Kevin Walsh M.D.

Partner: Industrial Medical AssociatesStaff Anesthesiologist University Hospital

Member of Medical Advisory Committee to Chairperson of WCB

Background

• Family Practice• Emergency Medicine• Occupational Health (IMA)• Anesthesiology• Interventional Pain Management

Today's Objective

• Review WC in context of 2006• Illustrate how the system is

dysfunctional• Identify three pivotal cost drivers

– How they may be better managed

• Case management illustration

Are Workers Compensation Costs Important?

• Business council of NYS– Major obstacles for recruitment &

retention of jobs in New York State• Tax Structure• WC Costs• Energy Costs

History of New York’s WC System

• Created by the Legislature around time of WWI

• Legal framework to protect injured workers and employers.

• Orderly litigation, predictable outcome

• Medical sciences were in their infancy, medical costs were irrelevant.

1980’s Conditions

• Relationship between worker, family, and employers• Health benefits were comprehensive and improving.• Providers preferred to care for injuries under BC/BS -

employees didn’t object.• Fewer MD’s• Fewer paramedical professionals

PT - OT - Chiropractic - Massage Therapy• Few diagnostic tools

Cat scans new to scene• Sparse legal interest locally• Pharmacy costs irrelevant• Biomedical engineering costs were non existent.

WC - The Players

• The Legislature• Lawyers• WCB • Injured worker• Employer• Physicians & Paraprofessional

Providers• Insurance Carriers

2006 Conditions

• Workers feel disenfranchised.• No loyalty between worker/employer.• Erosion or absence of benefits.• Private health insurers actively push cases to WC.• Patients and physicians see WC as default

insurance.• Full force of best pharmaceutical marketing

machine in the world with no constraints.• Biomedical engineering research funding.• Proliferation of medical providers and advanced

technologies.• Lifetime medical care.• Inability to close cases.

Problem

• Modern medical practice & Antiquated WC systemSquare peg / Round hole

• Trying to treat medical problems in a political versus market driven environment

The (Paradox/Dilemma) in WC Care

• Medical technology abundant• Diagnostic capabilities much improved• Supply of medical and paramedical

specialties abundant

Why is the severity of WC cases escalating rapidly and outcomes of care

are so poor?

Three Pivotal Cost Drivers

• Nature & Severity of the injury.• Interface between the worker and

employer.• Dynamic between the injured worker

and medical providers.

Employer / Injured Worker Interface

• Visceral response• Negative • Adversarial

Injured Worker / Medical Care Dynamic

• Review in detail what happens through the course of long term workers comp case.

• The Human condition + behavior and their implications

Workers Comp: Low back injury case review

Day 1 - “I really hurt my back”Day 7 - “Feeling a little better thank you”

4 Weeks Later…Feeling Worse

“The Pain Is Awful!”

Pain

Pain

Nociceptive Pain SufferingAlienation at Work

Fear of Job Loss

Disability

Financial Stress

Family Problems

Too much emphasis on investigating and treating pain.

Suffering is often the dominant factor and it is ignored

WC Care Walk-through cont’d

6 weeks• In physical therapy

Request CT or MRI scan 10 - 12 weeks

• The pain is worse• Abnormal MRI scan

Request Pain Blocks / EMG study 4 - 6 months

• The pain is worse• Failure of conservative therapy

Request authorization for surgery

Request for Surgery

• Based on abnormal MRI & report of persistent of pain.

• The most common cause of poor surgical outcomes is not bad surgeons.– It is operating for the wrong reason.

Pain

Pain

Nociceptive Pain SufferingAlienation at Work

Fear of Job Loss

Disability

Financial Stress

Family Problems

Too much emphasis on investigating and treating pain.

Suffering is often the dominant factor and it is ignored

Case Continued

6 months plus• Post operative visit

– Still have pain Repeat pain blocks & rehab

• Chronic medication requirement– Including narcotics

Workers Compensation Cost Cascade

In house health resource$

Off site health resource$$

Hospital based care - Emergency dept.$$$

Specialist consultation - Orthopedic$$$$

Imaging studies - CT, MRI, Pet Scans, EMG$$$$$

OT, PT, Chiro Massage therapy$$$$$$

Surgical Intervention Surgical fee $$$$$$$ Facility fee

More rehab - Pain ManagementNerve blocks $$$$$$$$ Pharmaceuticals

Managing the Cost Drivers-Nature & Severity-

• Safety training• Safety culture• Ergonomics• Engineering

Managing the Cost Drivers-Employer / Injured Worker Interface-

• Be positive and supportive.• Treat like a valuable athlete.• How can I help you recover?• You are important to the success of our

business.• Maintain regular personal contact.• Facilitate timely medical care.• Make sure compensation checks arrive

on time.• Make return to work pathway easy.

Managing the Cost Drivers-Dynamic between Injured Worker & Medical Provider-

• This is really a triad:• Worker• Employer• Medical Provider

• More Complex• Requires persistent effort• When I do right nobody remembers,

when I do wrong nobody forgets.

Managing the Cost Drivers-Dynamic between Injured Worker & Medical Provider-

• Keep it simple.• Engage with “problem solver”

medical providers / systems.• Attentive patient management.• Mechanisms to resolve disputes

quickly.• Utilization review.• Encourage early return to work.

Workers Compensation Cost Cascade

In house health resource$

Off site health resource$$

Hospital based care - Emergency dept.$$$

Specialist consultation - Orthopedic$$$$

Imaging studies - CT, MRI, Pet Scans, EMG$$$$$

OT, PT, Chiro Massage therapy$$$$$$

Surgical Intervention Surgical fee $$$$$$$ Facility fee

More rehab - Pain ManagementNerve blocks $$$$$$$$ Pharmaceuticals

Workers Compensation Reform

• Changes in law will never keep up with changing business environment.

• Employers who manage the process and human behavior can effectively reduce losses regardless of reforms.

• Reform efforts should address:• Direction of care.• Appropriate utilization of medical services.• Timely resolution of all disputes.

Employer Influence

• Employers can influence the length of the disability more than they realize.

• Manage the process.• Develop relationships/programs with

medical community.

Wrap Up

• Preemptive efforts:• Invest in the Recruitment Process• Invest in Safety & Training

– Make it important part of culture• Patient Care management:

• When accident or injury occurs don’t pass it off. Be involved in care management from day 1.

• Medical management: Have a “Friend In The Business”• Safety person• Occupational health nurse• Contracted service offsite• Physicians

• Positive ongoing relationship with Employee:• Treat like valuable asset• Frequent in person relationship• Facilitate medical care• Make sure compensation checks arrive on time• Make return to work pathway easy

Contact Information

Kevin Walsh M.D.Industrial Medical Associates

wcpainreview@aol.com

IMA: (315) 478-1977Digital Pager: (315) 441-1324