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SHOULD WORKERS’ COMPENSATION MEDICAL TREATMENT PROTOCOLS BE CHANGED?

Posted on April 5, 2022 by Edward Singer

California Workers’ Compensation Law has adopted the concept of Evidence Based Medicine as a means of allocating medical care to Injured Workers. A British Medicine Journal article should perhaps serve as a “wake up” call for the Department of Industrial Relations as to whether this reliance on EBM should be re-visited. The article entitled “The Illusion of Evidence Based Medicine.”

Evidence Based Medicine attempts to quantify the value of forms of medical treatment. Evidence Based Medicine can conduct various studies to determine whether particular surgeries, medications, treatments, or therapies are helpful to patients. Arguably, this is analogous to taking a survey on which ice cream flavor one likes. If there is a large consensus on vanilla, then there is a likelihood that vanilla will be served to everyone wanting ice cream. You, however, may prefer chocolate and derive much satisfaction from it.

Evidence Based Medicine depends upon reliable data from studies. It is reported, however, that confidential pharmaceutical industry documents have given insight that misrepresentations are present in the findings. This leads the author’s to conclude that evidence based medicine is an illusion. In other terms, Evidence Based Medicine, without proper evidence, is bogus.

The Workers’ Compensation System is premised on medical probability. Any false or inaccurate information, from any source, compromises the system. This includes opinions concerning medical treatment. Thus, bogus scientific studies cannot be used to deny medical care. Therefore, it would be wise if the Department of Industrial Relations reach out to those who administrate the medical authorization to address the serious concern raised by the article.

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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.

CAN A POLICE OFFICER CLAIM INJURY WHEN HE WAS BITTEN BY HIS PARTNER? INJURED WORKER IN THE NEWS, #26

Posted on March 31, 2022 by Edward Singer

In Florida, a Police Officer sustained a work-related injury when was bitten a fellow Police Officer. His K9 partner may have tried to take a bite out of crime but instead bit his partner’s arm. It is reported that the dog became agitated during an attempted arrest. The dog bit his handler. Dailymail.com

This fact pattern raises the questions as to whether an Employee can file a workers’ compensation claim when they get injured as a result of a co-worker’s mistake. The fact pattern raises a treatment issue. Dog bites present unique issues.

Can an Injured Worker File a Claim If They Are Injured By A Co-Worker?

Yes. Generally, workers’ compensation is a “no fault” system This applies to the actions of co-workers. Thus, the dog bite by his K-9 Partner is a valid workers’ compensation claim.

What Type Of Treatment Can Be Provided?

In the instance of a dog bite, there is a concern whether the dog may have had rabies. Thus, the Police Officer may be put on rabies treatment protocol. Likewise, treatment may be necessary to prevent infection.

Labor Code Section 4600 provides that “(a) medical, surgical, chiropractic, acupuncture, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of the worker’s injury shall be provided by the employer. In the case of the employer’s neglect or refusal reasonably to do so, the employer is liable for the reasonable expense incurred by or on behalf of the employee in providing treatment. (b) As used in this division and notwithstanding any other law, medical treatment that is reasonably required to cure or relieve the injured worker from the effects of the worker’s injury means treatment that is based upon the guidelines adopted by the administrative director pursuant to Section 5307.27.”

Thus, the medical providers treating these type of bite injuries, within the guidelines, will provide treatment to prevent infection on this matter.

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The Opioid Risk Tool (Ort) And Work Injury Treatment

Posted on April 19, 2021 by Edward Singer

In the field of medicine, tools are used to assess treatment’s nature and course. These tools are used to make assessments to medical treatment. The tools are frequently questionnaires filled out by patients on their own. These tools are considered a cost-effective and reliable means of obtaining information.

Opioid medications can be prescribed to treat work injuries. They can be used in circumstances of acute injuries and in circumstances of chronic pain. Medical Providers are very concerned over prescribed opioid medications as they are controlled substances and are subject to governmental scrutiny.

This article will discuss the Opioid Risk Tool (ORT), the topics addressed, in the ORT, how the ORT is scored, and why it is the ORT is important.

Are Opioids a Problem Within Workers’ Compensation?

It is reported that the “NCCI data shows that injured workers who were prescribed at least one prescription in 2016 received three times as many opioid prescriptions as the US opioid prescribing rate. These figures illustrate that workers compensation is directly affected by the far-reaching societal impacts of the opioid epidemic in the United States.” ncci

What Is the Opioid Risk Tool (ORT)?

The ORT was developed by Webster, et al. as a “self-performed screening tool designed for use by adult patients in primary care settings before beginning opioid treatment for pain management.” ncbi

Note: within workers’ compensation medical treatment, there is concern and analysis over what is medically appropriate treatment that is intended to cure or relieve the effects of an injury pursuant to Labor Code Section 4600. The ORT can be used as a basis for approving or denying the provision of narcotic medications. The ORT information may be employed by Utilization Review and Independent Medical Review for approval or denial of opioid prescriptions.

What are the Topics in the ORT?

The ORT includes the following topics:

Patient’s Gender
Patient’s Family History of Substance Abuse
1. Alcohol
2. Illegal Drugs
3. Prescription Drugs
Patient’s Personal History of Substance Abuse
1. Alcohol
2. Illegal Drugs
3. Prescription Drugs
Patient’s Age Range of Patient, Specially between 16 to 45 years
Patient’s History of Preadolescent Sexual Abuse
Patient’s Psychological Disease
1. Attention Deficit Hyperactivity Disorder
2. Obsessive-Compulsive Disorder
3. Bipolar Disorder
4. Schizophrenia
5. Depression

How Is the Questionnaire Scored?

The scoring on the questions are as follow:

“Family history of substance abuse including alcohol (Female=1; Male=3), illegal drugs (2;3), and/or prescription drugs (4;4) Personal history of substance abuse including alcohol (Female=3; Male=3), illegal drugs (4;4), and/or prescription drugs (5;5) Whether the patient age range is between 16 to 45 years (1;1) A history of preadolescent sexual abuse (3;0) Psychological disease including attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), bipolar disorder, schizophrenia (2;2); and/or depression (1;1).ncbi

Note: There are gender differences when scoring the test. Some drug and alcohol abuse answers score higher for males, and only females receive a score on the issue of preadolescent sexual abuse.

What Does the Score Mean?

“Scores are summed, and a score of 3 or below suggests a low risk for future opioid abuse, while a score of 4 to 7 indicates moderate risk. A score of 8 or greater suggests a high risk of future abusive drug-related behavior.” ncbi

Note: Score suggesting a high risk of future abusive drug-related behavior may be used to call into question prescriptions for those patients.

How Does This Impact Injured Workers?

Medical providers will analyze these scores as part of their decision to prescribe opioid medications. If the scores are too high, it is likely that a provider will consider alternative forms of medication and treatment for the individual to avoid the possibility of substance abuse.

Further, if opioids are prescribed to at risk patients, there may be additional monitoring taking place. “ Higher risk patients require more frequent monitoring than lower-risk patients. Follow-ups may include re-screening of risk, urine drug screening, and observation for other clues of drug abuse. These clues may consist of requests for dose escalation, doctor shopping, forging prescriptions, requesting early prescriptions, unscheduled clinic visits, or emergency room visits with complaints of pain.” ncbi

https://www.ncbi.nlm.nih.gov/books/NBK553147/

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

Posted on February 8, 2021 by Edward Singer

“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.

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

Posted on January 6, 2021 by Edward Singer

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.

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