Announcing New Pinnacol Vice President
August 2014In 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.
Treating Eye Injuries: An Overview
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.
The eye wall refers to the cornea and the sclera.
A mechanical insult to the eye can result in a:
- Closed globe injury is when there is not a full thickness wound of the eye wall, or an
- Open globe injury when there is a full thickness injury to the eye wall
A closed globe injury can result in an:
- Ocular contusion from blunt trauma to the eye or a
- Lamellar or partial thickness laceration of the eye wall with or without a retained foreign body, such as a corneal foreign body
An open globe injury can result in a:
- Laceration of the eye wall which is a full thickness wound from a sharp object. This might involve a retained intraocular foreign body (IOFB), or a penetrating injury where there is an entry wound only or a perforating injury where there is an entry and an exit wound or a
- Rupture of the eye wall caused by a blunt injury
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.
- Consent for foreign body removal to include documentation of potential for loss of vision.
- Removal of all foreign body material under slit lamp.
- Application of antibiotic and patch the eye.
- Antibiotic eye drops to be initiated the following day after patch removal.
- Follow up examination one day post foreign body removal.
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
End of Seventh CPI Reporting Period
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:
- End of seventh reporting period: June 30, 2014
- Start of one-month data compilation and preparation period: July 1, 2014
- Start of performance data appeals period: Aug. 1, 2014
- End of performance data appeals period: Sept. 15, 2014
- Update to SelectNet directory display of performance result star ratings: September 2014
- Performance rewards payout: October 2014
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The Difficult Ten Percent
Workers' Compensation Coordination
-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.
Acute Inpatient Rehabilitation for the Injured Worker
-Submitted by Jill Castro, M.D.
Many workers’ compensation injuries are treated and resolved in an outpatient setting. However, there are times when more catastrophic work-related injuries occur that require not only hospitalization, but further intensive rehabilitation to progress to the outpatient setting, and then to MMI.
These may include polytrauma such as multiple fractures, amputations, traumatic brain injury, spinal cord injury, or stroke. Once the injured worker is medically stable, there are options for further medical treatment to advance independence. Inpatient Rehabilitation Facility (IRF) can play an important role in patient’s recovery.
There are a few types of post acute rehabilitative services available to address the needs of the injured workers: IRFs, skilled nursing facilities (SNFs), long term acute care (LTAC) and home health services (HH). SNFs, along with PTs, OTs, and possibly SLPs, provide an inpatient setting for ongoing medical care but at less intensive level of care and at about three to five hours per week. Similarly, HH provides therapy and nursing services, if needed, at the patient’s home, but again at a lower intensity without the benefit of the advanced technology used to address balance, strength and gait disturbances. LTACs are designed to treat those with more serious injuries that require further long term care such as those intubated on ventilators.
IRFs offer ongoing medical care with oversight by a physical medicine and rehabilitation specialist, 24-hour nursing care by RNs in addition to CNAs, RTs, and physician face-to-face management at a minimum of three days per week. Multi-disciplinary medical management is available and includes consultation by internal medicine, neurology, psychology, infectious disease specialists, and others depending on the needs of the patient. Therapy intensity is a minimum of three hours per day or 15 hours per week. Team conferences measuring function and discharge planning occur weekly.
The benefits of transitioning to an IRF after severe injury compared to an SNF include shorter length of stay, higher rate of discharge to community (81% vs. 46%), lower re-admission rate (9% vs 22%), and no increase in FFS spending by Medicare from 2004-2010 for IRF stays. Further, IRFs have the benefit of admitting patients not only from the acute hospital stay but also from home, if failing after discharge from LTAC, as they improve medically and are able to participate in more therapies. They may also be admitted directly from the treating physician’s office or from the emergency department if demonstrating functional deficits but not critical enough to admit to the hospital setting.
Thus, for those complex medical injuries in the workers’ compensation setting, inpatient rehabilitation is a great option for advancing medical, physical, and cognitive function in combination with re-integration back to the community.Jill Castro, M.D., Medical Director, HealthSouth Rehabilitation Hospital of Denver
Dr. Jill Castro is a board certified physiatrist who serves as the medical director of the new HealthSouth Rehabilitation Hospital in Littleton, CO. Dr. Castro is a graduate of Texas A&M University and received her medical degree from the University of Texas. She went on to complete a physical medicine and rehabilitation residency and fellowship at the University of Texas / Baylor College of Medicine. In addition to performing electromyography and nerve conduction studies for diagnosis of neuromuscular disorders, she is a level II certified treatment provider for the Division of Workers’ Compensation in Colorado. She has been in practice for over eleven years in the Denver area, and enjoys spending time outdoors with her husband and four girls.
