the rational approach to the work comp patient – is there such a thing? st. luke’s occupational...

The Rational Approach to the Work Comp Patient –

Is There Such a Thing?

St. Luke’s Occupational Health ConferenceAugust 21, 2009

RONALD ZIPPER, D.O., FAOAO, FAADEP

Independent Orthopaedics & Sports Medicine, P.C.

[email protected]

O: 816-221-BONEF: 816-453-6914

Questions?Deductible??

mailto:[email protected]

mailto:[email protected]

http://www.amazon.com/gp/reader/0689854730/ref=sib_dp_pt/102-9242362-9621748

Elizabeth Genovese, MD, MPH, FAADEP

Doug Martin, M.D. FAADEPDave Randolph, M.D., MPH,

FAADEP Jim Talmage, MD, FAADEP

Who shared information from other presentations were used in part in

the development of this presentation

So, Is There a Rational Approach to Occupational Injuries? What Does It Include?

Answer-YES! What Should It Include? • Employee Safety Monitoring.• Informed employees with Safe Job Descriptions within their

capacities.• Early Incident Reporting & Medical Referrals.• Accurate Diagnosis & Early Aggressive Conservative

Interventional Physician Directed Care Based on EBM.• Early RTW – Transitional Work Facilitated by the Case

Manager.• Excellent Communication Between All “Players”.• Employer RTW & Wellness Programs Identifying High Risks.• Indemnity Benefits & Prompt Insurer Payments.• Attorneys Assisting the Injured Worker RTW Without Re-

injury.• Work Comp Boards Facilitating Consistent Standards &

Ratings .

With a Rational System Are There Any Problems?

“A World of Hurt”

“In Workplace Injury System, Ill Will on All Sides” F red Willette, a former metal grinder with lung disease, says he was fired for talk of filing a claim.

By STEVEN GREENHOUSE Published: April 1, 2009.

“Exams of Injured Workers Fuel Mutual Mistrust” There are questions about whether doctors hired by insurers to examine injured workers are

really independent. By N. R. KLEINFIELD Published: Sunday, August 16, 2009

“For Injured Workers, a Costly Legal Swamp”

The hurt workers wait on benches at the Queens office of the New York State Workers’ Compensation Board. By N. R. KLEINFIELD and By STEVEN GREENHOUSE

http://topics.nytimes.com/top/reference/timestopics/people/g/steven_greenhouse/index.html?inline=nyt-per

http://topics.nytimes.com/top/reference/timestopics/people/k/n_r_kleinfield/index.html?inline=nyt-per

http://topics.nytimes.com/top/reference/timestopics/people/g/steven_greenhouse/index.html?inline=nyt-per

Trends in Workers Compensation• As a source of support, Work Compensation is

surpassed only by Social Security.• Workers Compensation Claims have steadily

decreased at about 3%/year since the 1990’s.• The number & frequency of Permanent Total

Disability claims has significantly increased since 2005, primarily by workers >50 years old.

• Despite decreased claims, indemnity & medical costs in Workers Compensation have continued to increase 9-12%/year, while lost days from work have increased 5-7%/year.

Trends in Workers Compensation• Workers Compensation pays more than Group Health.

– Utilization differences dominate price differences, explaining 80% of the overall cost difference.

– Utilization differences vary principally by type of injury, with all injuries having higher costs than group health.

– Traumas to extremities (fractures) consistently have smaller cost & utilization differences, while chronic pain-related injuries such as bursitis, carpal tunnel and low back pain have the largest costs.

Trends in Workers Compensation• Costs & Utilization are increased in W.C. claims v. Group Health:

– Evaluation, management, and P.T. costs are greater in W.C. claims due to increased utilization.

– Radiology costs are greater due to higher prices and greater utilization.

– P.T. utilization is most prominent in acute trauma related W.C. claims than for other injuries.

– Higher W.C. utilization of office visits & radiology services is highest for chronic pain related soft tissue injuries.

– Group Health makes greater and more varied use of prescription drugs.

Are There Differences Between Private and Occupational Doctors?

Differences Between Private and Occupational Doctors

• In the traditional doctor - patient relationship the Doctor:– obtains the chief complaint & history.– does a detailed or focused physical exam.– orders diagnostic testing to support their

diagnosis.–provides treatment recommendations.– there are no other players other than the

insurer.

