THE CAGE-AID QUESTIONNAIRE AND WORKERS’ COMPENSATION: WHAT YOU NEED TO KNOW

Workers’ Compensation Medical Treatment can employ various questionnaires to assess an Injured Workers’ need for treatment.  One of these questionnaires is called CAGE-AID.

This article will discuss the purpose of the CAGE-AID questionnaire, how it is used in an industrial treatment setting, and how it may impact an injured worker’s treatment.

What is the CAGE-AID Questionnaire? 

The CAGE-Aid questionnaire is a substance abuse screening tool.  Substance abuse applies to alcohol, legal drugs and street drugs.

Why is Substance Abuse a Problem with Workers’ Compensation Treatment?

Substance abuse is a multi-factorial problem in workers’ compensation.  There are workers who, prior to their injury, have histories of either substance or alcohol abuse.  Further, there are workers, as a result of their injuries, begin to abuse drugs or alcohol.   This abuse can either be with prescription drugs, alcohol, or street drugs.  Finally, there are injured workers who, not as a result of their work injuries, engage in substance abuse.

Why is The Questionnaire  Called CAGE?

The abbreviation refers to some of the terms within the questions. The terms are cut, annoyed, guilty and eye opener.

What are the Questions Asked?

There are four questions.  They are:

Have you ever felt that you ought to cut down on your drinking or drug use?

Have people annoyed your by criticizing your drinking or drug use?

Have you ever felt bad or guilty about your drinking or drug use?

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover (eye opener)?

How is it Scored?  

It is scored one for yes and zero for no.

How is The Score Interpreted? 

If one or more responses is yes, then it is regarded as a positive screening test.  Thus, possible substance abuse is something that the medical provider should explore with the partient.

How Should Injured Workers Answer the Questions?

These questions may impact medical treatment decisions.  Medical providers need accurate information in order to provide appropriate treatment.  Substance abuse, when combined with prescription drugs, can lead to harmful and deadly drug interactions.   Therefore, it is important to be honest when answering the questions.

Additionally, if an injured worker has a substance abuse problem that is preventing their recovery from a work injury, it is possible that the workers’ compensation medical system may provide some assistance with respect to substance abuse treatment.  This, however,  would be subject to the limitations within Labor Code Section 4600.

What If I Need Advice?

If you would like a free consultation regarding workers’ compensation, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. We have been helping people in Central and Southern California deal with their workers’ compensation cases for over 28 years. Contact us today for more information.

 

UTILIZATION REVIEW IN CALIFORNIA WORKERS’ COMPENSATION:  A PERSPECTIVE FOR INJURED WORKERS

For Injured Workers seeking medical treatment for their workers’ compensation claims, Utilization Review (UR) of their Physician’s Requests for Authorization for medical treatment is all too common.   Injured Workers often receive letters denying treatment, modifying treatment, deferring treatment authorization, requesting further information and certifying treatment.  These letters are generated by the Insurance Companies via their Utilization Review process.

This article will briefly discuss the history of Utilization Review, what is Utilization Review, why the workers’ compensation system employs UR, and how an Injured Workers should address UR.

What Is the History of Utilization Review?

“Background Utilization management has been defined by the Institute of Medicine as “a set of techniques used by or on behalf of purchasers of health benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision.”[1] Utilization management is used in an effort to discourage the use of unnecessary or inappropriate medical services, without jeopardizing necessary high-quality care.

The terms “utilization management” and “utilization review” (UR) are used interchangeably in this report. By the late 1980’s, UR had become ubiquitous in health care, effecting virtually everyone with any form of health insurance coverage in the U.S., and many workers’ compensation claims administrators had also begun to use UR as a cost-containment tool.” Utilization Review in California’s Workers’ Compensation System: A Preliminary Assessment July, 2001 Division of Workers’ Compensation Public Health Institute Department of Industrial Relations Berkeley, California State of California [emphasis added]

What is Utilization Review?

“Utilization management is a set of techniques used to manage health care costs through the assessment of the appropriateness of care in individual cases. The primary focus of utilization management is reduction of the use of unnecessary or inappropriate medical services.” Utilization Review in California’s Workers’ Compensation System: A Preliminary Assessment July, 2001 Division of Workers’ Compensation Public Health Institute Department of Industrial Relations Berkeley, California State of California

In layman’s term, managing health care costs saves Insurance Companies money by denying treatment.  Denying treatment leads to less bills. Less bills leads to less costs.

What are the Reasons for Utilization Review?

Medical costs within the workers’ compensation system are driven my multiple factors.  These can include fraud, overuse, and greed.

First, fraud in workers’ compensation could include prescriptions for expensive and unnecessary treatment.

Second, overuse in workers’ compensation involved Injured Workers who were enthusiastic about their treatment and had providers who would enable it. For example, before UR, there were individuals with minor back injuries with open medical awards that would seek chiropractic adjustments 3 days a week in perpetuity.

Third, greed and distrust of medical providers. There is a distrust by insurance Companies of medical providers.   Medical providers may be incentivized to provide treatment to make money versus providing the care that was needed.   For example, epidural injections, at one point in time, became increasingly used.  Arguably, they were done because they were profitable for the providers rather than helpful to the Injured Workers.

How Should Injured Workers Address Utilization Review?

Injured Workers need to address utilization review by choosing treating doctors who are responsive to the UR process.  Further, Injured Workers should be aware of UR denials and the need to file for Independent Medical Review.

