Reduce Opioid Use and Speed Up Recovery by Treating Injured Workers Like Pro-Athletes

During a session on October 21st at the virtual National Comp conference, experts from Travelers and One Call will explain why biopsychosocial care is necessary when treating musculoskeletal disorders.
By: | October 9, 2020
Physical therapy is key to treating injured workers like pro-athletes

A cheering crowd in The Los Angeles Memorial Coliseum fell silent as Mary Lou Retton stepped up for her first vault during the 1984 Olympics. Eyes determined, Retton hesitated for a second before sprinting forward and completing her first vault.

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Within seconds, she was soaring through the flip of her first vault. Commentators declared it was the best of her life.

She only needed one perfect 10 to win the Gold Medal. So, when she stepped up for her second vault, she was already beaming. Then she was flying through the air once more, scoring another perfect 10.

More remarkable than earning two perfect scores and becoming the first American female gymnast to win an Olympic Gold Medal, was the fact that Retton had been sidelined with a knee injury only five weeks earlier. Retton had been sitting cross-legged on the ground signing autographs after a gymnastics camp seminar and when she stood up, she found her left leg was locked at the knee.

“She went and told her coach, Bela Karolyi, who told her to ‘kick it, kick it,’ which was his way of saying ‘walk it off,’ ” said Michelle Despres, vice president and national product leader at One Call.

“She went to bed that night and woke up the next day, and her knee was swollen and she couldn’t walk at all.”

Her doctors determined that a piece of cartilage had broken off and lodged itself in Retton’s knee joint. Arthroscopic surgery was a must, and doctors thought it was unlikely that Retton would be able to compete at the 1984 Olympic Games in Los Angeles.

Retton, however, was determined to compete. She knew that she was the best shot the Americans had of bringing home a gold medal. With the help of her doctors and the support of her family and coaches, she completed six weeks of physical therapy in only two weeks.

“She went on five weeks later to the Olympics and had a perfect vault twice. She scored two perfect 10s,” Despres said.

For Despres, Retton’s story is one of a remarkable — but not unachievable — recovery. Elite athletes, while healthier than most, still have human bodies. Although their physical fitness may hasten their recovery somewhat, it is really the kind of treatment they receive that makes the difference.

When an athlete is injured, all of the focus is on restoring the function of the injured body part so that they can return to competition. Everyone in their lives — family members, coaches, doctors — rallies around that goal.

They make sure that not only the physical injury is being treated but also that the athlete is in the right mindset for recovery, and they help them avoid relying on addictive pain killers that may delay recovery.

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“People will say, it’s an elite athlete so they may heal more efficiently. And I would argue, that’s true, but science doesn’t cease to exist in your body because you’re an elite athlete. There’s still a healing period,” Despres said. “As elite as anyone is, your body does not necessarily have the ability to overcome science and nature.”

All of which of course begs the question, if caring for an athlete by treating the physical, psychological and sociological factors that come with an injury speeds up their recovery process, couldn’t the same model work in workers’ compensation too?

At the virtual National Workers’ Compensation and Disability Conference, Despres and Dr. Marcos Iglesias, chief medical director and vice president at Travelers, will use Retton’s example to detail how treating injured workers like pro-athletes can help speed up recovery and reduce opioid use, especially when it comes to musculoskeletal injuries.

Their session, “Going For The Gold: From Injured Worker to Star Performer” will be held on October 21 from 2:00-3:00 p.m. Eastern Time.

Treating Injured Workers Like the Pro-Athletes They Are

Michelle Despres, vice president, national product leader, One Call

Treating injured workers like pro-athletes isn’t new in workers’ comp. Manual laborers have been called industrial athletes and some workers’ comp programs have adopted strategies to focus on their workers’ health in the same way that a coach would with an athlete.

While the idea has existed for some time, Iglesias and Despres plan to detail what the approach entails during their session.

One of the key distinctions they drew between the way workers’ comp injuries and pro-athlete injuries are treated is the emphasis on returning to function over removing pain.

Pro-athletes are expected, even pushed, to make a full recovery so that they can get back to their sport. As a result, their doctors, physical therapists and trainers focus on improving the function of their joints and muscles rather than treating their pain.

“It focuses on function as opposed to pain,” Iglesias said.

“Focusing on pain is not usually very helpful. But focusing on function is, because function really is something that is measurable. It’s objective.”

Injured workers, on the other hand, are often treated based on their pain levels. Doctors, physical therapists and other care providers ask about pain before they ask about other factors that could be affecting an injured employee’s healing process.

“Back in the day, we would say, when you walked into PT, Hey, what’s your pain today? Zero to 10, tell me your pain level,” Despres said. “When you focus on pain like that, then you set the expectation that a person should have pain.”