Changing Roles

Patient

Physical Exam DiagnosticTesting

History

Physician

Patient

Recommendation to Patient

Input from Colleagues

Patient

Patient

Legal AdvisorsCase ManagersInsurerEmployer

Adjudicator

Occupational Injuries

Disability/ Impairment Determination =$$??

Work RequirementsAccommodations?FCE’s, RTW, MMI?

Physician

Private Care

Differences Between Private and Occupational Doctors

• In Occupational injuries the Doctor’s role is:– Assess the injury.– Determine causality/work relatedness.– Perform structured histories and physical exams.– Provide aggressive conservative treatment within

EBM Guidelines and encourages early RTW.– Communicates with the patient, the HC Team,

Case Manager, Insurer and Employer.– Addesses the effects and impacts of Third Parties,

including the patient!

What the Occupational Physician Needs to Know

Role Awareness - Who Are All of the Players? Role Awareness - Who Are All of the Players?

Need for Precise Definitions - EBM Guidelines Need for Precise Definitions - EBM Guidelines

Need for Consistency: Early Return to Work (RTW) Need for Consistency: Early Return to Work (RTW)

Importance of Communication by all “Players” Importance of Communication by all “Players”

Differences Between the OM and Family Physician “Awareness Factors”• The Occupational Doctor must be aware of

the relationship to the injury and:– Occupational Factors– Work-Related factors– Employee Factors– Risk factors– Psychological Factors– Role of Third Parties– Incentives & Potential Secondary Gains

Occupational Injuries - Incidence

• Low back injuries account for 25% of all work related injuries.

• Knee injuries account for 9.2% of all injuries and 18.1% of all lost time from work.

• Most injuries are “soft tissue” i.e sprains/strains.

Who Are the “Players” in Occupational Injuries & What Are their Concerns?

• Patient• Doctor & Allied Health Caregivers• Case Manager• Insurer• Employer• Attorney• Government: Hearing Officer, Commissioner, &

Judge• Everybody has concerns and interests that often

conflict.

Patient Concerns• Initially

– When do I file the incident report?– Recovery / not getting hurt again – Financial stability while out of work (OOW).– Not being penalized or having a fear of employer

retaliation.• Later the same, but sometimes

– Lack of control over care that’s rendered.– Maintaining the status quo.– Decreased family support for chronic rehab is required.– Self perception of the injury and their assessment of it’s

“severity”.– Lack of control over claim settlement.

Doctor & Healthcare Providers Concerns

• Diagnosing the problem and its relation to the workplace.

• Treating the problem within EBM Guidelines.• Returning the patient to pre-injury status.• Creating & maintaining good doctor – patient

relationship.• Addressing Case Manager, Employer and

Insurer concerns.

Doctor & Healthcare Providers Concerns – Costs v. Reimbursement

• According to the Institute of Medicine, as much as 45% of medical care provided in the U.S. is either excessive, or inappropriate.

• Implementation of EBM Guidelines resulted in a 35% reduction in medical costs, most likely resulting from reduced utilization of services.

• The effect of the payer on Orthopedic practice expenses per patient visit were significant - $123 (self pay); $148 (Medicare); $178 (PPO); $208 (HMO/PPO); & $299 (W.C.).

Employer Concerns• Profitability

– Sales– Fixed costs– Variable costs – Lost Work Days

• Work Environment– Job Requirement Risks– RTW Programs & Monitoring– Injured worker accommodations– Effect on other employees

• Employee well-being ??– Insurance costs– Frequency of claims– Re-injury risks

Insurer Concerns

• Claim validity• Bill Payment• Cost Control (medical)• Cost Control (indemnity)• Case Management• Claim type: low risk/cost, to high

risk/cost and reserves allotted.

First Visit – OM Goals• Decisions regarding causation

– What is related; what is not.– Is there potential secondary gain?– Is there a more plausible source of injury or disease?

Management of RTW issues– In or out; full or modified (transitional).– Are there co-morbid diagnoses?

• Establishing rapport with the patient – Explain their injury in plain language.– Patients less defensive.– ? become invested in pleasing you.

• Priority: Treat the patient, not the injury.– What is the diagnosis & what do EBM Guidelines recommend?

• Withhold judgment: both + and –– Leads to diminished objectivity

Remember ….

• Best predictor of long-term outcome is the presence or absence of restricted duty options.

• Behooves one to get this right.• Easiest to just objectively assess capacities,

give a release, and leave the rest to the employer / insurer.

