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Chasing Pain Complaints Doesn’t Work: Why Function Belongs at the Center of Workers’ Compensation Care

The practice of rating pain has created a host of problems in workers’ compensation. Bringing focus back to functional restoration has benefits for all.
By: | March 2, 2020

Body temperature, pulse, respiration and blood pressure. These are the four primary vital signs used by doctors and nurses to measure your body’s most basic functions and detect life-threatening medical problems. Or at least they were until 2001, when the Joint Commission dubbed pain “the fifth vital sign.” The designation was the result of a years-long push by some medical professionals and the pharmaceutical industry to do more about patients’ pain.

“There was a growing narrative that we perhaps shouldn’t allow people to suffer unnecessarily when wonderful medications were available to treat pain,” said Dr. Maja Jurisic, Vice President, Medical Director of Strategic Accounts, Concentra Occupational Health.  “It became standard of care to ask patients to rate their pain on a scale of 0 to 10.”

Pain as a metric for recovery permeated the healthcare industry at large and had an outsized impact on the way workers’ compensation claims were managed. For many clinicians, recovery wasn’t considered complete until pain resolved, so claims could stay open as long as pain persisted.

This had multiple negative consequences for payers, employers and most importantly, injured employees.

“We need to shift the focus away from pain and toward function and overall wellness,” Dr. Jurisic said. “Doing so can support a speedy recovery and get injured employees back to their jobs and normal lives faster.”

Why Treating Pain Doesn’t Work

Dr. Maja Jurisic, Vice President, Medical Director of Strategic Accounts, Concentra Occupational Health

The practice of rating pain at every medical appointment has created the misconception that pain is inherently linked with the status of recovery from an injury. But it’s understood now that the experience of pain can be separate from the strains, sprains, breaks and tears that constitute the injury itself.

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.”

“Pain may or may not be correlated with injury severity or the state of healing,” Dr. Jurisic said. “The very same neural pathways that are activated by physical pain are also activated by emotional pain. And a lot of people don’t differentiate.”

An injured employee may believe that if his back hurts more today, he must not be getting any better. But if he just had an argument with his wife, or is worried about the family’s finances, or is feeling frustrated being out of work — all those emotional stresses can feed the perception of pain.

“Unless physicians take that into account when dealing with injured employees, we’re going to go down a lot of dead ends and take a lot of detours. And that’s exactly what happens,” Dr. Jurisic said. “There are many unnecessary diagnostic tests and procedures done when physicians chase pain complaints without considering whether it even makes sense medically.  And it’s no coincidence that the rise of opioid addiction coincided with the increased focused on pain management.”

Medicalizing emotional pain, and assuming all pain complaints correlate with “tissue damage,” even when that is not supported by exam and/or other diagnostic findings may slow down recovery by creating a mindset of fear. Thinking that something dangerous is going on in their bodies increases anxiety and feeds their perception of pain. Neural pathways are trainable; they grow and change in response to stimuli. The more injured employees are asked about pain, the more they think about it. The more they think about it, the better their neural pathways get at producing pain. After a time, they “learn” pain, which can persist long after their tissues have healed.

Constantly focusing on pain can cause an individual to feel broken and limited in their physical capabilities, which can be the beginning of a path toward psychological problems like depression and reliance on painkillers.

As claims drag on without any improvement in pain, medical providers and employers may become skeptical of the injured employee’s complaints.

“They’re not necessarily exaggerating. They are feeling real pain, even though it’s out of proportion to objective findings. And if they begin to feel that no one is helping them, an angry victim mentality, in my experience, becomes a big barrier to a successful return to work,” Dr. Jurisic said.

Bringing the Focus Back to Function and Wellness

A better way to measure progress is to assess objective findings, and what an injured employee can do.

For an employee with a sprained ankle, for example, recovery might be measured by his or her ability to fully flex and extend the joint, place their full weight on that foot, and walk with a normal gait.

Function-based assessments more accurately reflect what state of healing the damaged tissue is in and filter out subjective ratings of pain. This keeps medical practitioners from going down the potential rabbit hole of “curing” pain, and it stays true to the purpose of workers’ compensation care — restoring the capabilities that injured employees need to perform their jobs.

Focusing on function also turns a negative experience into a positive one. Thoughts turn away from pain and toward performance.

“How you think about yourself and your capacity makes a big difference in what you’re able to do,” Dr. Jurisic said. “If you think of yourself as disabled, you’re not going to get better very quickly. If you think of yourself as a person who still has abilities and can still contribute, you have a greater sense of value and self-worth.”

