ARE INJURED WORKERS SATISIFIED WITH THEIR INDUSTRIAL MEDICAL TREATMENT?  QUALITY WORK-RELATED MEDICAL CARE AND WORKERS’ COMPENSATION: WHAT YOU NEED TO KNOW

“I Can’t Get No, Satisfaction”

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California Industrial Medical Treatment is controlled by the Labor Code. Thus, it differs from both traditional Private Medical Care as well as Government Programs such as Medicare and Medicaid.

Industrial medical care is part of a risk management system designed to provide cost-cutting elements with respect to providing the service.

Researches have looked into Injured Workers’ satisfaction with respect to their treatment.

This article will discuss Injured Worker’s satisfaction with their medical treatment.

What is Industrial Medical Care?

In California, Industrial Medical Treatment is guided by the Labor Code.   The Labor Code contains various treatment limitations.

Medical Control is one limitation. Insurance Company Managed Provider Networks limit the doctors that Injured Workers can choose.

Medical treatment is limited by utilization review of medical treatment requests.  These utilization reviews can deny treatment that does not follow the set algorithms and schedules.

What Is Private Medical Care?

Private Medical Care can come from a variety of sources. There is cash payment in where there is a direct provider patient relationship.  There are personal insurance policies for which the individual purchases the policy directly from the medical insurance company.  Finally, there is employer provided health insurance policies.

What is Medicare?

Per the SSA, “Medicare is [the U.S]… health insurance program for people age 65 or older. Certain people younger than age 65 can qualify for Medicare, too, including those with disabilities and those who have permanent kidney failure.

The program helps with the cost of health care, but it does not cover all medical expenses.”

What Is Medicaid?

Per Medicaid.gov, Medicaid programs [are] designed to provide health coverage for low-income people. This program is separate from Medicaid.

Can Injured Workers have Multiple Insurance Coverages?

Yes. Injured Workers can have multiple coverages at the same time.   It is possible that an Injured Worker can have private coverage, medicare and workers’ compensation at the same time.  For Injured Workers with low income and are on social security disability, they may have medicare, medicaid, and workers’ compensation at the same time.

What was the Study’s Overall Finding? Were There Other Findings?

The study found that “that Workers’ Compensation status is independently associated with dissatisfaction with health care compared with other primary payer groups.” Compton J, Glass N, Fowler T. The Effect of Workers’ Compensation Status on the Patient Experience. JB JS Open Access. 2019;4(2):e0003. Published 2019 Jun 11. doi:10.2106/JBJS.OA.19.00003

The study, however, had other findings of interest as well.

Workers’ Compensation treatment rated lower than Private Insurance and Medicaid.   It did, however, rate at about the same level of satisfaction as Medicare. Compton J, Glass N, Fowler T. The Effect of Workers’ Compensation Status on the Patient Experience. JB JS Open Access. 2019;4(2):e0003. Published 2019 Jun 11. doi:10.2106/JBJS.OA.19.00003.

With respect to mental health issues, workers’ compensation treatment, satisfaction was rated lower than private insurance.   It was however comparable to both Medicare and Medicaid patients. Compton J, Glass N, Fowler T. The Effect of Workers’ Compensation Status on the Patient Experience. JB JS Open Access. 2019;4(2):e0003. Published 2019 Jun 11. doi:10.2106/JBJS.OA.19.00003.

There was one area in which there was some higher level of satisfaction with respect  to industrial medical treatment.   This was when the treatment included surgical authorization.  Patients with Workers’ Compensation who were scheduled for a surgical procedure were more likely to be satisfied with their care.  Patients with surgical authorization have higher levels of satisfaction.  Compton J, Glass N, Fowler T. The Effect of Workers’ Compensation Status on the Patient Experience. JB JS Open Access. 2019;4(2):e0003. Published 2019 Jun 11. doi:10.2106/JBJS.OA.19.00003

What Can Be Done to Improve Care Injured Workers’ Satisfaction?

This author believes that the following items may improve the level of satisfaction of industrial medical care.   First, expanded Managed Provider Networks with more doctors to choose from.  Second, improvement of the utilization review process to allow for greater authorization of treatment.