An Injured Worker should choose the right treating doctor for UR processes. An Injured Worker should look for treating doctors who understand the utilization review process.   This means that the doctors should understand the forms that need to be filled out to get treatment approval.  This means that the doctors should understand the treatment utilization schedules as to what treatment can be approved and how to request it. Finally, the doctor should be responsive to inquiries from utilization review when they request peer to peer discussions as well as requests for supplemental reports.

Also, Injured Workers need to have treating doctors who will be responsive to the utilization review company’s requests for further information.

What if I Need Advice?

If you would like a free consultation regarding workers’ compensation, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. We have been helping people in Central and Southern California deal with their workers’ compensation cases for 27 years. Contact us today for more information.

UPPER EXTREMITY WORKERS’ COMPENSATION SURGERIES: WHAT YOU NEED TO KNOW

Studies about workers’ compensation as always of interest to Injured Workers.   A lot of these studies tell us how and why insurance companies, employers and doctors act in particular ways.   A study addressing upper extremity surgeries provides us such insight. The study compared the results of industrial versus non-industrial upper extremity surgeries.

This article will discuss, upper extremity surgeries, issues relating to upper extremity surgeries, and the results of the study.

What Are Upper Extremity Surgeries?

 With respect to upper extremities, there are a variety of surgeries that are done on an industrial basis.  Upper extremity surgeries can range from shoulders to finger tips. Parts operated on can include areas such as the shoulders, biceps, elbows, forearms, wrists, and fingers.

For shoulders and elbows, there operations can include fracture surgeries, total shoulder replacements, shoulder arthroscopies, rotator cuff repairs, tennis elbow, golfer’s elbow, and elbow arthroscopy.

For the wrist, operations can include fracture surgeries, carpal tunnel releases, wrist arthroscopies, wrist joint replacements and wrist fusions.

How Are Workers’ Compensation Upper Extremity Surgeries Different Than Non-Industrial Upper Extremity Surgeries?

Approval:  Unlike Health Insurance Company approval for surgeries, Workers’ Compensation surgeries are subject to utilization review and independent medical review. Thus, there are guidelines and algorithms that must be met in order for surgeries to get authorized.  This can lead to delays in getting approval.

Medical Providers:  For many Injured Workers, they are constrained to using hand surgeons and upper extremity surgeons within the workers’ compensation insurance medical provider networks. Thus, the quality of the surgeon is subject to the insurance company’s dedication to having good providers.

Total Temporary Disability Benefits: For Injured Workers, they receive benefits is they remain symptomatic. Therefore, it is necessary that the voice all of their problems.

Permanent Disability Benefits: For Injured Workers, they need to be critical of the results of the surgery and be able to describe them.  Therefore, the result is viewed with this mindset.

What Was the Study’s Conclusion?

 The study “found that patients receiving WC[workers’ compensation] had worse postsurgical results after upper extremity surgery and demonstrated less pre- vs postoperative improvement than uncompensated patients regardless of which outcomes were measured. However, this effect was not uniform among different types of outcomes. Functional measures, such as AOM or grip strength, were least likely to demonstrate a significant difference between compensated and uncompensated patients. The same was true in studies that measured pre- vs postoperative improvement rather than only assess patient postoperatively.” Fujihara Y, Shauver MJ, Lark ME, Zhong L, Chung KC. The Effect of Workers’ Compensation on Outcome Measurement Methods after Upper Extremity Surgery: A Systematic Review and Meta-Analysis. Plast Reconstr Surg. 2017;139(4):923-933. doi:10.1097/PRS.0000000000003154. It was noted that this analysis was aware that compensated patients can result in artificial reduction of the therapeutic effect which may lead to incorrect conclusions. Supra.

The study noted that “.. the effect of WC on surgical outcome is not solely an issue of malingering Americans. Compensation systems that do not incentivise feigning impairment, also observe worse outcomes associated with WC. Rather, this may indicate that increased impairment among workers receiving WC may be a result of psychological effects on patients caused by a sense of victimization or injustice .” Fujihara Y, Shauver MJ, Lark ME, Zhong L, Chung KC. The Effect of Workers’ Compensation on Outcome Measurement Methods after Upper Extremity Surgery: A Systematic Review and Meta-Analysis. Plast Reconstr Surg. 2017;139(4):923-933. doi:10.1097/PRS.0000000000003154

In sum, it would appear that Injured Workers have poorer post-operative results.   There are factors of income, malingering, psychological effects of victimhood and injustice may be the factors lead to a poorer workers’ compensation result.

Knowing these Results, How Will an Injured Worker Be Treated?

 Insurance Companies, knowing the surgery result may be poor, may want to avoid providing for it.  This can be done in two ways: one, settling the case before surgery, two, contesting the need for the surgery.

Doctors take pride in their work.  Doctors like to have good results.  Therefore, doctors may not thrilled with Injured Workers because there will be some level of dissatisfaction and representations that the surgical result was not optimal.

Employers, like Insurance Companies, may not be happy with surgeries with poor results.  For them, they are faced with a costlier claim as well as possible issues with respect to return to work.   Return to work issues would involve either qualified Injured worker status or the need to provide alternative or modified work.

What if I Need Advice?

If you would like a free consultation regarding workers’ compensation, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. We have been helping people in Central and Southern California deal with their workers’ compensation cases for 27 years. Contact us today for more information.

 

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