Psychological resilience is just one factor in a holistic approach to treatment. In workers’ compensation, it’s common to focus on the compensable injury in isolation, but whole-body wellness is critical to efficient healing. That includes good nutrition and sleep hygiene as well.

“Restorative sleep goes a long way in helping tissues heal,” Dr. Jurisic said.

Shifting the Paradigm of Care in Workers’ Compensation

The challenge in eschewing the prioritization of pain lies in getting clinicians to go against their training.

“Most people trained in Western medicine take a mechanistic approach to care because that’s what they’re trained to do. You identify the pain generator, and you fix it,” Dr. Jurisic said. “So, we are constantly re-educating clinicians and trying to open their minds up to different approaches that have emerged since their training.”

A Concentra, the education effort involves sending daily clinical messages to physicians and therapists, reminding them to think of injured employees as whole people and consider all factors that could be influencing their recovery.

“How can you focus your conversation to help this person move forward if they have a dysfunctional way of thinking about their situation?” Dr. Jurisic said.

Concentra also got rid of the pain scale altogether (after the initial injury visit).

“We don’t use that anymore at rechecks. We replaced it with a functional restoration/status of healing scale based on job requirements,” Dr. Jurisic said. “We call it the FReSH scale. If an employee’s job requires lifting 50 pounds, that will be our goal, and we gauge their progress towards that goal. Concentra therapists have a template where they fill in objective data around what the injured employee is able to lift, push, pull, carry, etc.”

There’s also a system in place to catch outliers. A data analytics team flags cases that have unusually long case duration, more than the average number of PT visits, referrals to specialists, or lack of continuity of care. These cases – which constitute a small percentage of Concentra’s claims – get reviewed again by Center Medical and Therapy Directors, and then by more senior clinical leadership. Taking a step back to see the arc of a case provides an opportunity for mentoring and allows clinicians to alter their approach and try alternative strategies to help injured employees who are stuck move towards functional restoration.

“These are the cases that end up costing everyone the most money. Since we implemented this review process, we’ve decreased the duration of those outlier cases by about a month,” Dr. Jurisic said.

“What we’ve seen is that many people get better no matter what. Our bodies are beautifully designed to be self-repairing. But we have an opportunity to improve the process of return to work for even the most vulnerable people, those who have little resilience near the end of their coping skills, without the additional risks introduced by chasing and treating pain complaints that are not supported by objective findings.”

To learn more about Concentra, visit https://www.concentra.com/.

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This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Concentra. The editorial staff of Risk & Insurance had no role in its preparation.




Concentra® is America’s leading provider of occupational medicine, delivering work-related injury care, physical therapy, and workforce health services from more than 520 Concentra medical centers, more than 130 onsite clinics, and more than 30 community-based outpatient centers in 44 states.

More from Risk & Insurance

More from Risk & Insurance

Risk Scenario

The Betrayal of Elizabeth

In this Risk Scenario, Risk & Insurance explores what might happen in the event a telemedicine or similar home health visit violates a patient's privacy. What consequences await when a young girl's tele visit goes viral?
By: | October 12, 2020
Risk Scenarios are created by Risk & Insurance editors along with leading industry partners. The hypothetical, yet realistic stories, showcase emerging risks that can result in significant losses if not properly addressed.

Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.

PART ONE: CRACKS IN THE FOUNDATION

Elizabeth Cunningham seemingly had it all. The daughter of two well-established professionals — her father was a personal injury attorney, her mother, also an attorney, had her own estate planning practice — she grew up in a house in Maryland horse country with lots of love and the financial security that can iron out at least some of life’s problems.

Tall, good-looking and talented, Elizabeth was moving through her junior year at the University of Pennsylvania in seemingly good order; check that, very good order, by all appearances.

Her pre-med grades were outstanding. Despite the heavy load of her course work, she’d even managed to place in the Penn Relays in the mile, in the spring of her sophomore season, in May of 2019.

But the winter of 2019/2020 brought challenges, challenges that festered below the surface, known only to her and a couple of close friends.

First came betrayal at the hands of her boyfriend, Tom, right around Thanksgiving. She saw a message pop up on his phone from Rebecca, a young woman she thought was their friend. As it turned out, Rebecca and Tom had been intimate together, and both seemed game to do it again.

Reeling, her holiday mood shattered and her relationship with Tom fractured, Elizabeth was beset by deep feelings of anxiety. As the winter gray became more dense and forbidding, the anxiety grew.