As noted above, Injured Workers are happy when there are results that occur as part of the treatment.  This is shown in their level of satisfaction with respect to surgical authorization.

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.

MEN, DEPRESSION, SUICIDE, AND WORKERS’ COMPENSATION: WHAT YOU NEED TO KNOW

Stress impacts Men and Women differently.   Studies show there are differences in the workplace.  The findings are both significant and complicated.

This article will discuss depression, suicide, the differences between men and women, and the implications with respect to workers’ compensation cases.

What Is the Psychological Diagnosis of Depression?  

 Per the American Psychiatric Association, Depression (major depressive disorder) is an illness that negatively affects how you feel, the way you think and how you act.

”Depression symptoms can include: Feeling sad or having a depressed mood, Loss of interest or pleasure in activities once enjoyed, Changes in appetite — weight loss or gain unrelated to dieting, Trouble sleeping or sleeping too much, Loss of energy or increased fatigue, Increase in purposeless physical activity (e.g., inability to sit still, pacing, handwringing) or slowed movements or speech (these actions must be severe enough to be observable by others), Feeling worthless or guilty, Difficulty thinking, concentrating or making decisions, Thoughts of death or suicide.” APA

A depression diagnosis requires these symptoms last for an extended period of time. “Symptoms must last at least two weeks and must represent a change in your previous level of functioning for a diagnosis of depression.” APA

Which Sex Is Diagnosed Most with Depression?

 Studies show that women are diagnosed at twice the rate as men. “[c]omparatively, in Western countries, men are formally diagnosed with depression at approximately half the rate of women” (Kessler et al., 2005Wilhelm, Parker, Geerligs, & Wedgwood, 2008).” 1. Oliffe JL, Han CSE. Beyond Workers’ Compensation: Men’s Mental Health In and Out of Work. American Journal of Men’s Health. January 2014:45-53. doi:10.1177/1557988313490786

Note: These findings raise questions.  There is the issue of “men’s reluctance to express concerns about their mental health and reticence to seek professional health care (Emslie, Ridge, Ziebland, & Hunt, 2006Sharpe & Heppner, 1991Winkler et al., 2006).” 1. Oliffe JL, Han CSE. Beyond Workers’ Compensation: Men’s Mental Health In and Out of Work. American Journal of Men’s Health. January 2014:45-53. doi:10.1177/1557988313490786

In other words, men may not seek mental health treatment. Thus, there would be fewer depression diagnosis for men.

Is There a Connection Between Depression and Suicide?

Severe depression can … significantly increase the risk for suicide.  (Emslie et al., 2006Kessler et al., 2005Wilhelm et al., 2008World Health Organization, n.d.), 1. Oliffe JL, Han CSE. Beyond Workers’ Compensation: Men’s Mental Health In and Out of Work. American Journal of Men’s Health. January 2014:45-53. doi:10.1177/1557988313490786

Which Sex is at Most Risk of Suicide?

Men have been found to have higher rates of suicide. “[S]uicide rates are approximately four times higher in Western men than in women (Centers for Disease Control and Prevention, 2012Hawton & van Heeringen, 2009Levi et al., 2003Moller-Leimkuhler, 2003Rihmer, Belso, & Kiss, 2002Statistics Canada, 2012a2012bWasserman, 2000Wolfgang & Zoltan, 2007).” 1. Oliffe JL, Han CSE. Beyond Workers’ Compensation: Men’s Mental Health In and Out of Work. American Journal of Men’s Health. January 2014:45-53. doi:10.1177/1557988313490786

Thus, there is the question as to why men’s suicide rates are higher when their depression rates are lower.

Are There Suicidal Issues Related to Occupation?

The issue of suicide has multiple issues.  There is suicidal thought or ideation.  There is the act of suicide.

