The following guest post is by Dr. Douglas Lurie, a board-certified orthopaedic surgeon with Orthopaedic Associates of New Orleans. He graduated magna cum laude from Birmingham Southern College as a Phi Beta Kappa with a Bachelor of Science degree in Business Management. Dr. Lurie then graduated from the University of South Alabama School of Medicine where he was elected to the Alpha Omega Alpha medical honor society. He completed his Orthopaedic Surgery internship and residency at Ochsner Clinic Foundation in New Orleans, where he was a chief resident. In the workers’ comp arena, Dr. Lurie has performed thousands of utilization reviews since the Medical Treatment Guidelines were implemented. He is also the National Medical Director for Propeer, a URAC-certified independent review organization.
I recently read a book called The Outliers by Malcolm Gladwell. One of the examples he gives is that most major plane crashes are not due to some grossly negligent behavior, but were instead due to multiple small failures of communication. Often the culture of the crew and how they communicate together was the most important factor. I feel that this is unbelievably analogous to failures in workers’ compensation.
In my practice, I find that the culture and communication of all stakeholders is of tantamount importance to the outcome of the claim. The culture starts with the employer and employee. If the employee knows from their point of hire that their employer will accommodate light duty and believes return to work is actually a part of treatment rather than an impediment to recovery, then they will have better outcomes. On the flipside, if communication is steadily eroded throughout the life of the claim, outcomes can be disastrous.
The following three cases – all shoulder injuries which I frequently treat for workers’ comp patients – reveal the roots of system failure.
My first example case is a merchandiser for a local company. She sustained a “slap tear” [an injury to the ring of cartilage that surrounds the socket of the shoulder joint] when she fell in a freezer. I know this patient from a prior injury with the same employer. There is a distinct contrast between the claims, which is two-fold.
The first injury I cared for was when the company was locally owned and provided light duty the whole time. She never missed any work because she was able to work in the office. For the second injury, the 100 year old company had sold out to a national group which no longer provides light duty, further, the carrier changed from a local TPA to a national workers’ comp giant. Worse, the day before the surgery, the patient was notified that the company was closing the local distribution center, and she would no longer have a job when she was released. Couple this with two different four-week delays in authorization for post-op physical therapy and her prognosis has become poor, and the claim is in litigation. No one from the company has ever called to check on her and she knows she has no job to go back to after fourteen years as a merchandiser – her likelihood of ever returning to work at full duty is minimal
The second case involves a 26 year old who works for an auto glass company. He was holding a piece of glass out away from his body when he felt a pop and could no longer raise his arm. He was sent for physical therapy and the therapist sent him back to the doctor after two visits because he wasn’t progressing. The treating physician recommended an MRI, which was denied because he hadn’t failed an adequate trial of physical therapy. As such, the patient returned to physical therapy until he failed an additional 6 sessions, at which point an MRI was approved.
The MRI revealed a slap tear and he was referred to me. I recommended surgery because he failed the trial of physical therapy before MRI. Surgery was denied due to inadequate trial of non-operative therapy. I then requested physical therapy due to the denial for surgery. That request was denied because he had previously not responded to physical therapy. Then, a peer to peer was required by the carrier when I re-submitted, and finally the physical therapy was approved.
The patient did two sessions of therapy and was sent back to me again for failure to progress. I again requested surgery and it was denied with the same rationale. So, in accordance with the Medical Treatment Guidelines we were butting up against, I sent him back for the four more approved sessions and the surgery was approved.
Strangely, post-op physical therapy was denied because he had failed to respond to prior PT. After another runaround, six weeks after the surgery, the post-op PT was finally approved. All the while, the patient’s employer did not accommodate light duty or maintain any communication with the claimant. At this point, he had not been at work since last December [of 2015]. Note that it took a total of six months to get the surgery approved, and in the meantime, he received a letter that his health insurance and benefits were dropped because premiums hadn’t been paid out of his check because he had not been working.
All in all, his prognosis is terrible. This claimant has never been contacted by his company and has no local case manager. Everything is being handled by a national carrier with a national third party utilization review company. This case has also now entered the legal system too.
The final example case that I will discuss here involves a 56 year old certified nursing assistant who fell and dislocated her shoulder. The MRI revealed a massive rotator cuff tear after she failed a short course of therapy. No light duty has been offered since the time of injury. Surgery was performed and after twenty-one sessions of PT, further therapy was denied.
The first twelve or so therapy visits were completely passive and the patient was making slow progress when a home exercise program was recommended. The optimum range for PT after cuff repair is 24-36 and the maximum is 48, per Louisiana’s Medical Treatment Guidelines. Ultimately, I was able to get nine more visits approved by appealing to the carrier, but only after a month’s delay.
After this delay, the patient returned to me. She was doing worse and notified me that she had retained an attorney. At this point, she was only about ten weeks post-op, which is very early in the recovery process. The recommendation stemming from the denial was that she should be able to perform a home exercise program – reality check, this is a 56 year old who has never exercised in her life. It’s no surprise that the claim devolved.
All three of these cases demonstrate poor management in the workers’ comp system, which is already a hot bed of bureaucracy. The importance of communication cannot be understated. Communication must be maintained with all parties, including the provider, claimant, adjuster, and employer. Someone has to be the point of contact – whether it be a case manager or safety officer. Don’t wait to assign this task until after the case has entered litigation. Then it’s too late – the plane is already crashing.
Keeping an employee engaged with an employer and at work is important. After a six month absence from work, (most shoulder injuries, like in these cases, take six months for a full release) the probability of ever returning to the same job is very, very low. Employers who insist on a hands-off approach will have greater disability after injury and more expensive claims.
And further, the cultural background of the claimant is important – where you live and what you do have an impact on how you react to injury and certainly contribute to whether you view yourself as a victim after a work injury.
Lastly, interpreting utilization review rules can be subjective. Healthcare and injuries are emotional for most people. A denial for therapy after surgery is going to create anger. Anger for someone who sees themselves as a victim will lead to litigation. When it comes to post-op therapy and even diagnostics, it probably makes more sense to try to use the guidelines as a tool for approval rather than looking for any possible reason to deny a request, which seems to be the modus operandi of huge national UR companies.