Fed up, she broke up with Tom just after Christmas. What looked like a promising start to 2020 now didn’t feel as joyous.

Right around the end of the year, she plucked a copy of her father’s New York Times from the table in his study. A budding physician, her eyes were drawn to a piece about an outbreak of a highly contagious virus in Wuhan, China.

“Sounds dreadful,” she said to herself.

Within three months, anxiety gnawed at Elizabeth daily as she sat cloistered in her family’s house in Bel Air, Maryland.

It didn’t help matters that her brother, Billy, a high school senior and a constant thorn in her side, was cloistered with her.

She felt like she was suffocating.

One night in early May, feeling shutdown and unable to bring herself to tell her parents about her true condition, Elizabeth reached out to her family physician for help.

Dr. Johnson had been Elizabeth’s doctor for a number of years and, being from a small town, Elizabeth had grown up and gone to school with Dr. Johnson’s son Evan. In fact, back in high school, Evan had asked Elizabeth out once. Not interested, Elizabeth had declined Evan’s advances and did not give this a second thought.

Dr. Johnson’s practice had recently been acquired by a Virginia-based hospital system, Medwell, so when Elizabeth called the office, she was first patched through to Medwell’s receptionist/scheduling service. Within 30 minutes, an online Telehealth consult had been arranged for her to speak directly with Dr. Johnson.

Due to the pandemic, Dr. Johnson called from the office in her home. The doctor was kind. She was practiced.

“So can you tell me what’s going on?” she said.

Elizabeth took a deep breath. She tried to fight what was happening. But she could not. Tears started streaming down her face.

“It’s just… It’s just…” she managed to stammer.

The doctor waited patiently. “It’s okay,” she said. “Just take your time.”

Elizabeth took a deep breath. “It’s like I can’t manage my own mind anymore. It’s nonstop. It won’t turn off…”

More tears streamed down her face.

Patiently, with compassion, the doctor walked Elizabeth through what she might be experiencing. The doctor recommended a follow-up with Medwell’s psychology department.

“Okay,” Elizabeth said, some semblance of relief passing through her.

Unbeknownst to Dr. Johnson, her office door had not been completely closed. During the telehealth call, Evan stopped by his mother’s office to ask her a question. Before knocking he overheard Elizabeth talking and decided to listen in.

PART TWO: BETRAYAL

As Elizabeth was finding the courage to open up to Dr. Johnson about her psychological condition, Evan was recording her with his smartphone through a crack in the doorway.

Spurred by who knows what — his attraction to her, his irritation at being rejected, the idleness of the COVID quarantine — it really didn’t matter. Evan posted his recording of Elizabeth to his Instagram feed.

#CantManageMyMind, #CrazyGirl, #HelpMeDoctorImBeautiful is just some of what followed.

Elizabeth and Evan were both well-liked and very well connected on social media. The posts, shares and reactions that followed Evan’s digital betrayal numbered in the hundreds. Each one of them a knife into the already troubled soul of Elizabeth Cunningham.

By noon of the following day, her well-connected father unleashed the dogs of war.

Rand Davis, the risk manager for the Medwell Health System, a 15-hospital health care company based in Alexandria, Virginia was just finishing lunch when he got a call from the company’s general counsel, Emily Vittorio.

“Yes?” Rand said. He and Emily were accustomed to being quick and blunt with each other. They didn’t have time for much else.

“I just picked up a notice of intent to sue from a personal injury attorney in Bel Air, Maryland. It seems his daughter was in a teleconference with one of our docs. She was experiencing anxiety, the daughter that is. The doctor’s son recorded the call and posted it to social media.”

“Great. Thanks, kid,” Rand said.

“His attorneys want to initiate a discovery dialogue on Monday,” Emily said.

It was Thursday. Rand’s dreams of slipping onto his fishing boat over the weekend evaporated, just like that. He closed his eyes and tilted his face up to the heavens.

Wasn’t it enough that he and the other members of the C-suite fought tooth and nail to keep thousands of people safe and treat them during the COVID-crisis?

He’d watched the explosion in the use of telemedicine with a mixture of awe and alarm. On the one hand, they were saving lives. On the other hand, they were opening themselves to exposures under the Health Insurance Portability and Accountability Act. He just knew it.

He and his colleagues tried to do the right thing. But what they were doing, overwhelmed as they were, was simply not enough.

PART THREE: FALLING DOMINOES

Within the space of two weeks, the torture suffered by Elizabeth Cunningham grew into a class action against Medwell.