Studies have found high suicide rates in male-dominated workgroups. This included manual workers, farming, military and nursing.” 1. Oliffe JL, Han CSE. Beyond Workers’ Compensation: Men’s Mental Health In and Out of Work. American Journal of Men’s Health. January 2014:45-53. doi:10.1177/1557988313490786

Suicidal ideation is also an issue for men. Being a failed breadwinner can have an impact on suicidal thoughts. “Linkages between men’s work, depression, and suicide have also been described. Self-perceptions of being a “failed breadwinner” led older men with a history of depression to think about suicide (Oliffe, Han, Ogrodniczuk, Phillips, & Roy, 2011), whereas some middle-aged men countered suicidal ideations by focusing on work as a means of providing for their family (Oliffe, Ogrodniczuk, Bottorff, Johnson, & Hoyak, 2012. 1. Oliffe JL, Han CSE. Beyond Workers’ Compensation: Men’s Mental Health In and Out of Work. American Journal of Men’s Health. January 2014:45-53. doi:10.1177/1557988313490786

Is There a Connection Between Depression and Retirement?

Depressed workers are more likely to retire than nondepressed workers (Doshi, Cen, & Polsky, 2008) 1. Oliffe JL, Han CSE. Beyond Workers’ Compensation: Men’s Mental Health In and Out of Work. American Journal of Men’s Health. January 2014:45-53. doi:10.1177/155798831349078

What Does This Information Mean with Respect to Workers’ Compensation Claims?

These studies impact workers’ compensation cases in that they provide insight into the injured worker.

There studies show that there is some uniqueness for a man to file a claim for depression. These studies provide “red flags” as to certain occupations that men perform and their risk for suicide.  These studies may give some insight to employers as to whether depressed male  injured workers are going retire or return to work.  These studies show that working may assist a man’s mental state.

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.

 

WHY IS MY WORKERS’ COMPENSATION CLAIM DELAYED?  INJURED WORKERS, OUTSTANDING CLAIMS, AND WORKERS’ COMPENSATION: WHAT YOU NEED TO KNOW

Many Injured Workers have their workers’ compensation claims delayed.

This article will discuss why claims are delayed and what Insurance Company activities occur during the delay period.

Why Are Claims Delayed?

Insurance Companies delay claims in order to verify that there is a legitimate claim.  Per the Labor Code, they are afforded this opportunity to investigate.

As part of their investigation, Insurance Companies will investigate the following matters.

Coverage: Insurance Companies need to verify that they actually insure the Employer for the date of the injury.

Employment Verification: Insurance Companies need to verify the Injured Worker actually worked for the Insured Employer.

Date of Injury:  Insurance Companies need to verify the date of injury.

Employer Injury Knowledge:  Insurance Companies need to know if the Employer knows about the work injury.  They need to know the details how the injury happened, whether there were witnesses,  and whether it was reported to management.

Medical Verification: Insurance Companies will seek to obtain the medical reporting from the Industrial Clinic or the Medical Provider who treated the worker.

Statements: Insurance Companies may seek the use of an investigator to take statements of the injured worker, other employees of the company, or witnesses,  to verify the injury.  Investigations can be done by Attorney who may take depositions.

Records:  Insurance Companies may seek records from prior employers, insurance companies or medical providers

Qualified Medical Evaluation: An Insurance Company may seek a Panel Evaluator from the State of California to obtain a medical opinion on causation. .

What is the Authority for Delaying a Workers’ Compensation Claim?

Labor Code Section 5402(b) provides for a 90 day period upon which Insurance Companies have to deny a claim.  Thus, there is a 90 day period to delay the claim and investigate.  This 90 days is from the knowledge of the claim.

The date of knowledge is per LC 5402(a) which provides that “ [k]nowledge of an injury, obtained from any source, on the part of an employer, his or her managing agent, superintendent, foreman, or other person in authority, or knowledge of the assertion of a claim of injury sufficient to afford opportunity to the employer to make an investigation into the facts, is equivalent to service under Section 5400.” Thus, employer knowledge can trigger the start of the insurance company’s delay period

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.

 

CALIFORNIA’S TOTAL TEMPORARY DISABLITY RATES FOR 2021: INJURED WORKERS, WORKERS’ COMPENSATION, AND DISABILITY PAYMENTS: WHAT YOU NEED TO KNOW

The State of California Department of Industrial Relations announced the total temporary disability rates for 2021 (See DIR Release Number: 2020-95, November 2, 2020.)

The current maximum rate is now $1,356.31, per week.  The current minimum rate is to be $203.44.

