ROTATOR CUFF SHOULDER SURGERIES AND WORKERS’ COMPENSATION: INDUSTRIAL VS. NON-INDUSTRIAL SURGERY RESULTS: WHAT YOU NEED TO KNOW  

In the US, annually, almost 2 million adults visit doctors for rotator cuff injuries. AAOS. A number of these individuals seeking this shoulder treatment on a work-related basis.  If conservative care does not resolve the issues, surgery is indicated.

With all types of surgeries, medical researchers like to compare the results of the Industrially provided versus those done on a non-industrial basis.  A study was done with respect to Rotator Cuff Surgeries.

This article will discuss the Rotator Cuff, Rotator Cuff Injuries, Causes of Rotator Cuff Injuries, Rotator Cuff Surgeries, and the Study’s Findings.

What is a Rotator Cuff?

The rotator cuff is a group of four muscles that come together as tendons to form a covering around the head of the humerus in the shoulder. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm. AAOC

How Does a Rotator Cuff Get Injured?

 A rotator cuff injury can occur when one or more of the tendons are torn.  Tears can range from  partial to full-thickness(complete.) AAOC

What Are Symptoms of Rotator Cuff Injuries?

 The symptoms for rotator cuff tears can include pain at rest and at night, pain when lifting and lowering your arm, pain with specific movements, weakness when lifting or rotating your arm and cracking when moving your shoulder. AAOC

 What Is Rotator Cuff Surgery?

A rotator cuff surgery will  attempt to repair the torn tendons.   This can include re-attaching them to the bone. AAOC

What Work Activities Can Cause an Industrial Rotator Cuff Injury?

There are a number of factors that have been identified as causative towards industrial shoulder problems.   These factors that are considered as occupational risk factors for shoulder tendinopathy, impingement, and rotator cuff tears include: the combination of risk factors (eg force and repetition, force and posture); some evidence, highly repetitive work alone or in combination with other factors, some evidence, and awkward postures: strong evidence ( sustained shoulder postures with more than 60 degrees of flexion or abduction) AMA Guides to the Evaluation of Disease and Injury Causation, 2nd Edition,  P. 320

Thus, painters, carpenters, and others who do overhead work also have a greater chance for tears. They can also be caused by a traumatic injury such as a fall. AAOC

What are the Factors that Can Impact the Results of a Rotator Cuff Surgery?

There are a number of factors that can impact the recovery from a rotator cuff surgery.   This factors affecting postoperative outcomes include age, gender, and smoking status. Other factors that can impact the outcome include the number of surgeons, tear size, operation method, and surgical technique.  Kim KC, Lee WY, Shin HD, Han SC, Yeon KW. Do patients receiving workers’ compensation who undergo arthroscopic rotator cuff repair have worse outcomes than non-recipients? Retrospective case-control study. J Orthop Surg (Hong Kong). 2018 May-Aug;26(3):2309499018802507. doi: 10.1177/2309499018802507. PMID: 30270747.

Also, factors most commonly believed to affect postoperative outcomes also include fatty degeneration and diabetes mellitus. Kim KC, Lee WY, Shin HD, Han SC, Yeon KW. Do patients receiving workers’ compensation who undergo arthroscopic rotator cuff repair have worse outcomes than non-recipients? Retrospective case-control study. J Orthop Surg (Hong Kong). 2018 May-Aug;26(3):2309499018802507. doi: 10.1177/2309499018802507. PMID: 30270747.

What Were the Results of the Study?

 The study found thatAlthough workers’ compensation recipients who undergo arthroscopic rotator cuff repair had worse outcomes before the end of WCB(Workers’ Compensation) benefits, the outcomes became similar after WCB(Workers’ Compensation) benefits ended” Kim KC, Lee WY, Shin HD, Han SC, Yeon KW. Do patients receiving workers’ compensation who undergo arthroscopic rotator cuff repair have worse outcomes than non-recipients? Retrospective case-control study. J Orthop Surg (Hong Kong). 2018 May-Aug;26(3):2309499018802507. doi: 10.1177/2309499018802507. PMID: 30270747.

The data supported “the hypothesis that patients with workers’ compensation claims would have worse outcomes.” Kim KC, Lee WY, Shin HD, Han SC, Yeon KW. Do patients receiving workers’ compensation who undergo arthroscopic rotator cuff repair have worse outcomes than non-recipients? Retrospective case-control study. J Orthop Surg (Hong Kong). 2018 May-Aug;26(3):2309499018802507. doi: 10.1177/2309499018802507. PMID: 30270747.

 As an Attorney, Why Do You Believe That An Injured Worker Have Worse Results?

As an attorney, I will express my opinion as to what could be the cause of poor results for industrial rotator cuff surgeries.

First, industrial medicine treatment, versus non-industrial treatment, may have more delay and denials in getting the treatment and surgery authorized.  Additionally, there may delays and denials in getting treatment authorized.

Second,  workers’ compensation claims determine impairment and dysfunction as part of a disability award.  Thuys, an injured worker may be focused on recalling their dysfunction as opposed to a non-industrial surgery in which there is no reward for a poor result.

Third, if there was dissatisfaction with the workers’ compensation process, an injured worker may have lingering emotional unhappiness with respect to the result.

Fourth, if the case was settled with a Compromise and Release Buy-Out of future medical care, the Injured Worker may not  access to follow up medical treatment needed for their shoulder.

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.

 

 

 

 

 

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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