In addition to the violation of her privacy, the investigation by Mr. Cunningham’s attorneys revealed the following:

Medwell’s telemedicine component, as needed and well-intended as it was, lacked a viable informed consent protocol.

The consultation with Elizabeth, and as it turned out, hundreds of additional patients in Maryland, Pennsylvania and West Virginia, violated telemedicine regulations in all three states.

Numerous practitioners in the system took part in teleconferences with patients in states in which they were not credentialed to provide that service.

Even if Evan hadn’t cracked open Dr. Johnson’s door and surreptitiously recorded her conversation with Elizabeth, the Medwell telehealth system was found to be insecure — yet another violation of HIPAA.

The amount sought in the class action was $100 million. In an era of social inflation, with jury awards that were once unthinkable becoming commonplace, Medwell was standing squarely in the crosshairs of a liability jury decision that was going to devour entire towers of its insurance program.

Adding another layer of certain pain to the equation was that the case would be heard in Baltimore, a jurisdiction where plaintiffs’ attorneys tended to dance out of courtrooms with millions in their pockets.

That fall, Rand sat with his broker on a call with a specialty insurer, talking about renewals of the group’s general liability, cyber and professional liability programs.

“Yeah, we were kind of hoping to keep the increases on all three at less than 25%,” the broker said breezily.

There was a long silence from the underwriters at the other end of the phone.

“To be honest, we’re borderline about being able to offer you any cover at all,” one of the lead underwriters said.

Rand just sat silently and waited for another shoe to drop.

“Well, what can you do?” the broker said, with hope draining from his voice.

The conversation that followed would propel Rand and his broker on the difficult, next to impossible path of trying to find coverage, with general liability underwriters in full retreat, professional liability underwriters looking for double digit increases and cyber underwriters asking very pointed questions about the health system’s risk management.

Elizabeth, a strong young woman with a good support network, would eventually recover from the damage done to her.

Medwell’s relationships with the insurance markets looked like it almost never would. &

Bar-Lessons-Learned---Partner's-Content-V1b

Risk & Insurance® partnered with Allied World to produce this scenario. Below are Allied World’s recommendations on how to prevent the losses presented in the scenario. This perspective is not an editorial opinion of Risk & Insurance.®.

The use of telehealth has exponentially accelerated with the advent of COVID-19. Few health care providers were prepared for this shift. Health care organizations should confirm that Telehealth coverage is included in their Medical Professional, General Liability and Cyber policies, and to what extent. Concerns around Telehealth focus on HIPAA compliance and the internal policies in place to meet the federal and state standards and best practices for privacy and quality care. As states open businesses and the crisis abates, will pre-COVID-19 telehealth policies and regulations once again be enforced?

Risk Management Considerations:

The same ethical and standard of care issues around caring for patients face-to-face in an office apply in telehealth settings:

  • maintain a strong patient-physician relationship;
  • protect patient privacy; and
  • seek the best possible outcome.

Telehealth can create challenges around “informed consent.” It is critical to inform patients of the potential benefits and risks of telehealth (including privacy and security), ensure the use of HIPAA compliant platforms and make sure there is a good level of understanding of the scope of telehealth. Providers must be aware of the regulatory and licensure requirements in the state where the patient is located, as well as those of the state in which they are licensed.

A professional and private environment should be maintained for patient privacy and confidentiality. Best practices must be in place and followed. Medical professionals who engage in telehealth should be fully trained in operating the technology. Patients must also be instructed in its use and provided instructions on what to do if there are technical difficulties.

This case study is for illustrative purposes only and is not intended to be a summary of, and does not in any way vary, the actual coverage available to a policyholder under any insurance policy. Actual coverage for specific claims will be determined by the actual policy language and will be based on the specific facts and circumstances of the claim. Consult your insurance advisors or legal counsel for guidance on your organization’s policies and coverage matters and other issues specific to your organization.

This information is provided as a general overview for agents and brokers. Coverage will be underwritten by an insurance subsidiary of Allied World Assurance Company Holdings, Ltd, a Fairfax company (“Allied World”). Such subsidiaries currently carry an A.M. Best rating of “A” (Excellent), a Moody’s rating of “A3” (Good) and a Standard & Poor’s rating of “A-” (Strong), as applicable. Coverage is offered only through licensed agents and brokers. Actual coverage may vary and is subject to policy language as issued. Coverage may not be available in all jurisdictions. Risk management services are provided or arranged through AWAC Services Company, a member company of Allied World. © 2020 Allied World Assurance Company Holdings, Ltd. All rights reserved.




Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]