Thus, total temporary disability payments that are due for dates of injury occurring on 1/1/21, and thereafter in 2021, are to be at these rates.  For prior injury dates, if the total temporary disability payments are made two years after the date of injury, then they are to be paid out at these new amounts as well.

Generally, total temporary disability payments are calculated by 2/3rds of the Injured Worker’s Average Weekly Wage at the time of the injury.

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.

 

DOCTORS’ ATTITUDES TOWARDS WORKERS’ COMPENSATION TREATMENT: INJURED WORKERS, THEIR TREATING DOCTORS, AND THEIR MEDICAL TREATMENT: WHAT YOU NEED TO KNOW

Doctors, as much as Injured Workers, can be frustrated with the administrative process controlling work injury treatment. This frustration is in large part due to the rules, regulations and statutes which govern industrial medical treatment.

California Workers’ Compensation System medical treatment rules for authorization are different than regular health insurance. Thus, treatments that are may be authorized under regular health insurance without difficulty may not be authorized as part of treatment for a workers’ compensation claim.

Part of the difference in treatment between workers’ compensation and regular health insurance is that Workers’ Compensation Law has adopted  Evidence Based Medicine (EBM) as a means of determine what treatment should be authorized. Labor Code 5307.27. adopted a medical treatment utilization schedule which is to incorporate evidence-based, peer-reviewed, and nationally recognized standards of care

This article will discuss Evidence Based Medicine (EBM), how medical providers view EBM, and what an Injured Worker can do to address their workers’ compensation treatment.

What Is Evidence Based Medicine (EBM)?

Evidence Based Medicine looks towards science to determine whether treatment helpful.  Thus, they will look at scientific studies as a basis for treatment.  These studies could include ones in which they look at the benefits of a particular mode of therapy within a population.

For example, if 90 percent of the individuals in a study report a significant benefit from a form of therapy, then, there would be a likelihood that therapy would be recommended in an EBM format.

Also, EBM will look at the quality or strength of studies to determine which ones should be followed.  This determination is made by experts who are qualified to make such an assessment. Benjamin Djulbegovic, Gordon H Guyatt, Progress in evidence-based medicine, The Lancet, Volume 390, Issue 10092, 2017, Pages 415-423, ISSN 0140-6736, https://doi.org/10.1016/S0140-6736(16)31592-6.

Note: My criticism of EBM is that each patient responds differently towards treatment. Thus, while a treatment may not be considered effective with respect to the general population, it may be something that is effective toward on an individual basis.

An individual may have a history with a particular form of treatment, i.e. chiropractic, which had been effective in the past for the individuals.   Thus, a general scientific study is being chosen against real data concerning the real patient.  It is important to note that it is the real patient who is going to get the treatment and not a statistical patient.  It can be argued that a small scientific study based upon the individual’s success with a treatment is more valuable than a broader study.  Arguably, it is far more relevant.

What Is Workers’ Compensations’ Interest In EBM?

In an article, the following was the commentary with respect to this issue: “[t]he workers’ compensation scheme expects that such a tool (EBM) could reduce the uncertainty about the appropriateness and effectiveness of a treatment. Reducing the uncertainty could speed up the decision-making process and reduce the need to seek second opinions from medical examiners. Health care practitioners would no longer have to complete additional paperwork for those evidence-based treatments. In general, it could facilitate a common understanding across those requesting treatment/services and those reviewing the services requested.” Elbers, N.A., Chase, R., Craig, A. et al. Health care professionals’ attitudes towards evidence-based medicine in the workers’ compensation setting: a cohort study. BMC Med Inform Decis Mak 17, 64 (2017). https://doi.org/10.1186/s12911-017-0460-2

Note: While this was the view in the study, this was not an assessment of the California Workers’ Compensation scheme concerning medical treatment.  Despite the EBM approach, doctors are still subjected to considerable amount of paperwork to get treatment authorized.  Further, EBM requests for treatment are still subject to a Utilization Review process and are not automatically authorized.  Further, there is a training problem in that not all medical providers are adequately versed with respect to EBM. As a result, requests for treatment from certain providers may be denied as being improper.

What Is Insurance Companies’ Interest in Evidence Based Medicine?

