Joseph Adragna, MD, with Peak Family Medicine in Montrose, is the latest physician featured in our series about best practices in workers’ compensation. Based on his performance in Pinnacol’s clinic profiling report, we asked him a few questions about treating injured workers in a rural area and the importance of being involved with his employers and community.
Why did you decide to get involved in the treatment of injured workers?
Joseph: I was exposed to occupational medicine in high school when I shadowed a family doctor in Montrose. I carried those experiences with me throughout my training. The family doctor was an advocate for finding the right diagnosis, implementing the correct treatment plan, coordinating care with ancillary care teams and specialists when needed, and following the patient to maximum improvement.
The treatment of injured workers requires a diverse skill set for which primary care doctors are strongly suited. These include the ability to quickly form a trusting relationship with an ill or injured person, continuity of care, coordination of care with a diverse set of ancillary and specialty providers, treatment of the physical and emotional dysfunction that can result from injuries, and combining all of this into a functional assessment.
What are the biggest challenges you face in caring for injured workers?
Joseph: I’m fortunate to have a great team of professionals in my practice. Our office has a workers’ compensation coordinator, something Pinnacol suggested years ago that we brought on as our volume increased. Having a coordinator is not common in small practices, but it streamlines our paperwork, including prior authorization requests. It helps ensure good communication between the adjuster and the practice, the practice and the employer, and the practice and the injured worker.
I’m supported by two other physicians and three physician assistants, which helps improve access. We’re open after usual business hours and on Saturdays. We have good partners where we have open communication about what is working and what is not working. Pinnacol shares data that allows us to assess the quality of our care measured by time to resolution compared with our peers, referral patterns, cost of care, and patient complaints. We have the opportunity to improve our practice by providing better customer service to all parties and tighter adherence to treatment guidelines.
What is your philosophy for how you care for injured workers?
Joseph: My philosophy starts with the principal role I have as a primary care doctor to make the correct diagnosis. We as physicians captain the ship. Where we point it, the ship will go. If we make the right diagnosis, we can leverage the full power of years of acquired knowledge to resolve, heal, comfort, and treat our patients. Should we get the diagnosis wrong, everything else will be wrong.
I see the role of the primary workers’ compensation provider to be an advocate for the injured worker, keeping an eye out for patterns that put others at risk, and providing professional opinions related to the medical nature of the injury while being careful not to get into the legal realm of who is at fault.
When we provide the maximum number of services in the same office setting, we are more likely to get the injured worker back to work in the fastest and lowest-cost manner. Having the ability to suture, splint, take X-rays, cast, and perform injections with ultrasound all in-house improves patient compliance and saves time.
What do you believe is needed to support injured workers in a small-town setting?
Joseph: There are several things. A healthy relationship between the payer, employer, and the practice. Pinnacol is the only carrier that has ever sent their team to meet face-to-face about treatment guidelines and Pinnacol resources. They are the only carrier where I can pick up the phone and talk with the medical director. Pinnacol cares about the injured worker. As workers’ compensation providers, we need a carrier where the injured worker says, “They are good to work with. They’re taking care of me.” When the injured worker trusts that the doctor, boss, and carrier are all rooting for their success, I see less resentment and more motivation for full participation in the treatment plan.
The payer needs a robust return-to-work program. If we place restrictions on a patient who is covered by Pinnacol, we make a referral to Pinnacol’s return-to-work team. They troubleshoot barriers and try to get the worker back into the workspace as quickly as possible. Experienced providers know the therapeutic benefit of being in the work environment, even when it requires duty modification.
A payer that shares actionable data on quality. We only know what we know. Looking at this from a 50,000-foot view when my resolution times are compared with peers with similar cases helps me to reflect on my treatment philosophy and expectations.
Support for in-office procedures, streamlined approval processes, and minimal prior authorization requirements. Faster implementation of treatment plans will result in less morbidity and cost.
What do you think are the most important things to discuss with an injured worker during the first visit to your clinic?
Joseph: I like to discuss expectations with the patient up front. I explain the role of the workers’ compensation system, where it originated, and what our goals are. I discuss the therapeutic benefit of being at work even if there are job duty modifications, the need for treatment adherence, and the need for frequent contact to ensure our treatment plan is working. I discuss the expected course of treatment based on the diagnosis and the expected time to resolution. People do poorly with the unknown. I tell patients up front what the journey looks like, so it progresses as quickly and smoothly as possible. I also discuss what alternative treatment options might be necessary if the initial treatment options fail. Finally, I share my confidence in the treatment plan, noting the injury is common and I have experience with it.
You are very involved in your community. Tell us more about your relationship with local businesses. How do these relationships help you support high-quality care of injured workers?
Joseph: I’d say a few things have contributed to our success. First, we are available. If you walk into the office bleeding from a laceration, we’re getting you in and taken care of even if that means I’m double booking. The patient loves this. The employer sees a lower cost of care when considering an emergency department visit. Employers want to know you have their back.
We have a fantastic relationship with our physical therapy (PT) colleagues. I would recommend having a really solid relationship with one or two therapists in your area. Share your cell number. Go to lunch. You will be working together a lot on cases, as PT is a foundation for a lot of injury treatment. This will pay dividends. Instead of one more fax when something isn’t going right, you get a call and a heads up so you can pivot quickly. Conversely, when you are not getting the rehabilitation results you expect, you can easily pick up the phone and find out what’s going on. This can provide more context and background to the sterile medical record. How many missed visits have occurred? How is the effort? Any new injuries? Adherence to home exercise programs? This helps our relationship with employers because their employees get better faster. They see that and love it.
We’re available to the employer for more than acute care. We do onsite reviews, workflow assessments, and teach about exposure limits, particularly around repetitive trauma complaints. We had one employer with a lot of cumulative upper extremity trauma. After the claims adjuster (non-Pinnacol) stated they “approve everything,” we connected with the employer. We found all of their workers in a particular department met exposure criteria for cumulative trauma. It was only a matter of time until everyone would be in our office. We worked with the employer to start rotations where the worker’s exposure was minimized while maintaining overall operational output. We saw a 50 percent reduction in visits within a few months. Short term, not great for our business, but long term, it’s exactly what we are supposed to do as professionals. Other employers will hear about this and before you know it, you’ll be the workers' compensation provider of choice.
We are responsive to the employer when there are questions about paperwork or clarification on restrictions is needed. We work with employers around modification suggestions. We also ensure the employer is kept in the loop on the status of the claim.