Dr. Meredith Warner, MD, MBA, of Warner Orthopedics and Wellness in Baton Rouge, is a foot and ankle surgeon, pain specialist and Veteran who treats workers’ comp patients with a keen eye toward return to work. Louisiana Comp Blog sat down with Dr. Warner to discuss her work and the provider experience in Louisiana’s workers’ comp system. Read on to get Dr. Warner’s thoughts on why more education is needed on all sides.
Comp Blog: From a provider’s perspective, what is the major difference between comp patients and other patients?
Dr. Warner: It used to be that providers would complain that comp patients involved a lot of paperwork, but nowadays, I don’t know if it’s because of the ACA or just the way healthcare is going in general, every patient requires massive amounts of paperwork.
In the work comp arena now in this state, we have utilization review and the medical treatment guidelines. You have to get permission for every patient now, comp or not. It’s almost like we’re not doctors anymore, we’re more like technicians. That’s just the game of all types of insurance.
Comp Blog: When a workers’ comp patient comes to your office, how do your processes work as a provider?
Dr. Warner: First, obviously we have to check on everything and make sure that they were approved and that it’s actually a work injury. After that, every carrier is different as to what they’re going to let you do on that first visit. Some want you to do a 1010 for braces, some don’t. Some want you to do 1010s for medicine, some don’t. Then of course you’re going to take the history and the chief complaint. There you’re depending on the patient’s self-report, which is difficult to get any degree of accuracy, but it’s all we have. From there you go to imaging, if you need it.
Comp Blog: “Evidence-based medicine” is one of those buzzwords in workers’ comp on a national level. Can you explain what that means for you in practice?
Dr. Warner: I practice as much as possible evidence-based medicine, mostly because I believe in science and I don’t try to do fairytale-land medicine. Two examples of how this works in practice are narcotics and imaging.
If a patient comes in with basic back pain, the last thing you want to do is get them on narcotics right away, you’re almost dooming them to a lifetime of failure.
The second thing that has been shown to increase treatment but not make outcomes better and, in fact, delay return to work, is early MRI. Unless you have a neurologic deficit, (meaning actual weakness, sensory loss or loss of reflex) or unless you see a tumor or a fracture on the x-ray, you’re not supposed to get an MRI before the two to four month time frame of continued pain.
Comp Blog: Why the wait on the MRI?
Dr. Warner: The problem with MRIs is that everybody has a disk [problem], everybody has arthritis, everybody has end plate changes. There is study after study showing the prevalence of this – in you, in me, in 20 year olds, asymptomatic, symptomatic, male, female, the list goes on. Something will be seen on the MRI, and then 99 times out of a hundred, treatment is directed toward that “something” – whether or not it has anything to do with the pain.
The key to this is to have the time to sit and explain to the patient why they’re not getting an MRI, because they’re just blasted by this in the media all the time. The attorney might be telling them they need it, the family might be telling them that. So a lot of it is education. And then if you do get an MRI, you have to have the time to explain what the results mean rather than just saying, “okay, you need a fusion.”
So I do practice evidence-based medicine, but what I’ve learned is that if you spend the time talking to the patient and educating the patient, and they can get really good physical therapy early, the outcomes are better. Everyone wants the knowledge, and when the patient understands their body better, they don’t wake up with back pain and think they’re going to be paralyzed tomorrow.
Comp Blog: Can you elaborate on the education angle?
Dr. Warner: You’ve got to get past that fear. The worst thing a patient can do is sit still and avoid motion – it makes the pain worse and it makes the disability worse.
There’s actually something called “fear-avoidance behavior” where people avoid work and activity because they’re either afraid of the pain or they’re afraid that pain equals damage, or both. I try to empower my patients and direct their treatment so that they’re active participants and get to know their own bodies better.
Comp Blog: You mentioned attorney involvement with workers’ comp patients and the pressure from those sources. Have you encountered much of that?