First Visit - History• Chief Complaints.• Right/Left or Bilateral?• Mechanism of the injury – acute/repetitive?• Occupation & Job Description.• History since the DOI to the present.• Past history (detailed), including perceived

pain & “need” for Rx meds.• Pre DOI and current work status.• Assess non-work activities.• Prior Claim history?

First Visit History – Mechanism of Injury • Is the CC acute/chronic/repetitive?• Onset: insidious/post-traumatic?• Mechanism of injury (MOI)?• Position of patient when injury occurred?• Loss of Consciousness, Dizziness, Vision

Changes?• Audible “pop”?• Acute effusion, swelling?• Able to ambulate –immediately or with help?• Is there locking, instability, or a feeling of

“giving way”?

Mechanism of Injury Twisting

Multi-Directional

Blunt TraumaRepetitive Trauma

First Visit -Occupational Factors

• Posture• Motion• Vibration• Compression• Temperature• Eccentric contraction

• Contact stress• Repetitive use• Work pace• Fatigue• Inflammation• External vs. internal

load

First Visit- Mechanism of Injury

• Were the forces applied to the body part in question sufficient?

• Are the symptoms and findings consistent with the mechanism?

• Could the extent of injury be explained by the intensity or duration of the forces involved?

First Visit: Accuracy of the Patient History?

• 42% of self reported histories taken at visit #1 & at one year were forgotten by the patient.

• 41% of the 1st years visits were forgotten, and of those “remembered”, 28% never occurred.

• 48% of ED pts. forget at least one Rx.• Pts. Claimed pre-injury status as superior in

15/16 areas tested. • Non-Compensated pts. self-assessed their

post-op functional abilities 4 times greater than W.C. pts.

First Visit – Accuracy of the Patient History

• 80% of MVC claimants with spinal/shoulder soft tissue injuries denied pre-existing histories of their cc’s and histories of heavy ETOH use, illicit drug use or psychological dx. Within 3 mos. Post DOI.

• Under-reported pre-existing dx’s preclude the doctor’s ability to intervene on health issues. This increases future risks of re-injuries to the worker & their co-employees.

• 89.9% of pts. who reported someone else was responsible for their MVC had medical – legal claims.

• Denial rates for claimants with attorneys approximated 100%.

First Visit: How Can the History Elicited be Improved?

• Refuse to accept ambiguous answers.• Use an open ended interview style including the pt’s

psychosocial concerns. • Ask the history in reverse chronological order.• Ask redundant & overlapping questions.• Reviewing questionnaires with the pt. increased their

accuracy rather than relying on the questionnaire alone.

• Discuss the pt’s recovery expectations – 75% of pts. With positive answers had earlier RTW & decreased claim costs.

First Visit – Physical Exam• Inventory questionnaires (DASH,

OSWESTRY) & diagrams (Pain & Katz Hand) increase the P.E. reliability.

• Focused examination with baseline measurements (ROM, MMT, Atrophy).

• Document positives/negatives.• Identify “old” problems.• Describe non-physiologic findings

(Symptom distraction testing).

OMP Gatekeeper – Physical Exam Reliability

• History had no impact on reliability of PE tests, but increased with the prevalence of positive findings.

• Majority of gatekeepers diagnosis are inaccurate = prolonged PT utilization & re-injury rates.

• Amount of experience directly correlated to accurate diagnosis.

Bertilson, 2003

First Visit – OMP Should Think About …..

• Natural hx of a condition without intervention• Efficacy, risks & costs

– Of current, alternative interventions– Of proposed interventions– Of doing nothing

• Likelihood & degree of improved outcome– Especially as relates to specific patient– Functional criteria weighted heavily

First Visit – Decision Making

• The more costly the test or intervention (utilization), the more caution should be considered prior to ordering a test or treatment, especially early.

• Testing & treatment decisions should be a collaboration between the OM doctor & patient with full disclosure of benefits and risks.

• Treatment should not create dependence or functional disability.

First Visit - Testing

• Most occupational injuries are “soft tissue” sprains/strains of the low back, shoulder, & CTS.

• Imaging or testing usually are not needed in the early phases of treatment.

• Diagnostic tests should be ordered to confirm a clinical impression when there’s little or no improvement with recommended treatment.

• Test results should affect the course of treatment.

Who Should Undergo X-Rays After Knee Trauma?

Ottawa knee rules:1. Age 55 years or older.2. Tenderness at head of fibula.3. Isolated tenderness of patella.4. Inability to flex knee to 90 degrees.5. Inability to walk four weight-bearing steps immediately

after the injury and in the emergency department.

