the report to determine permanent work restrictions, which often have legal and/or occupational consequences. Without a reliable FCE, this can be a bit like looking into a crystal ball. Yet not all FCEs are created equal. Useful and dependable FCE conclusions depend on the components of the evaluation and the skill level of the evaluator.

A thorough FCE that provides meaningful conclusions is based on a job description and includes a musculoskeletal screen, strength testing, cardiovascular tolerances and work simulation.

Before the testing starts, the evaluator must choose the appropriate tests to collect pertinent data that will lead to well thought out and meaningful conclusions related to the injured worker and his job. A job description will guide these choices. The entire testing protocol should be tailored specifically to the individual who is being evaluated.

A musculoskeletal screen establishes range of motion and movement patterns and assures the evaluee’s safety. It also provides an opportunity for distraction-based testing to observe for consistency of verbal reports compared to actual demonstrated ability.

Strength testing determines a person’s work level (sedentary, light, medium, heavy, or very heavy). It is a central component of most FCEs as the results can make or break the future occupational career. Ability to lift on an occasional basis and on a frequent basis should be tested separately. Frequent lifting ability should never be determined by a formula or by extrapolation. Lifting must be thoroughly tested and considered against effort tests and reliability of verbal reports in order to assure accurate outcomes.

Cardiovascular testing (MET testing) reveals whether the person’s cardiovascular capacity supports the ability to work in the tested work level. For example, a person who has the strength to lift in the heavy work category must also have the cardiovascular capacity to support that level of work.

Work simulation provides important information about a person’s ability to return to their job. Based on the job description, the work simulation portion of the test assesses positional tolerances that are critical to the job in question, such as sitting, standing, reaching or dexterity. Sufficient time must be allowed to determine a person’s ability to sustain the posture or task, if necessary.

A primary concern throughout the evaluation process is whether the evaluee is giving full effort, often referred to as “validity”. Some FCE protocols call for an isometric grip test to offer validity information, leaving the evaluator to offer an opinion of a person’s effort based on one single test. Reliable protocols, however, call for a battery of effort tests that include isometric tests, behavioral tests and cardiovascular investigations, as well as clinical observations. Effort tests only reveal a person’s inclination to give full effort, and are not meant to identify those who may be imitating an injury. Low-effort findings, often called invalid testing, do not prove a person is imitating an injury. A thoughtful, skilled evaluator uses all of the resources at his disposal to provide an unbiased effort assessment.

Tests that reveal how well verbal reports match actual behavior will tell how much one can rely on the injured worker’s reports of pain. This is done through various self-report tests, and clinical observations. A thorough FCE includes this type of testing and the skilled evaluator will consider the results when putting the whole picture together.

In the world of industrial rehabilitation there are many FCE products that promise to make the evaluation process quick and easy. Several protocols promise to automate the process, choosing the testing protocols, calculating the results and creating the conclusions. Critical thinking skills are not required by the evaluator because these protocols drive the conclusions, requiring little more than a technician to operate the tests. Clearly, a reliable FCE is more than scientific data communicated by charts and diagrams, but rather requires a highly trained and skilled evaluator to offer well thought out conclusions.

Conscientious interpretation of the data distinguishes the professional, thinking evaluator from a technician, or even the automatically-produced conclusions offered by computerized protocols. Skill levels of FCE evaluators vary from the novice to the expert level.

A skilled evaluator demonstrates the training and expertise required to offer thoughtful outcomes and is essential to provide useful, meaningful and accurate evaluation outcomes. There is no doubt that a knowledgeable evaluator has the option to use computer programs and computerized equipment as tools to complete the task of evaluating a person, but they should be considered only as tools in the hands of the skilled practitioner.

FCE outcomes often have far-reaching legal and occupational consequences. Thorough testing by a well-trained, knowledgeable evaluator is essential to deliver accurate, unbiased information to the physician who will determine permanent work restrictions. With so much riding on the outcome of an FCE should we ask for anything less?

