What You Need To Know About Back Surgery, Return To Work, & Workers’ Compensation

Workers’ Compensation Medical Studies have been done on many topics.   Studies have reported on surgeries performed within the workers’ compensation environment.  Some studies have looked examined spinal surgeries.

Study results impact Injured Workers.  Studies results can create insurance Company expectations concerning surgery success and recovery times.   Insurance Company expectations from these studies can be imposed upon treating doctors concerning temporary and permanent disability.

This article will discuss back surgery, a study concerning back surgery, the back surgery study’s results. and what the study means for injured workers.

What Is Back Surgery?

The Spine has three segments: cervical, thoracic, and lumbar.  The lumbar segment of the spine is usually referred to as back or low back.  Back surgeries are generally on the area referred to as the lumbar spine.   There are various types of surgeries.   There are surgeries to address lumbar spine disks and there are other procedures that address the stability of the spine.   Common surgeries are laminectomies, fusions and disc replacement.

Besides the problems being operated on, there is also issue of levels.   The lumbar spine has multiple levels.   Some surgeries operate on one level and others involve multiple levels.

There are a variety of reasons why a particular surgery may be indicated.  This article will be addressing one of the reasons. A surgery to address a herniated lumbar disk. Specifically, a surgery to address a disk at only one level.   This procedure is called a laminectomy.

Why Is Back Surgery a Significant Workers’ Compensation Issue?

Back Surgeries are expensive.T they cause periods of temporary disability and may result in findings of permanent disability.   Back Surgeries can have complications that can be costly such as treatment for post-operative infections.  Thus, Insurance Companies, in a risk management analysis, may wish to prevent surgery liability by either denying the treatment or settling the case.

What Were the Study’s Results?

The study addressed focused only on a single-level lumbar disk herniation surgery.

According to the study, “[p]atients receiving WC(workers; compensation) with shorter duration of radiculopathy before diskectomy had higher RTW(return to work) rates; fewer physical therapy, chiropractic, and psychotherapy sessions; and fewer postoperative diagnoses of psychological illnesses.”  Ren BO, O’Donnell JA, Anderson JT, Haas AR, Percy R, Woods ST, Ahn UM, Ahn NU. Time to Surgery Affects Return to Work Rates for Workers’ Compensation Patients With Single-Level Lumbar Disk Herniation. Orthopedics. 2021 Jan 1;44(1):e43-e49. doi: 10.3928/01477447-20201202-06. Epub 2020 Dec 7. PMID: 33284984.

The study found that “within 12 weeks of injury, post-diskectomy patients do reasonably well, with a 70.0% (95% CI, 65.9%–74.1%) rate of RTW.”

The study also found that “[o]n the other hand, if a patient waited more than 2 years to have surgery for radiculopathy, RTW(return to work) rates decreased as low as 31.3% (95% CI, 26.3%–36.3%).” Ren BO, O’Donnell JA, Anderson JT, Haas AR, Percy R, Woods ST, Ahn UM, Ahn NU. Time to Surgery Affects Return to Work Rates for Workers’ Compensation Patients With Single-Level Lumbar Disk Herniation. Orthopedics. 2021 Jan 1;44(1):e43-e49. doi: 10.3928/01477447-20201202-06. Epub 2020 Dec 7. PMID: 33284984.

Note: the study’s results are confounding to Insurance Companies.  The study suggests that acting promptly to approve a surgery can lead to more promising results.   The study implies that a long drawn out battle for a back surgery can result in a poor result.  Thus, acting quickly and spending a considerable amount of money for treatment leads to a better result in this circumstance.  Thus, these types of cases are a true test for Adjusters.

Was There Anything Else Interesting from the Study?

Irrespective of surgery, the factors of  legal representation, psychological co-morbidity and mean household income can negatively impact return to work. Ren BO, O’Donnell JA, Anderson JT, Haas AR, Percy R, Woods ST, Ahn UM, Ahn NU. Time to Surgery Affects Return to Work Rates for Workers’ Compensation Patients With Single-Level Lumbar Disk Herniation. Orthopedics. 2021 Jan 1;44(1):e43-e49. doi: 10.3928/01477447-20201202-06. Epub 2020 Dec 7. PMID: 33284984.

