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Online registration for Pinnacol Assurance’s annual SelectNet conference, Asking the Tough Questions in Workers’ Comp is filling up, so register today. Registration is first come, first served as space is limited. The conference is free to invited SelectNet providers, and participants can earn up to 5.75 AMA PRA Category 1 Credits.

The conference will be held Friday, May 17, at Sports Authority Field at Mile High in Denver. Visit Pinnacol.com to view the lineup of speakers and complete agenda. Participants can also opt to take a tour of the stadium after the conference. View the registration information for more details.

Please contact your provider relations specialist with any questions. We look forward to seeing you in May.

In 2010, as a response to the growing evidence of widespread opioid abuse, OxyContin’s manufacturer reformulated the medication in a manner so that it was more difficult to crush, break or dissolve. If an attempt is made to crush the pill, then the medication becomes a viscous gel which cannot be prepared for injection. This new “tamper proof” formulation of OxyContin will not come off patent protection until 2025 and, therefore, generic versions will not be available until that time.

Any pharmaceutical company that seeks to obtain FDA approval for a generic version of OxyContin will have to submit for approval a formulation that also includes its own abuse-deterrent medication design. It is significant that in 2012, OxyContin represented 30 percent of the U.S. market for pain medication.

This decision by the FDA represents a major policy move because it is based on both the clinical efficacy of the medication and the FDA’s determination to require additional formulation to prevent tampering for inappropriate use. In its decision, the FDA stated, “We recognize that we are looking at new territory.” As part of this decision, the FDA also approved a new label for the “tamper proof” OxyContin, which states that it is less prone to abuse. This is the first time that the FDA allowed a pharmaceutical manufacturer to state that its narcotic drug is tamper-resistant.

Opana has also been reformulated to include an inherent tamper proof design. If a similar line of reasoning as evidenced by this recent FDA decision is to continue, then generic forms of the original Opana formulation might be barred. The FDA has stated that it will continue “to encourage the development of abuse-deterrent formulations of opioids.” As you develop your care plan for pain management in an injured worker, this recent FDA decision to focus on maintaining a clinical pharmaceutical environment that includes both pain medication efficacy and anti-abuse formulation is an important mile stone. This FDA decision assures physicians that OxyContin, which they prescribe, will continue to have the tamper proof formulation.

Edward Leary, M.D.
303.361.4951
edward.leary@pinnacol.com

Acupuncturists, chiropractors and massage therapists offer passive treatments that aid healing, especially during the initial phase when the area of injury should not be aggravated by over stretching or exercise. The use of medication may be necessary to control pain but should be reduced as soon as possible.

Chiropractors often offer a variety of alternative services at one clinic where multiple therapies can apply during the same visit for the most effective treatment of problems, which might require a primary intervention that can be facilitated with other therapies applied at the same visit.

Manipulation is very effective for neck and mid back pain. The first two vertebrae at the top of the neck are not separated by discs, which makes them relatively less complicated and amendable to adjustment. Lower back conditions, however, can be much more stubborn because of discs that are under constant stress from weight bearing. These conditions do, however, resolve with proper treatment and education, as well as minimizing both bending and twisting at the waist and lifting.

Passive therapies like electric stimulation and heat are often used for their own benefit in addition to preparing the area for adjustment. Flexion distraction, used by half of chiropractors, consists of manual mobilization of each of the lumbar vertebrae on a special table. Intermittent motorized traction can also be used to pump the discs for better hydration. Massage therapy, which relaxes tight muscles, is a great complement to the treatment of many spinal conditions.

Acupuncture with or without electric stimulation addresses muscle conditions including those of the lower back. It also works well in the treatment of tendinitis like tennis elbow, which is irritation of the attachment of the wrist extensors that originate at the lateral aspect of the elbow. Acupuncture can be combined with ultrasound and other passive therapies. An arm strap also may be recommended to displace vectors of force that tend to keep the condition aggravated with use; these vectors should be decreased as much as possible during treatment.

Comprehensive care of musculoskeletal conditions can be achieved by including the services of chiropractors, acupuncturists and massage therapists, who are prepared to spend the sometimes considerable time necessary for rehabilitation of injuries. A series of visits are usually recommended because of the way natural medicine works, but the results are well worth the time spent in undergoing treatment.

These questions are part of the issues addressed by the therapist when doing an ergonomic or worksite evaluation. Ergonomics is the study of matching the task to the person performing the task in a manner that eliminates awkward postures, energy overload and the stressful forces that can be harmful when in a position that is held for many hours or until the task is finished.