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Cost Containment: Average Wholesale Price

Clinical Corner

November 2014
2014 Workers’ Compensation Drug Trend Report

© 2014 Progressive Medical and PMSI

Prescription drug inflation in Average Wholesale Price (AWP) continues to follow an upward trend, growing by 7.8 percent this year. For brand medications, the percentage increase of AWP inflation averaged 13.3 percent, whereas the percentage of AWP inflation for generic medications increased by 0.7 percent.

Analysis shows that the AWP for many top brand medications grew at a rate of approximately 20 percent, including Celebrex®, Cymbalta®, and Lyrica®. Brand formulation Percocet® grew by 24 percent this year, consistent with its pattern of regular increases in AWP since its release on the market. Other brand medications whose price grew over 20 percent include Exalgo® (23 percent), Fentora® (21 percent), and Amrix® (54 percent). It appears pricing for Exalgo may be following the trend of other medications that have had a substantial increase in the AWP prior to the release of a generic alternative.

Also contributing to the 13.3 percent inflation in brand AWP are new medications that entered the market; for example Khedezla® a serotonin-norepinephrine reuptake inhibitor (SNRI) and Zubsolv® which is used for opioid dependence.

With respect to generic medications, in 2013 the inflation rate of 0.7 percent is higher than reported in our previous drug trend reports. Comprising the highest percentage of our overall generic drug spend, hydrocodone/APAP (the direct generic alternative for brand name Vicodin® and Norco®), had an inflation rate of 6 percent. The therapeutic class of muscle relaxants also had meaningful inflation in AWP. An example of this is metaxalone (the generic for Skelaxin®), which grew at 7 Percent. As this document goes to press, additional medications continue to show increases over prior years. For example, the direct generic alternative for brand name Percocet® and Endocet®, oxycodone-acetaminophen 5 mg-325 mg has increased by 220.7 percent, oxycodone-acetaminophen 7.5 mg-325 mg by 87.5 percent and oxycodone-acetaminophen 10 mg-325 mg by 94.6 percent. Growth in prices for these products may be traced to the Food and Drug Administration initiative to limit the amount of acetaminophen to 325 mg per dosage unit in opioid combination products by 2014. Another potential reason for these price increases may be the country’s push to decrease the use of opioid analgesics, yielding to economic supply and demand forces. Others have also postulated such increases are due to the changes in health care law and the uncertainties associated there within.

Regardless of the cause, the continued development in AWP inflation for both brand and generic medications is largely beyond the payer's control. The ability to effectively mitigate the influence of out-of-network bills and both compounded and specialty medications is one way payers may experience cost savings. A proactive mail order program may also serve to lower costs.

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Study: Who prescribes more opioids?

Clinical Corner

November 2014
Nurse practitioners and physician assistants wrote more opioid prescriptions for injured workers in 2013.
Read more about this trend and the “2014 Drug Trend Report”, which reviewed more than 300,000 claims and combined results of the pharmacy programs of Westerville, Ohio-based Progressive Medical Inc. and Tampa, Florida-based PMSI Inc.

Pinnacol Assurance is committed to raising awareness about the risks involved with taking painkillers. Not only can this type of drug abuse make it harder for an injured worker to return to work, it can affect the injured workers’ recovery period. We believe that with education comes prevention. Learn more about the role nurse practitioners and physicians assistants play in the opioid epidemic, according to the 2014 Drug Trend Report.

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Announcing New Pinnacol Vice President

President's Message

August 2014
In the last issue of Provider Pulse, I told you that one of my first actions as Pinnacol’s new CEO would be to search for a new executive leader with specific healthcare and medical operations experience. That search is now complete and I am happy to announce that we have hired Karyn Gonzales as Pinnacol’s new vice president of medical operations and healthcare strategy.

Karyn is coming to us from Catholic Health Initiatives where she is currently the national director of clinically integrated networks and has played a key role in the development of population health management and accountable care capabilities across all of CHI’s markets. With more than 20 years of healthcare experience, Karyn is the ideal choice to take on this new role. Her knowledge of the healthcare industry will help us ensure the well-being of injured workers and will guarantee that we are on the front end of medical trends that impact workers’ compensation. In addition, her experience working with providers and developing population health management capabilities will help ensure that Pinnacol has the expertise needed as we explore this new area of opportunity. Karyn began her duties on July 31.

