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Georgia Physician Discusses Concerns Over Trends in Workers' Compensation's Treatment of Injured Wor
Author: | Wednesday August 25, 2010
Dr. Jeffrey Grossman has a concern; Will good doctors be driven from the Georgia Workers' Compensation system?
GA Workers’ Compensation
In the Following Interview, We Learn from
Dr. Jeffrey Grossman His Perspective on
Returning the Injured Person Back to Work
GA1st: What has been the secret to your success in treating workers’ compensation patients?
Dr. Grossman: I have always prided myself on “calling it like it is.” In doing so, I have sometimes upset defense attorneys, plaintiff attorneys, adjusters, case managers, employers and unfortunately even patients.
When there is litigation, it is difficult to do the right thing in workers’ compensation as a physician and not disappoint some of the parties almost all of the time. Regardless of who may be negatively impacted financially, I always do what I think is the right thing medically for my patients.
GA1st: How does treating a workers’ compensation patient differ from other patients in your practice?
Dr. Grossman: What I do medically is no different. The clinical component is in some respects the easy part. With commercial insurances, services are contractually spelled out with guidelines that are somewhat more concrete. With medicare, there are written guidelines that you follow. No pre-certification is required with medicare.
A different degree of communication is necessary in workers’ compensation. With a commercial or Medicare patient, I typically only communicate with the patient and family members. In workers’ compensation, it becomes extremely important to understand and document causation. Also, the key to obtaining prior authorization is accurate documentation and a very thorough and complete medical record, as well as addressing causation.
Timely treatment is so important to obtaining the
best outcome when treating back pain. In workers’
compensation, timely treatment, for a variety of
reasons, does not always occur.
In many instances, the claims adjusters are not the ones determining if a treatment is authorized. This decision is being managed by utilization review companies. This often impacts my ability to deliver optimal care in that it takes time to submit the treatment plan for review. Often one-on-one phone time with the physician reviewer is required. Often, an appeal is necessary which further delays treatment.
It is not difficult for a utilization review company to find a controversial non-scientifically supported guideline or poor clinical study to justify the denial of a procedure. Unfortunately, there are no clinical guidelines to assist the physician with providing the best treatment when our recommendation is not approved.
GA 1st: What are some of your most difficult clinical challenges?
Dr. Grossman: In some instances, the most challenging thing I do to serve my patients is to advocate against a treatment, when I believe that this specific patient probably has a greater chance of getting worse from the procedure.
This is a hard thing to do as surgeries and procedures can result in a higher settlement value and lead to financial gain even at the expense of a patient’s quality of life and well being.
Advocating for a patient’s rights by doing the medically correct and ethical thing by helping a patient avoid the wrong procedure has actually at times put me at odds with my patients and their attorneys. Having a patient perceive you, their physician, as their adversary, is very a difficult thing for me.
GA1st: As our economy has worsened, what changes have you seen in your practice?
Dr. Grossman: Things have gotten much more challenging in the last year. In the past, our practice’s reputation has earned us the privilege of serving on hundreds of employer panels, providing our practice the opportunity to manage the needs of many injured workers around the state.
I have always understood that the decisions I make often have financial implications for multiple parties. Recently I have found the payors are taking longer to approve procedures. I try to do what I can to remind the insurance companies that good clinical outcomes require timely treatment.
On the positive side, as jobs become more scarce, injured workers seem more motivated to return to work. Returning to the same job that caused the back injury can be anxiety provoking. I try to spend a lot of time educating my patients on lifestyle changes that they can make to prevent future recurrences.
It is also important to reassure the patient that with the vast majority of injuries that result in back pain, there is no significant structural injury.
Additionally, when patients return to work, it is essential for them to understand that experiencing pain while performing a task rarely means that there is structural injury. Many times, the most unhealthy thing one can do for an injured back is to remain sedentary.
GA1st: Do you have any recent specific examples from your own practice that reflect a potential change in the financial limitations on the part of the payers?
Dr. Grossman: The key to any spinal procedure or intervention is being very stringent with your criteria of who is and who is not a candidate.
I recently advocated for a patient of mine that had radio-frequency ablation that provided relief for 15 months. This procedure allowed the patient to return to work and stay off narcotics. After the pain returned 15 months later, I recommended that this procedure be repeated.
This request was denied. Only when the patient returned to my office complaining of suicidal ideation and, after a significant delay in treatment, was this request approved.
This patient, who previously had a good experience with the workers’ compensation system, then decided to retain an attorney. I have to believe this scenario would have played out differently five years ago.
GA1st: Many insurance companies hire medical directors. How do they assist you in your clinical responsibilities?
Dr. Grossman: This question is a little bit complicated. The title of medical director suggests that this physician is given the task of providing other physicians with all of the necessary resources to treat their patients.
From my experience, the medical directors in workers’ compensation I often speak with serve a different role. When I have a challenging question, I will turn to other physicians in my practice for advice, as opposed to the medical director.
From my experience, the medical directors I have worked with often use their former medical knowledge to justify why a treatment should not happen.
It is challenging for me to communicate with the medical director, as the physician I am speaking with, often times has never clinically performed the procedure. While I will try to educate the physician on spinal treatments, the medical director is often located in another state and in another specialty and may be in over their heads to provide the assistance needed in facilitating prompt medical care for the injured worker.
GA1ST: What recommendations do you have to help insurance companies to save money without compromising the best medical care for the injured worker?
Dr. Grossman:Doing everything possible to assist a patient to safely return to work would make the biggest difference in cutting costs. I think the focus should be less on utilization review which delays treatment. The quickest way to create ill will with an injured worker and increase litigation is to delay approval of their treatment. If delaying treatment by delaying approvals continues as a strong cost containment initiative, my concern is that such a policy will drive the good “call it like it is” physicians out of the workers’ compensation system.
When treating back pain, I always judge the efficacy of the treatment by the amount of functional gains the patient achieves. In workers’ compensation, I use return to work as my desired outcome measure. There is a finite window to assisting patients with their return to work. This requires everyone working together to provide timely care.
If delaying treatment by delaying approvals continues as a strong cost containment initiative, my concern is that such a policy will drive the good “call it like it is” physicians out of the workers’ compensation system.
Lastly, employers need to be better educated. If I provide work restrictions, regardless of how motivated the patient is, the employers need to be willing to accommodate the work restrictions.
This will require flexibility and in some cases creativity on the part of the employers to do everything possible to create conditions to make it as easy as possible for an injured worker to return to work.
Instead, I often hear from my patients that just the opposite situation occurs at work. Many of my patients have the perception that their supervisors treat them worse upon returning to work. It would make a big difference if the employers and supervisors understood the financial implications of their not doing everything they can to facilitate the return to work.
Ed. Note: Jeffrey S. Grossman, M.D. is a non-surgical lumbar and cervical specialist. Peachtree Spine has locations in Atlanta, Decatur, Marietta, Johns Creek, Lilburn and South Atlanta. For more information visit www.peachtreespine.com or call 404-843-3323.
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