Instead of focusing on pain, Despres and Iglesias recommend treating injured workers like pro-athletes by asking them about their functionality.  Providers should ask if they’re having an easier time lifting common household items, tying their shoes or completing other activities that could be inhibited by their injury.

“If we instead frame up function and don’t focus on the pain, the pain may not change, the pain may always be there, but if you’re doing more things functionally and you’re more successful at doing those things, then the pain starts to subside, and it’s less in the forefront of your mind,” Despres said.

Biopsychosocial Care Goes for The Gold

In addition to treatment that focuses on improving functionality, professional athletes are often surrounded by supportive communities who are all working to help them heal. Recalling the example of Retton, Despres noted how her whole community — coach, parents and doctors — supported her journey and helped her heal.

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“She had a coach that was supportive and a family that was supportive and a medical community that was supportive,” Despres said.

In workers’ comp, the practice of involving every aspect of an injured worker’s life in their treatment is known as the biopsychosocial care model.

In biopsychosocial care, providers focus on treating the behavioral health and socioeconomic conditions that may be negatively affecting an injured worker’s recovery alongside the physical injury.

“It really involves putting the injured employee, the patient in charge of their recovery,” Iglesias said.

“Helping them to set goals, helping them to see how they’re progressing, getting them to be active — physically active, socially active, cognitively active.”

A worker who feels negatively about work, for example, may have a harder time recovering than someone who loves their job, even if they have the same injury. Similarly, an injured worker who is struggling financially may face a longer road to full-functionality due to the stress and anxiety they’re experiencing.

“If a person’s very motivated and they love their job and they’ve got a supportive family and all their friends are supportive and they’re looking forward to going back to work, they generally have a good outcome regardless of the diagnosis,” Despres said.

“If someone’s not happy with their work, they don’t really want to go back, if their family maybe is annoyed with them, and if that person maybe has depression or has some other things going on, all of that leads to a less optimal outcome. Same person, same injury, depending on what those biopsychosocial factors are, could have two very different end results.”

A Winning Strategy for Reducing Opioid Use

Marcos Iglesias, chief medical director, vice president, Travelers

By exploring how treating injured workers like pro-athletes shifts the focus away from pain, the session will also help workers’ compensation care providers learn how they can reduce opioid usage amongst injured workers.

Opioid use has been on the decline in workers’ comp — a recent WCRI report found that opioid spend has decreased from 20% to 9% on average in most states — but it can still be used as a clutch for patients who are experiencing pain, Iglesias noted, even though it may not be the best option.

“A lot of times we have looked at drug therapy, especially opioid therapy, as the best pain control for every problem and that’s just simply not the case,” Iglesias said. “We need to understand the injury, and we need to understand the pain that we’re dealing with because oftentimes we lump pain and injuries as one.”

Part of this is due to misunderstanding the nature of the pain an injured worker may be experiencing. Acute pain, like the pain an injured worker experiences after surgery, may go away over time on it’s own and thus may be best treated by a brief opioid prescription. Chronic pain, however, requires a different treatment approach.

“Are we trying to address pain that is acute or is it chronic?” Iglesias said. “The tools that may be very effective for treating acute pain are seldom effective in chronic pain and in fact, may be counterproductive.”

This dynamic is especially true of musculoskeletal disorder treatment. One of the most common work injuries, musculoskeletal disorders can lead to absenteeism and delayed return-to-work when opioids are prescribed early on in the claim, several studies have shown.

While more research is needed in this area, providers and prescribers should be concerned about the correlation between prolonged recovery and opioid use for injured workers with musculoskeletal disorders, especially when research shows there may be better treatments out there.

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A WCRI study from this year found that for injured workers with low back pain — the most common musculoskeletal disorder — early physical therapy could help reduce costs and avoid opioid use.

Average claims payouts were 24% higher for patients who began PT 30 days post-injury than those who began 3 days after being hurt, the study found. On the opioid front, injured workers who began PT 30 or more days after their injury were 46-47% more likely to receive an opioid prescription.

“Physical therapy is one of the most known, most researched, best ways to avoid an opioid,” Despres said.

“Consider PT first and consider PT early with any musculoskeletal disorder versus medications and rest. Movement is key. So when somebody then does rest, problems start to creep in.” &


National Comp will present a special free one-day event on October 21, followed by an ongoing digital session series that runs through next fall.

The event will begin with an opening keynote, “The 5 Most Critical Challenges Facing Workers’ Comp in the COVID Era” at 11:00 a.m. ET and will continue throughout the day with four additional sessions and a closing panel discussion.

“Going for the Gold: From Injured Workers to Star Performers” will be held from 2:00-3:00 p.m. ET.

You can register for the conference’s virtual event and find out more information about the sessions here.

Courtney DuChene is a staff writer at Risk & Insurance. She can be reached at [email protected]

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]