On behalf of everyone at Pinnacol, thank you for your support. The healthcare industry is undergoing enormous changes – from the Affordable Care Act to the organization and payment of medical services. That is why our partnership with you is so critical as we work together to strategically improve health outcomes for Colorado workers.

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Treating Eye Injuries: An Overview

Featured Story

August 2014
-Submitted by Ronald E. Wise, M.D.

Eye injuries are common at work. Common sense and the use of protective eyewear can reduce the frequency of such injuries. When an acute eye injury occurs, the injured worker should be evaluated by a medical professional within 24 hours and referred to an ophthalmologist, if necessary.
All moderate and severe chemical eye injuries require an immediate ophthalmic consultation. The first step in the appropriate management of mechanical eye injuries demands an understanding of eye trauma terminology. There are different ways of describing an eye injury and using a common classification system, such as the Birmingham Eye Trauma Terminology, avoids confusion.

The eye wall refers to the cornea and the sclera.

A mechanical insult to the eye can result in a:

A closed globe injury can result in an:

An open globe injury can result in a:

All open globe injuries must be immediately referred to an ophthalmologist.

At work, the most common injury referred to an ophthalmologist is a retained corneal foreign body. I have personally removed over 1,500 corneal foreign bodies, and we are in the process of retroactively reviewing my data to provide prognostic and management guidelines for this common occupational injury.

My current protocol involves the following:

A full ophthalmic exam, including a slit lamp examination with eyelid eversion, dilated fundoscopy, and slit lamp photograph.

In conclusion, occupational healthcare providers should feel comfortable removing corneal foreign bodies. You must remove all the foreign material and warn your patients of the potential for vision loss related to their injury. Refer central corneal foreign bodies to an ophthalmologist.

Ronald E. Wise, M.D.
Assistant Professor Cornea and External Disease, Cataract and Refractive Surgery
Medical Director University of Colorado Eye Center at LoDo
Department of Ophthalmology University of Colorado School of Medicine

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End of Seventh CPI Reporting Period

Corporate News

August 2014

On June 30, 2014, Pinnacol’s Clinic Performance Initiative (CPI) reached the end of its seventh data collection period.

This milestone represents a collection period that began Jan. 1, 2014, and concluded June 30, 2014. It also marks the onset of the one-month data compilation period, followed by a 45-day appeals period.

Additional information regarding the CPI appeals period is being sent to participating clinics, via email and U.S. mail, in mid-July. It is important that clinics thoroughly review this material and be prepared to view their CPI scores beginning Aug. 1. Clinics will have 45 days from this date to appeal disputed data and seek adjustment to clinic scores. Pinnacol must be notified of any data concerns no later than 5 p.m. on Sept. 15, 2014.

Following the completion of this formal appeals period, CPI star ratings and performance results will be shared, via the SelectNet directory, with outside parties, including Pinnacol policyholders. The results will also be used to determine any applicable performance rewards. CPI data will not be changed once a reporting period’s appeals timeframe has expired and the resulting data has been shared with outside parties.

The CPI will continue to be used for the primary care providers (PCPs) but will no longer be available for the specialists in the SelectNet network after the Jan. 1 to June 30, 2014 metric period. Separate notifications were sent to the affected SelectNet network specialists on May 30, 2014.

If you have any questions regarding Pinnacol’s CPI or the upcoming data appeals period, please contact the medical operations team at 303.361.4945 and speak to the provider relations specialist assigned to your contract.

Important dates related to the CPI’s third data collection and reporting period:

If you have questions about this article, please send an email to selectnet@pinnacol.com.

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The Difficult Ten Percent

Workers' Compensation Coordination

August 2014

-Submitted by Maja Jurisic, MD

Employers rightfully have concerns about the cost of medical care for injured workers. Yet, from my experience over the years, most of the injured workers I see are treated and discharged from care in less than three weeks, and have fewer than four physician visits.

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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