Pittsburgh decision rules:1. Blunt trauma or a fall as mechanism of injury plus either of the following: a. Age younger than 12 years or older than 50 years. b. Inability to walk four weight-bearing steps in the emergency department.

Who Should Undergo X-Rays After Knee Trauma?

• OKR Results: • OKR is a highly sensitive clinical guide.

• Despite OKR, it has NOT resulted in a significant reduction in the # of x-rays ordered.

No x-rays saved an ~ $103/patient

First Visit - Diagnosis

There are multiple etiologies of occupational pain.


• Review of relevant anatomy & physiology as well as of available diagnostic & treatment options with the patient.

• Discuss what “evidence” does or does not support their history – and why.

• Assess co-morbid diagnoses that may hinder RTW.


• Provide a diagnosis, but ...–keep it simple

• Identify what’s related .....–what is not, & what could be

• Order treatment/RTW • Schedule follow-up

Occupational Injuries - Diagnosis

Most injuries are sprains, strains, and tendonitis,

BUT DON’T IGNORE THE OBVIOUS!

Non- Red Flag Occupational Injuries –Treatment Guidelines

Diagnosis – Red Flags =Specialty Referral

ACOEM Guidelines

First Visit - Overall• Assess causation; set tenor of future RTW

decisions; & establish rapport– If done well, subsequent care is easier

• Regardless …. provide quality care & monitor patient response

• But what is quality care ????• Evidence-based ? Anecdotal ? Both ?

D/D: Evidence-Based medicine supports psychosocial issues in Workers’ Compensation Claims

Day 2 – Broaden Scope

• Specific discussion of certain techniques, options & interventions– PE “tricks”; PT; Injection therapy

• Discussion of outliers – early & late– Urgencies & emergencies– Delayed recovery

• Treatment should be interactive & integrative; not static – need tools through which to achieve this

Goal Setting for the Occupational Injury

Goal Setting • Optimize Rx - Monitor • Focus on increasing function

–educate and exercise–discourage disability

• Provide capacities for RTW• Create & support expectations

Goal Setting – Indications for Increasing Utilization

• Frequency and intensity of services (testing, consults, FCEs) should be based on duty status and the patient’s “attitude” (missed appointments, no pain relief).

• Exaggeration of symptoms, especially when profound, justifies more proactive aggressive management.

Goal Setting – Indications for Increasing Utilization

• Treatments should improve on the natural history of the disorder, which in many cases is recovery without treatment.

• Invasive treatment should be preceded by adequate conservative treatment and may be performed if conservative treatment does not improve the health problem.

• The more invasive and permanent, the more caution should be exerted in considering invasive tests or treatments and the stronger the evidence of efficacy should be.

Goal Setting

• Occupational Health Team Goals– To protect employees from health and safety

hazards.– To protect the local environment.– To facilitate safe placement of employees

according to their physical, mental, and emotional capacities.

– To assure adequate medical care & rehab of the occupationally ill and injured.

Goal Setting

• RTW is the primary Goal of injury mgt.• RTW = Functional Restoration.• The Doctor and Physical therapist should set

goals during the acute, sub-acute and chronic phases of the injury.

• The Case Manager and Employer should facilitate early RTW of the employee with appropriate accommodations.

Current Trends in Rehabilitation of

Shoulder Injuries

Early RTW – How Do We Know it’s Good for the Patient?

Because Dr. Talmage & Melhorn Told Us It Was!

Importance of Returning the Injured Employee to Transitional Duty

• An aggressive interdisciplinary team managed intervention model emphasizing aggressive immediate treatment intervention and early RTW with transitional light duty addresses appropriate care, cost containment, decreases employer/insurer costs and has the best outcomes.

• A structured early RTW program immediately after a soft tissue spinal injuries results in more rapid RTW than prior studies indicated.


• The OHC Care Nurse Manager plays a central role in the administrative coordination of the interaction between the OHC team, the injured employee’s supervisor, and Human Resource specialists.

• When Occupational Health Consultations were ordered with disability specialists by the Case Manager it facilitated early and successful work accommodations by the employer.


• Transitional Duty (restricted duty) is defined as work activity performed by an employee with a work related injury precluding their working their J.D. without limitations.

• Work accommodation offers and employer acceptance of advice communicated directly from the HCP regarding re-injury prevention were significant predictors of shorter work absence duration indexed by self reported and administrative data.

• However, an ergonomic evaluation was a significant predictor of shorter receiving of benefits only.


• Are Return to Work Coordinators Effective in early RTW Programs?

