This interview with Matt Miller, M.D., Front Range Occupational Medicine, Golden, is the first in a series about best practices in workers’ compensation. Based on his performance in Pinnacol’s clinic profiling report, we asked him a few questions about his practice style and treatment plans.
When we compared your clinic’s profile reports to those of other SelectNet practices, we noticed your costs per claim tended to be significantly lower. Why do you think that is?
Miller: I am conscious of the costs associated with treatment. One thing that increases costs is whether you prescribe a lot of medication. I try to be thoughtful about whether medicines are needed or likely to be helpful. I also look at supplies and whether they are really necessary.
Another thing that makes a real difference is therapy and chiropractic treatment. We use both modalities, and I’m a big believer in both, but one of the biggest mistakes is overutilization. In our practice, we say, “Let’s try six sessions of therapy and then come back and see me. Did the therapy make a difference? If your function has improved, let’s do some more therapy. But if PT hasn’t moved the needle, let’s try something different.” That’s probably a big reason why we keep our costs lower; we're careful about how we prescribe therapy and chiropractic treatment. In addition, we start out passively but very rapidly switch over to active therapy.
We also give the patient the tools to do the therapy themselves. The patient has to take some responsibility to get better.
What is the most important topic to discuss with an injured worker at the first visit?
Miller: Early education is key. We spend time educating people, not just about their diagnosis, but also how to deal with pain, the difference between pain and physical damage, and how the injury is likely to progress. We focus heavily on function. Sometimes, providers and patients focus so much on pain that they forget to acknowledge that it’s okay to hurt. Becoming pain-free is a poor goal. We focus on function and how to get people moving and back to not only their job but also their lives.
In your clinic, the average number of temporary total disability days for back injuries is only 3.8 compared with your peers’ average of 10.9 days. What is your approach to return to work? Is there anything unique about your treatment plans?
Miller: Again, we focus on education and function. We tell people we want them to move and to be active, and we will work with their employers to get them back to work in some capacity. We try to create strong relationships with our companies so they understand the importance of their employees returning to work. Most companies are very good at accommodating whatever we request and even create new roles to keep their injured workers moving.
When we give restrictions, our goal is to prevent further damage. For example, we don’t want a patient lifting 50 to 60 pounds when it may worsen their condition. We will instead tell them, “Lifting 20 pounds won’t damage you and, in fact, you risk more harm by not staying active. You’ll lose function; you’ll lose strength, flexibility and endurance.” Most of the time, we have good buy-in once we explain all of this to the patient. Usually, they feel better moving than sitting still, so that’s one of our keys to guiding people to recovery.
We recognize that all of this can be challenging for small companies because they have more difficulty offering modified duty. In circumstances where no light duty is available, we stress to employees that while they have restrictions they should do whatever they can at home. If we can get patients moving, we very rarely see them overdo it. In fact, once we get them active, it seems to lead to even more movement.
How do you choose your referral specialists?
Miller: I tell my patients I pick the same people to whom I would send my family. There are some very technically gifted surgeons who struggle with the concept of getting someone back to work and active again. They seem to be overly conservative to the point of delaying recovery. One of the things we run into is surgeons who hand out excessive restrictions above and beyond those necessary to protect the surgery. In those cases, I have to step in and say, “That’s not your role; let me handle the work restrictions.” I’ve been doing this long enough now that I’ve generally got a regular group (of specialists) who understand.
See the example of the clinic profile report for comparisons to peer groups.