Is There Anything an Injured Worker Should Do?

Injured Workers with spinal problems should get appropriate medical care at the onset of injury. In the case of severe back pain and in cases with radiculopathy, they should seek out an orthopedic surgeon to have their condition assessed.

Per the study, if surgery is truly indicated, surgery it suggests that it be done promptly. Each individual’s medical condition and recovery, however, is different. Thus, the treatment course should be done on an individual basis and not per a study.

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.

What You Need To Know About The Cage-aid Questionnaire And Workers’ Compensation

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.

 

THE PAIN, ENJOYMENT AND GENERAL ACTIVITY SCALE (PEG) AND WORKERS’ COMPENSATION: WHAT YOU NEED TO KNOW

The California Workers’ Compensation System employs various scales and tests to assist with Injured Workers’ evaluation and treatment.  One of these tests is the Pain, Enjoyment and General Activity Scale (PEG.)

This article will discuss the PEG Scale and how it can be used within the workers’ compensation system.

Why Are Scales Used in General?

Scales can be used for many reasons.   Scales are generally self-reporting. Thus, all that is needed to administer one is a pen, a clipboard, and the questionnaire. Thus, they are a cheap, quick and easy way to extract information from Injured Workers. Scales can show that an injured Worker is credible.  They can show that an Injured Worker is malingering or exaggerating. Scales can show a cry for help.

One way a scale can be used Is by comparing them to prior scales.  When compared, it can show a patient’s assessment of medical improvement or lack thereof.

Scales are employed by medical examiners, treaters and utilization review evaluators to assess the Injured Workers’ disability status, permanent disability, and whether forms of treatment are indicated and should be approved.

In an article discussing PEG, it was noted that “[t]he competing demands of primary care, in which visits are short and pain is only one of several problems warranting attention, make efficiency of assessment a paramount concern.  A balance must be found between feasibility and key characteristics such as reliability, validity, and responsiveness.”  Krebs EE, Lorenz KA, Bair MJ, et al. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. J Gen Intern Med. 2009;24(6):733-738. doi:10.1007/s11606-009-0981-1

What Is PEG Scale’s Complete Name?  How Does It Relate to Workers’ Compensation?

The PEG Scale’s full name is the Pain, Enjoyment of Life and General Activity Scale.

California Workers’ Compensation Law employs the AMA Guides to assess permanent impairment.  In the assessment of permanent impairment, Pain is a factor that is considered.  Also, Activities of Daily Living is also a factor.

In sum, the scale overlaps some of these issues.

What Does the PEG Scale Consist Of?

The PEG Scale consists of three questions that are rated from 0 to 10.

What is the Pain Scale’s First Question?

The first question is “what number best describes your pain on average in the past week?”

How is the First Scale Question Answered?

The question is answered in a 0 to 10 scale. 0 being “no pain” to 10 being “pain as bad as you can imagine.”

What is the Second Question of the Pain Scale?

The second question is “what number best describes how, during the past week, pain has interfered with your enjoyment of life?”

How is the Second Question Answered?

The question is answered in a 0 to 10 scale. 0 being “does not interfere” to 10 being “completely interferes.”

What is the Third Question on the Pain Scale?

The third question is “what number best describes how, during the past week, pain has interfered with your general activity?”

How is the Third Question Answered?

The question is answered in a 0 to 10 scale. 0 being “does not interfere” to 10, “completely interferes.”

How is the PEG Scale Scored?

The scale is scored by adding up all three numbers and dividing by 3.

What Is the PEG Scale Specifically Used For?

“This scale can be administered in person at a clinic or hospital, answered via phone interview or personally completed at home. It is a flexible scale that can be used for many scenarios. For example, the PEG scale is often used to determine if a medication is effective; using it for this purpose helps determine an individual’s level of functioning while taking medication(s). Individuals who show a stable level of functioning, with no other factors that suggest a dosage adjustment, a medication taper or a medication change is needed, would then continue on their medication regime.”  Painscale.com

Is There Any Advice to An Injured Worker?

Yes. These scales will be used possibly for two purposes: first, to evaluate your credibility, and  second, to evaluate your improvement with respect to prescription medications and treatment.

Thus, it is best to make your best efforts to accurately answer them.

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.

 

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.

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.

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