Dr. Warner: It can be really touch-and-go when attorneys try to make medical decisions, which really shouldn’t happen, but it’s a pretty frequent issue. I’ve had cases where I didn’t want to order an MRI and the attorney sent the injured worker to a different doctor that would [order it.] I understand that [attorneys] are trying to advocate for their client and they think that’s the best way to help them, but that’s the same lack of knowledge issue.
Comp Blog: What’s the most common injury that you see among your workers’ comp patients in this practice?
Dr. Warner: For me, it’s probably fifty percent back and neck pain, and fifty percent extremity. I have a fellowship training in foot and ankle surgery but that’s only half of my practice, the other half is aches and pains, of which back pain is very common. Nationally, the most common occupational injury is extremity fractures.
Comp Blog: More and more insurers are reimbursing for alternative medicine, things like yoga and acupuncture. How do feel about that for your patients? Do you recommend it?
Dr. Warner: I’m a big fan of yoga, and I’ve actually sent a few injured workers to yoga and it’s been approved recently. I think yoga is very helpful, and I also think acupuncture has a strong history. We also [recommend] chiropractic care [frequently], and some people do well with herbal remedies for pain, it all depends. Yoga and acupuncture have been around for at least 10,000 years. Obviously, if it’s been around that long and more than half of the world uses it, there’s something going on there.
And I’ll say, conversely, lumbar fusions for back pain have terrible evidence. There’s next to nothing to support it and evidence to show that patients who have a lumbar fusion [to treat pain] go to work less often, take more narcotics, and have more disability – but a lot of insurers will approve that.
So for example, if I want to send an injured worker to the gym to get a personal trainer and build up muscle strength, that won’t get approved, but I can clear a lumbar fusion and Percocet without a problem – that doesn’t make sense.
Comp Blog: Louisiana has what is an undisputedly huge opioid abuse problem. Would you be in support of a prescription drug monitoring law like the one implemented in Kentucky? Or is there something else that you think should be done to curb the problem?
Dr. Warner: Better physician education is where it starts. I use the [prescription drug monitoring] database we have here, but the problem is, in this state, you can go to Texas very easily and also Alabama and Mississippi. We don’t have access to their databases. The only one we do have access to is Arkansas. The patients are either going to cross the [state] line or get it on the street, and then there’s not much we can do about that.
For me, the problem is the doctors. We’re the ones with the power. If we all wrote narcotics appropriately there wouldn’t be a problem. And in medical school, we don’t learn enough about the body of knowledge surrounding pain. There’s a lot that goes into that: how your brain works, psychosocial concerns, education level, etc. It’s difficult, because you want to treat the pain and believe your patients when they come in and say they’re in pain. But at a certain number of pills per month for an individual patient, there needs to be a cut-off; some of the numbers I’ve seen are just ridiculous.
Comp Blog: What else goes into this pain treatment issue, what other options are there?
Dr. Warner: Well there’s been a big issue with compounded topical medications, a lot of insurers won’t pay for them. But at least it’s non-narcotic and it’s a option, some patients respond well to them. Again, I could write for Percocet, Gabapentin, Opana ER, whatever narcotic I want, and [some insurers] won’t even blink. But if I try to write for a non-narcotic pain cream one time – that’s it. It may be that some insurance companies would cover compounds if the pricing were consistent and more reasonable. If we want to reduce the use of narcotics across the board, then alternatives need to be approved.
I treat chronic pain patients and I do injections [ESI]. Part of the reason I do them myself is because I don’t want my patients to get stuck on the treadmill of narcotics and repeated injections.
Basically, if you have a really good physical therapist, and you educate the patient and the patient is a willing participant in this process, almost all of them get better.
Comp Blog: So return to work as soon as possible is your goal for your patients?
Dr. Warner: I try and get them back to work sooner rather than later. If your back is going to hurt, it’s going to hurt whether you’re or at work or whether you’re watching daytime TV. In fact, usually it’ll hurt less during work because there’s a distraction and the patient is mobile. And on the psychological side, [working can] give a pain patient their sense of self-worth back and it motivates them. It’s a disservice to keep an injured worker out of work longer than they need to be out.