Sustained Exertion
Sustained exertion is one of the risk factors that the physical or occupational therapist evaluates. This could be merely the constant strain of holding right elbow even a few inches away from your side to reach that computer mouse that is up too high on a desk. A lower keyboard tray would reduce the constant load on the rotator cuff muscles that causes fatigue and reduces blood flow. This can lead to muscular degeneration and, possibly, a muscle tear.

Repetitively reaching above shoulder height may cause excessive compression of the cartilage of the ball and socket joint. The rotator cuff muscles may also be exposed to repetitive compression. The resulting Impingement Syndrome can be a common outcome when muscles are not balanced in their strength and length, and when inflammation causes an already small space to become even smaller. The neck may also be involved after looking up excessively with repetition causing compression of spinal joints. Leaning over a car engine for prolonged periods, or leaning and reaching for even light weight tools can add progressively more stress to ligaments, joint capsules and muscles of the low back. Even light items lifted repetitively and incorrectly can cause that body to finally reach a threshold that leads to muscle strain and, possibly, disc degeneration.

There are many little simple changes that the therapist can suggest to make your desk, workstation , kitchen, home office or construction site an environment that is less stressful to your joints and muscles.

• Items of frequent use – such as a phone or hammer – should be placed within arm’s reach without you having to lean and grasp them.
• Raising your computer chair to make the desk fit your height may require placing a foot rest under your feet, which could be a box or reams of paper until you can obtain the proper foot rest.
• Reams of paper can be used to elevate the computer screen so your forehead is the same height as the rim around the screen.
• Lifting one leg out behind you as you lean into the car reduces torque at low back. Lunging forward and then pivoting at feet instead of twisting your back can reduce stressful forces on the lower back.

We’re looking for well-written articles that address important issues affecting providers each day, such as workers’ comp specific injuries or other findings specific to a specialty. In a recent survey, SelectNet providers who regularly read Provider Pulse told us that articles contributed by other Colorado medical providers and/or specialists are important to them.

Any SelectNet provider can submit an article for consideration, but please keep the following in mind:

• Articles should be approximately 500 words.
• Keep the SelectNet provider audience in mind.
• The article should not be time sensitive, as it may take some time for it to be published.

If you’re interested in the opportunity to provide valuable information to a large audience via Provider Pulse, please contact your provider relations specialist.

The conference will be held Friday, May 17, at Sports Authority Field at Mile High in Denver. Two medical/legal panels will answer questions about causality, medical treatment guidelines, surveillance, independent medical examinations and more. Panelists include the following experts:

• Dr. Kathryn Mueller of the Division of Workers’ Compensation
• Attorneys Paul Krueger (Ritsema & Lyon, PC) and John Sbarbaro (Law Offices of O’Toole & Sbarbaro, PC)
• Pinnacol Strategic Claims Representative George Ortiz
• Dr. Sander Orent (Arbor Occupational Medicine), Dr. Douglas Hemler (Star Sport and Spine), Dr. Mark Paz (Union Medical, PC), Dr. Jutta Worwag (Ivy Pain and Rehab) and Dr. Kathy McCranie (Centennial Rehabilitation Associates and Advanced Medical Specialists)

Presentations will be made by John Nicoletti, Ph.D.; Dr. Joanne Halbrecht of Boulder Institute For Sports Medicine; Dr. Lee Newman and Liliana Tenney from the Colorado School of Public Health; Dr. Thomas Mann of Cornerstone Orthopedic & Sports Medicine; and Dr. Jonathan Sollender from Aurora Plastic Surgery.

Please contact your provider relations specialist with any questions. We look forward to seeing you in May.

If I ask the injured worker about suicide, will it trigger the suicide act?

It is a myth that asking someone about suicide will give him (or her) the idea to try it (White, 1999). If a claims representative, nurse case manager or customer service representative is having a phone conversation and hears a suicide threat or reference, Pinnacol encourages our employees to ask openly about the statement. In a recent case, a female claimant said in an emotional outburst, “I can’t take this anymore … I want to blow my head off … I’m in pain 24 hours a day, 7 days a week…” Here, we stress that it is OK to stop the conversation and respond with something like, “You just said you want to blow your head off — are you thinking about hurting yourself?” We believe that talking openly about suicide with people who may be suicidal will show them we are taking them seriously and that we understand they are in real distress.

