Wellness Research at Pinnacol

From the Desk of Karyn Gonzales

March 2015
New Research Confirms Value of Pinnacol’s Worksite Wellness Program

As you know, Pinnacol has offered a worksite wellness program since 2010. This wellness program was part of a study with the Colorado School of Public Health, Johns Hopkins University and Truven Health Analytics and featured in the January issue of the Journal of Occupational and Environmental Medicine (JOEM).

Key findings include:

Pinnacol’s health and wellness strategy supports our companywide focus on finding new and innovative ways to serve and bring enhanced value to our stakeholders, while remaining committed to making Colorado a great place to live, work and grow a business.

Our emphasis on health and wellness is an extension of our core business model. One way we can help our policyholders minimize the frequency and cost of workplace injuries is by helping keep their employees healthy.

As part of this strategy, we’re pleased to announce we have selected Virgin Pulse, a market leader in worksite wellness programs, to be our partner for our new worksite wellness program.

A part of Sir Richard Branson’s Virgin Group, Virgin Pulse helps employers create worksite wellness programs with an engaging, award-winning online platform to foster healthy habits and sustainable behavior change to help employees thrive at work and across all aspects of their lives.

We’re working closely with Virgin Pulse to customize the program for Pinnacol. In April, we will be rolling out a “soft launch” of the program to policyholders that have participated in our health risk management wellness program. The program will be available to all policyholders later in 2015.

If you would like more information about our worksite wellness program, please contact Karen Curran, worksite wellness director, at 303.361.4784 or Danielle Nieto, health and wellness promotion specialist, at 303.361.4768.

Karyn Piché Gonzales is the vice president of medical operations and healthcare strategy for Pinnacol Assurance.

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What Is Vestibular Rehabilitation?

Featured Story

March 2015
Submitted by Nancy Bonifer, PT, DPT, MS

Physical therapy can play an important role in the rehabilitation of symptoms of dizziness, vertigo, headache and disequilibrium. After an auto accident, whiplash-associated injury, work-related accident or fall, or concussion or blow to the head, individuals may complain of symptoms including vertigo, dizziness, motion sensitivity, nausea, headaches, poor balance and/or disequilibrium. Such symptoms can arise from an injury to the central nervous system (brain), peripheral vestibular system (inner ear), or neck and spine (cervicogenic origin).

Vestibular dysfunction can limit a person’s ability to perform work-related tasks, drive, perform head and neck motions, or walk. In addition, vestibular issues can result in problems with postural control and balance reactions and increase the risk of falls.

A physical therapist with specialized training and certification in vestibular rehabilitation therapy (VRT) can perform a comprehensive evaluation to determine the cause of the symptoms as well as develop an individualized treatment and patient education program for rehabilitation.

VRT is an exercise-based program designed to promote central nervous system habituation or compensation. Vestibular rehabilitation is an evidence-based approach that has been shown to help in a number of conditions that may result from an on-the-job injury, including benign paroxysmal positional vertigo (BPPV), unilateral or bilateral vestibular hypofunction (reduced inner-ear function on one or both sides), complications from a brain injury or concussion, cervicogenic dizziness (dizziness arising from neck dysfunction), and falls or unsteadiness.

Repositioning maneuvers are used to treat the altered biomechanics involved in BPPV, a condition in which calcium carbonate crystals within the inner ear become detached and displaced, leading to symptoms of vertigo and nausea and difficulty with balance. BPPV commonly occurs after an accident involving the head or neck. Habituation exercises repetitively expose the client to sensory inputs that cause a moderate level of symptoms with a resulting minimization of symptoms. Habituation exercises may be necessary after concussion or whiplash-type injuries. Adaptation exercises strengthen intact sensorimotor pathways to help a client compensate for a permanent loss of vestibular functioning. In addition, exercises can be prescribed to maximize postural control and normal balance reactions, thus decreasing the risk of falls and further injury.

Manual therapy techniques, postural education and exercise prescription can address issues of head and neck pain as well as cervicogenic dizziness after an injury. Since the neck has approximately 400% more sensory receptors than other areas of the body, accidents involving this region can result in significant impairment if not addressed.

Physical therapy for vestibular rehabilitation should also include client education. Many of the symptoms associated with head and neck injuries can be very frightening and upsetting. Educating the client regarding the cause of their symptoms as well as the normal course of rehabilitation can reassure the person that functional progress and a return to work duties can occur.

For further information, feel free to contact Nancy Bonifer, PT, DPT, MS, or visit her clinic website Nancy has over 20 years of experience treating physical therapy clients for orthopedic, neurologic and vestibular disorders. She has a specialty certification in vestibular rehabilitation and has successfully assisted individuals with significant dizziness and vestibular issues in decreasing their disability and returning to work.

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New Provider Choice Law

Workers' Compensation Coordination

March 2015
During the 2014 Colorado Legislative Session, state lawmakers passed House Bill 1383, which requires employers to increase the number of physicians or corporate medical providers they designate to treat their injured workers from two to four. The new law goes into effect April 1, 2015.

We are encouraging our policyholders to designate their additional medical providers now. However, if they do not designate their four providers, Pinnacol will designate SelectNet providers for their policy by the April 1 deadline. To be compliant with the law, employers will still need to provide the Designated Providers List Notification Letter to their employees at the time of injury.

For more details on this new law, including details on the rural exemption, visit

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Friendly Reminder on Protection of Medical Records

Corporate News

March 2015
Pinnacol receives many injured worker medical records, and we do send out medical records to parties on the claims. We have policies and procedures in place to safeguard these records and ensure that they are distributed appropriately. We also want to do our best to protect the injured workers’ medical records once they leave our office. As such, this is a friendly reminder so that physicians who treat injured workers and consult on their claims do their part in the safekeeping and disposal of injured workers’ medical records.

Physicians are ultimately responsible for ensuring that medical records are stored and maintained according to federal and state legal requirements and the principles related to the protection of medical records. Under Colorado Medical Board Policy, physicians must develop a written plan to ensure the security of patient medical records, addressing at least the storage and proper disposal (if appropriate) of medical records, and the method by which patients may access or obtain their medical records promptly.

Colorado Medical Board recommends retaining all patient records for a minimum of seven years. In cases of litigation, records must be retained until resolution. For injured workers, the medical records must be retained until the claims are closed and the period for request of reopening of a claim has passed. The period for a request of reopening of a claim is two years from the last date of treatment, which may be treatment by any of the medical practitioners on record for that claim.

All patient records and data must be kept in a safe and secure environment - restricted access areas or locked filing cabinets - to protect against loss of information and damage. These same precautions apply regardless of whether the information is stored on premises within the physician’s control or otherwise. Physicians who take records out of the clinic or receive medical records outside the clinic must take appropriate measures to prevent loss, restrict access, and maintain the privacy of patients’ personal health information. This is especially true in cases where an independent medical evaluation (IME) is arranged.

Physicians must not dispose of a record of personal health information unless their obligation to retain the record has come to an end. Records must be disposed of in a secure manner such that the reconstruction of the record is not reasonably foreseeable in the circumstances. In cases of IMEs, the physician must either return the medical records to Pinnacol for proper disposal or acknowledge on the Pinnacol IME form that the records have been properly disposed of.

Physicians must notify Pinnacol should there be a loss or breach of injured workers’ medical records so we can assist in mitigating any adverse impacts to the injured workers involved. If you have questions, please contact your provider relations specialist at 303.361.4945.

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In The News

In The News

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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 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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