• Answer –Not Yet!– 29 RTW coordinator activities were identified for

occupational musculoskeletal injuries.– Marked variations in training identified inconsistencies in 6

Core Competencies:• Ergonomic & workplace assessment• Clinical interviewing skills• Social problem solving• Workplace mediation• Knowledge of business & legal aspects• Knowledge of medical conditions – this was the least important

Impact of Communication in Occupational Injuries


• Successful RTW Programs involves communication:– Employee: Reporting injuries promptly – claims not

reported >29 days cost 45% more than claims reported by the next day.

– Employer: educating supervisors to report all injuries and help make sure employees work within their restrictions.

– Employer: referring the injured employee immediately, then determine if the employee understands their injury & restrictions.

– Education of management of the RTW policy.


• Successful RTW Programs involves communication:– Employer, Physician, Case Manager & Insurer

regarding expectations, job descriptions & accommodation policies.

– Employer communicating with the injured when out of work.

– Investigating the Incident, make improvements as needed & communicate to the injured employee.


• Doctors must recognize their abilities and limits in communicating with their patient, the AHC team, employer, case manager & insurer.

• Most complaints against doctors have more to do with their attitude than clinical competence.


• Occupational physicians expected communication competencies include:– Build rapport, listen, persuade & negotiate.– Take responsibility, make decisions and lead with

authority.– Be open, non-defensive, be empathetic and have

a sense of humor.– Be resilient & flexible, & cope with set-backs.


• Keys to good OMP-pt. relationships:– Empathetic understanding of their patients cc’s &

secondary concerns.– Tactful inquiry into the pt’s job description, career

development, team-working abilities, & co-morbidities.

– Provide clear, structured goals that reintegrate the pt. into the workplace, & convey this to the employer.

– Understand the employer’s needs, & expected working patterns when the employee RTW.

– Understand the pt’s career development plans.


• Effect of the Doctor-Patient Communication – The effect of patient reported Doctor proactive

communication was associated with a greater likelihood of RTW during the acute phase of low back injuries (<30 days of disability)

– This effect disappeared when workload characteristics were taken into account during the subacute/chronic phases post injury and to a 60% RTW.


• The HCP giving the patient a RTW date, and giving guidance on how to prevent recurrence and re-injury were positively associated with early RTW.

• Contact by the HCP directly to the employer has a positive impact on early RTW, but to a lesser extent.

Identifying Risk Factors that Adversely Affect Claims

High Risk Health Factors = Days Lost

• Lifestyle:– Smoking.– Physical Activity less than once a week.– ETOH: Heavy Drinker= >14 drinks/week.– Drug/Medication use > a few times per month.– Using safety belts < 100%.


• Health & Biologic Risks:– Blood Pressure Systolic>139, Diastolic >89, or Rxs.– Cholesterol > 239.– Body Weight >20% over ideal body weight.– Medical Dx’s: CHD, CA, DM, Bronchitis/COPD.– Work absence due to illness >6 days/year.


• Psychological Risks:– Self perception of physical health =Fair or Poor.– Personal life or Job Satisfaction = Partially/Not

Satisfied.– Stress – Scale Score >18.

Depression & Poor Coping Skills Effect on RTW - Relevant Factors

Predisposition Environment

Work Site

Depression in the Workplace

• Employees with depression are 27 times greater work loss likelihood than non-depressed employees.

• There is a clear link between employee depression, work impairment and days lost.

• Improving the quality of depression care for employees requires a fundamental shift in thinking away from treatment cost and towards return on investment (ROI) in human capital.

Depression in the Workplace

• Primary management of occupational depression includes:– Employer promoting mental health programs.– Providing resilience promotional support.– Identifying risk (stress) factors.– Promotion of mental health literacy by reducing

its negative stigma.– Universal screening programs.

Role of the OM Physician – Decreasing Occupational Depression

• Avoid the “Blame Game” between Dr. & pt.• Use the Biosocial model:

– Prevention thru wellness therapy.– Clinical recognition & intervention.– Appropriate specialist referrals.– Integrating chronic, stepped & collaborative pt.

care.– Advocacy and education.

Poor Employee Coping Skills-Effect on RTW

• 32% of laborers who self perceived their injury as severe had the greatest risk of developing long term disability.

• Even in objectively severe injuries, the #1 reason for delayed RTW or LTD was the patient’s self-assessment of the their ability to RTW.