Some people use suicide references as manipulation

Some people threaten suicide not because they want to die, but because they want to manipulate others or effect a change in their environment. Even though a suicide threat is an extreme way to effect change, they do it because it usually works (White, 1999). For us, the risk is too great to assume that the suicide statement is a manipulative ploy and to do nothing. Even if we suspect the suicide reference is a ruse, we have a responsibility to do something.

“She didn’t say specifically that she was going to kill herself”

We cannot assume that an indirect reference to suicide is any less serious than a direct statement. In an early study by Robins et al (1959), 69 percent of people who committed suicide verbalized their intent to die — and not always directly. Just as we investigate threats to harm others, if subjects verbalize the intent (even indirectly), we take them to mean it and start the discussion.

What we do: Involving Pinnacol’s Threat Assessment Team

If an injured worker makes a suicide reference or statement, employees are encouraged to notify Pinnacol’s Threat Assessment Team early. Internally, we can capture and review the audio record of the telephone call to evaluate together whether Pinnacol has an obligation to act, and what our best course of action might be. Also this is an opportunity to objectively review the statement for perceived risk. If a suicide threat is present, the Threat Assessment Team will liaison with the local police to conduct a welfare check on the subject. If the police determine the person is suicidal, they have the authority to immediately take the person into custody and transport the person for emergency mental health evaluation. The threat assessment team will monitor the claim over time for ongoing risk and to ensure the situation doesn’t escalate to threats directed at our employees or business.

Should I call 911 if an injured worker is thought to be at risk?

Employees at Pinnacol are trained to call 911 if an immediate threat at Pinnacol exists. Using the Threat Assessment Team in this type of situation allows us to reach out to the appropriate police jurisdiction where the injured worker lives without being transferred through the 9-1-1 system. Also, if the threat assessment team makes the call, our claims staff is in a better place to re-establish communication after the police intervention — they can tell the injured worker that they are bound by internal procedure to report the call to security or human resources. This process allows our claims staff to distance themselves from the call to police and move quickly to re-establish the claim relationship.

Looking after the injured worker — and Pinnacol

We want to do what’s right by our injured workers — at times, this may involve a difficult decision to have police go to their home and make contact ensuring they are OK. Remember, we’re responding to suicide references and believe that by facilitating the right resources, we can get them the help they need. We are also looking after Pinnacol, ensuring that we’re acting appropriately in situations in which we have credible information to believe a situation exists and in which have an obligation to act.

References:
Robins, E., Gassner, S., Kayes, J., Wilkinson, R., and Murphy, G. (1959). The communication of suicidal intent: A study of 134 consecutive cases of successful suicide. American Journal of Psychiatry, 115, 724-733.
White, T. (1999). How to identify suicidal people: A systematic approach to risk assessment. Philadelphia, PA: The Charles Press.

In addition, we’re excited to announce that performance reward checks will be printed and mailed to qualifying clinics beginning mid-April.

Primary care provider (PCP) clinic star ratings and performance information are accessible to the public via the SelectNet Directory, while program results for specialist clinics are only available to referring PCPs via a password-protected website.

As previously noted in Provider Pulse, the CPI was designed to measure medical provider clinic performance, share measurement results and reward those clinics that meet or exceed specified performance standards. Thank you for partnering with us to accomplish these goals.

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

Clinic Performance Initiative

One topic of our conversations will be Pinnacol’s Clinic Performance Initiative (CPI). The CPI has completed its fourth evaluation period, and I commend SelectNet providers who have improved their scores over this time period. The CPI continues to disseminate best practices to improve the CPI measures for all SelectNet providers.

Physician advisor program

Pinnacol’s physician advisor program is comprised of independent physician reviewers who completed 3,105 case reviews in 2012. These case reviews are intended to support SelectNet physicians in their treatment of injured workers and provide conformity with the Division of Workers’ Compensation Medical Treatment Guidelines.

Addressing the opioid epidemic

Pinnacol has joined with a broad-based coalition of Colorado health care stakeholders to address the opioid “epidemic.” Tragically, Colorado ranks second in the United States in inappropriate opioid prescribing. As I’ve shared with you over the past few months, the Pinnacol approach to opioid misuse has consisted of three components:

• The requirement beginning in 2013 that SelectNet providers applying for recredentialing have completed the Colorado School of Public Health Opioid Educational Webinar
• Implementation of the opioid physician advisor program
• Increasing the availability of the Opioid Educational Webinar to all Colorado providers

I look forward to meeting as many SelectNet physicians during 2013 as possible and, again, I thank you for the care you provide to Colorado’s injured workers.

Edward Leary, M.D.
303.361.4951
edward.leary@pinnacol.com