In an article, it is noted that “[t]he tool is primarily developed to be used by claims managers. However, the treatment approval process is an interaction between claims managers and health care professionals.” Elbers, N.A., Chase, R., Craig, A. et al. Health care professionals’ attitudes towards evidence-based medicine in the workers’ compensation setting: a cohort study. BMC Med Inform Decis Mak 17, 64 (2017). https://doi.org/10.1186/s12911-017-0460-2

Thus, EBM is a means upon which Insurance Companies can assert control of medical treatment away from doctors.  They can use EBM to dictate to providers as to what treatment will be authorized. Thus, Insurance Companies have supplanted doctors with decades of experience to determine necessary treatment.

What Are the Criticisms of EBM?

There are a variety of criticisms for EBM.

Cookbook Medicine:  This term has the implication as to whether a doctor is needed.   Thus, all one needs to administer medical care is look at the guidelines.  Thus, who needs training, experience and expertise to provide treatment?

Decreased Professional Freedom:  The profession of medicine is referred to as both a practice and an art.  EBM takes away a doctor’s experience, knowledge and acquired skills from being employed to treat patients.  When I treat for my industrial injuries, I want to go to an experienced and talented doctor.  I do not necessarily want to go to a doctor who knows EBM.

What are the Visions and Problems for EBM?

It may provide guidance to clinicians in that they would know what they can request for authorization.

It may limit over-servicing or over-prescription of a particular medicine or treatment.

It may work as a basis to guide patients’ expectations as to what they can receive and how long their course of treatment will last pending return to work.

It may cause problems in that treatment will be insurance company formulaic as opposed to being dictated by the provider.

It may conflict with patient’s concerns about their treatment and as to what would benefit them.  Sometimes, they are confronted with a doctor wanting to perform surgery and an insurance company denying the authorization.  Also, patients come in conflict with their doctors when they wish to try treatment which is not within EBM guidelines.

There are questions as to the quality and quantity of the evidence that is used. Studies can be generated to produce results favorable to insurance companies’ positions and then adopted within the EBM guidelines.

The article indicated that there may be more timeliness on approval of treatment.   In California, however, as long as treatment requests are sent to UR, there will be delays in providing industrial treatment even if they fall within EBM based guidelines.  Some claims departments have taken an approach of pre-authorizing some forms of treatment to eliminate this process. This has been helpful.

There are concerns with respect to those analyzing the data and recommendations within an EBM setting. There may be some bias involved which may relate to countries, legal systems and forms of medical delivery or insurance.

There are concerns that the Insurance Industry will use EBM as a tool to dictate medical treatment at the expense of the Injured Worker.   There are medical providers who will reject EBM and discontinue treating cases on an industrial basis.  This will leave the field of medical providers as ones who will simply comply with EBM rather than fight for patient’s medical treatment needs.

EBM creates problems.  It creates distrust in medical providers who want to do their job.  It throws out the window medical expertise from providers with decades of experience.   It discourages Injured Workers who simply wish to get their treatment provided on a timely basis. It emboldens Insurance Companies and their representatives to tell Injured Workers that they are better off getting their treatment elsewhere.   This is offensive in that the industrial treatment is mandated to be done through this system.   It is unfair to force injured Workers to treat within a broken or ineffective system.

What are Doctors’ View of Evidence Based Medicine?

Per the study on doctor’s attitude, they noted that “Overall, HCP[health care providers] are supportive of EBM, but have strong concerns about implementation of EBM based decision making in the workers’ compensation setting.

The participants felt that an EBM tool should not be applied rigidly and should take into account clinical judgement and patient variability and preferences.

In general, the treatment approval process in the workers’ compensation insurance system is a sensitive area, in which the interaction between HCP and claims managers can be improved.” Elbers, N.A., Chase, R., Craig, A. et al. Health care professionals’ attitudes towards evidence-based medicine in the workers’ compensation setting: a cohort study. BMC Med Inform Decis Mak 17, 64 (2017). https://doi.org/10.1186/s12911-017-0460-2

What Should an Injured Worker Do?

It is very important that an Injured Worker find medical providers that both understanding the paperwork needed to be placed in for treatment requests as well as understand the treatment guidelines which are in part based upon Evidence Based Medicine concepts.

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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