• Pts. who perceived severe accidents as relatively low had a RTW in 121 days v. 287 days by pts. who self-assessed their injuries as severe & were less optimistic regarding their coping abilities.

Depression in the Workplace• Current Barriers are multi-focal:

– Patient: employees are afraid of being labeled & are reluctant to seek care. If treated there is a high rate of discontinuance of care and recurrence.

– Physicians: high variance in training; inappropriate focus on physical rather than emotional/cognitive s/s = failure to dx.; lack of time, incentive, or interest to trt.; & under-utilization of mid-level providers.

– Clinical practice: focus on the acute injury rather than the chronic neg. affects of days lost & failure to utilize case managers or to integrate trt. and rehabilitation.

– Employers/insurers: failure to incentivize investment in infra-structure and the chronic care model & lack of integration between the OM docs & mental health providers.

Poor Coping Skills - Why Is This Important?

• Affects injury reporting/causation• Affects symptoms and disability• Impacts upon compliance

– With treatment recommendations– With return to work decisions

• Final outcome can be reflective of non-medical > medical factors

• Awareness of these at the time of the first visit will increase likelihood of recognizing their potential impact later.

What Are the Highest Risk Factors in W.C. Claims?

• The most significant predictors of delayed RTW and high costs in expected low cost claims are:– Attorney = 72%, especially when in low cost claims.– Low Back Injury= 30.2%.– Married/divorced > single. – Small Company size – Payroll < $500,000.– Delays Reporting the Incident > 5 days.– Claims open > 2 years.– High Insurance Premiums– Employees > age 50 -59– 2% of all claims = 32% of W.C. costs.

How Does the OMP Handle Legal Involvement?

• Despite the Code of Ethics the OMP has conflicting pressures.

• The OMP’s priority is the health & safety of injured workers.

• Most stressors arise from employers & insurers, not pts. They fund OH services & have conflicting interests.


• The ethical dilemma for the OMP is complex, including conflicts of interest with managed care :– Concerns about costs to employers are not just

economic that outweigh employee health.– There are legitimate concerns about fair allocation

of resources amongst all employees.


• The OMP has legal conflicts between the employee and employer.

• Legal liability & Ethical Responsibility Conflict– When limitations are placed on the physician’s

judgment in patient treatment recommendations.– When demands are made on the OMP to release

pt. information under HIPAA.– When the OMP performs medical evaluations for

litigated claimants.

Does Who Chooses the OMP Affect W.C. Costs & Outcomes?

• What results in the best outcomes?– Employer chooses provider?– Employee chooses a new provider?– Employee chooses a prior provider who had

treated an unrelated condition?• RESULTS: Outcomes are equal when the employer

picks the provider, or when the employee picks a prior provider, BUT employee satisfaction is higher when the employee picks a prior provider.

So, is There a Rationale Approach to the Work. Comp. Patient? NO!


• The psychosocial status of the injured worker at the time of the injury – low job satisfaction, low self perception of the injury & poor social networks.

• The psychosocial status of the employee after the injury, compounded by employers unwilling to accommodate transitional RTW or RTW programs & lack of family support of prolonged rehabilitation.

• The psychosocial vulnerability of the injured worker resulting in chronic pain.


• The initial response to claimants by insurers assuming fraud, which results in defensive “I’ll show them I’m really sick” attitudes.

• Mismanagement of initial treatment – doctor not identifying high risk factors, not setting goals, and not encouraging early transitional work.

• Mismanagement by the treating doctors by continuing ineffective or unnecessary trt., or delays in Red Flag referrals.

• Employer mismanagement – lack of RTW programs & not educating employees of insurance benefits.


• The number of medical examinations required by insurers or attorneys.

• The length of time out of work.• Encouragement of some plaintiff attorneys to

remain inactive in order to increase settlements.• The length of time between the DOI & settlement

date.• The sense of powerlessness of the employee

having no control over repeated exams, decisions about their claims or when they’ll be settlement.

• The adversarial W.C. case mgt. by all “players”, including the judiciary.

There’s Too Many Players on the Field! And Everyone Has the Same Thing in Mind

Everybody Wants a Piece of This…..

While Wanting to do This….

Thank You

Rationale Workers Compensation –Bibliography

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Addressing the Nation’s Health Care Crisis. 2006• ACOEM: Ethical Guidelines for Occupational and Environmental Medicine Physicians Serving as Expert Witnesses.

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The Forensic Examiner, March 22, 2006

the rational approach to the work comp patient – is there such a thing? st. luke’s occupational...

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