HealthSouth Rehabilitation Hospital of Denver is a new inpatient acute rehabilitation hospital (IRF) that opened May 2013. HealthSouth’s freestanding 40 bed hospital offers all private rooms, specialized programs and spacious rehabilitations areas to accommodate state-of the-art treatments and technologies. For more information, please visit www.healthsouthdenver.com or call 303.334.1111.
Unless another source is noted, the data cited in this document are drawn from the Medicare Payment Advisory Commission’s March 2011 Report to Congress, June 2011 Data Book and Dec. 16, 2011 Commissioners Meeting; and SNF Final Rule.
From Pinnacol's Medical Director
The Effect of Physician-Dispensed Medications on Workers' Compensation Claim Outcomes
Physician dispensing of opioids and other prescriptions can have a negative impact on workers’ compensation outcomes including higher lost time, higher medical costs and higher indemnity costs.
During my tenure as Pinnacol’s Medical Director, I have personally encountered cases of clinical care for injured workers that have been adversely impacted by prolonged dispensing of medications by physicians’ offices. The Colorado Division of Workers’ Compensation (DOWC) Rules and Regulations specifically state that long-term pain medication shall be provided through a pharmacy. In addition, a pharmacy management program has built-in safety guards that identify multiple prescribers, multiple pharmacy vendors and, in the case of narcotic prescriptions, reporting of medication usage to the Colorado Prescription Drug Monitoring Program (PDMP). Pinnacol also encourages pharmacy dispensing, and the Pinnacol Provider Agreement states that physician office-dispensed medications be limited to a fourteen day supply. There is outcome data that supports limitation of physician office-dispensed medications.
The lead article in the May issue of the Journal of Occupational and Environmental Medicine provides an insightful discussion regarding this topic. Even though it is recognized that there could be confounding variables when attempting an outcomes comparison between workers receiving physician-dispensed versus pharmacy-dispensed medications, the authors used regression analysis to achieve a 95 percent confidence interval. They accounted for sex, age at accident, medical complexity and attorney involvement in their outcome comparison between workers who received physician dispensed versus pharmacy dispensed medication. The authors further compared outcomes between injured workers who received physician office-dispensed opioid prescriptions versus pharmacy-dispensed opioid prescriptions.
The authors, Jeffrey A. White, MS, et.al, begin by noting that every state in which physician dispensing is permitted has reported a rapid increase in quantity and cost of prescriptions. In fact, in five large states, physician-dispensed medications accounted for approximately half of medication expenditures. The authors note that a 2013 California Workers’ Compensation Institute study demonstrated a 16.4 percent higher medical cost and a 6.9 percent higher indemnity cost when claims involved physician-dispensed medications. For the study group that forms the basis of their article, the authors studied outcomes of 6,842 workers’ compensation claims in Illinois that opened and closed between January 1, 2007, and December 31, 2012. In Illinois, the percentage of prescriptions dispensed by physicians had increased 26 percent from 2007 to 2008, and 43 percent from 2010 to 2011.
After statistically adjusting the comparison groups so that a 95 percent confidence level was obtained, there were significant differences between the two groups.
- The average amount of lost time based on all prescribed medications was 64 days for pharmacy-dispensed versus 85 days for physician-dispensed.
- The average amount of lost time based on opioid prescriptions was 66 days for pharmacy-dispensed versus 122 days for physician-dispensed.
- The number of prescriptions dispensed was 2.99 times greater for all medications and 3.2 times greater for opioid medications when they were physician dispensed.
- A similar greater medical and indemnity cost was present; physician- dispensed all medication types had 39 percent higher medical costs and physician-dispensed opioid medications resulted in 78 percent higher medical costs.
- Physician-dispensed all type medications had 27 percent higher indemnity costs and physician-dispensed opioid medication claims had a 57 percent higher indemnity cost when compared to the pharmacy-dispensed medications group.
In further analysis of the data, the authors noted the particular adverse outcome associated with physician-dispensed opioid medication where there was an 85 percent higher frequency of lost-time days when compared to the pharmacy dispensed group. In their conclusion, they state that the worse outcomes associated with physician dispensing was not due to injury complexity, sex, age or attorney involvement, but rather an attribute of physician practices that dispense medications. I want to thank those 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.Ed Leary, M.D.
A Strong Partnership
March 2014Although 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
Two Thirds of the 5-Star Rated Clinics Achieve Summit Elite DesignationAt 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
2014 SelectNet Conference: Managing Workplace InjuriesPinnacol 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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