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Seeing the Bigger Picture: Three Misconceptions About Physical Therapy in Workers’ Comp

When employers have a focus on workers’ compensation cost control they may miss out on the optimal benefits of physical therapy, both for their injured workers and the health of their workers’ comp program.
By: | August 1, 2019

According to 2015 Bureau of Labor Statistics data, musculoskeletal injuries accounted for 31 percent of occupational injures requiring days away from work, nearly 360,000 cases annually. Treating occupational related musculoskeletal injuries can be complex because the injury itself is generally diagnosed via a complex combination of thorough history, understanding the mechanism of injury, objective clinical exam findings, and intermittent use of diagnostic tests.  The additional challenge is the range of signs and symptoms associated with common diagnoses and ICD-10 coding (International Classification of Diseases, 10th edition).  For example, a diagnosis of an ankle sprain may range from a mild twist of an ankle to partially or fully torn ligaments of the ankle. The range of severity and acuity inherent in the diagnosis leads to challenges in understanding the complexity of the injury and, more importantly, the optimal management of the injury and functional restoration of the injured worker.

Due to the variability of symptoms inherent in musculoskeletal injuries, some employers and treating physicians choose to take a “wait and see” approach first, delaying active physical therapy treatment in hopes that resting at home and assistance of over-the-counter medication will do the trick. However, according to research (Phillips and Shoemaker, JOEM 2017), this method often causes more problems than it solves, specifically driving up clinical costs and extending case duration.

“Occasionally, employers and/or payers may have concerns regarding physical therapy utilization because it can be viewed as a cost driver for workers’ comp claims,” said Giovanni Gallara, Senior Vice President, National Therapy and Ancillary Services Director, Concentra Occupational Health. But when implemented correctly, physical therapy as a first-line treatment for musculoskeletal injuries often results in less time away from work; faster return to function; lower utilization of medications, specifically opioids; and decreased need for costly diagnostic and specialty intervention. (Liu et al., PTJ 2018)

“All of this leads to lower costs for payers and employers,” said Peter Deziel, Vice President of Rehabilitation, Concentra Occupational Health.

Concentra explores three major physical therapy misconceptions and suggests how to best leverage and evaluate therapy to implement a best-in-class workers’ comp program to drive optimal outcomes:

1) Misconception One — “Wait and See” Keeps a Cap on Costly Physical Therapy Treatment

Giovanni Gallara, Senior Vice President, National Therapy and Ancillary Services Director, Concentra Occupational Health

When treating physicians send an injured worker home to rest without physical therapy consideration, they could be setting their patient up for failure by fostering a “disability mindset.”

“A patient who is at home and in pain may feel no one’s looking after them. Due to the perceived lack of clinical care and perception of pain, the injured worker may ask for stronger prescriptions or costly diagnostic tests to understand the source of their pain and ultimately how to get relief. By the time the patient begins rehab, they may already feel they’re disabled and could be frustrated by the lack of treatment activity. This person is much harder to rehab,” Gallara said.

Mental status and patient outlook play a major role in recovery. When individuals believe they will never return to full function because of a work-related injury, it can become a self-fulfilling prophecy. Conversely, when a clear-cut active treatment plan is immediately delivered, many patients experience far better outcomes (Linz et al. 2002 JOEM)

To lay the foundation for a positive outlook, the first step is to communicate with the injured worker that pain perception is not always correlated with tissue damage or loss of function, and to explain how movement promotes the recovery process.

“It’s important to educate injured workers that while there may be some pain associated with movement, it’s part of the healing process. Staying immobile leads injury into disability, both physically and from a biopsychosocial aspect,” Gallara said.

When an injured worker experiencing a musculoskeletal injury is immediately sent to rehab, there is detailed education provided on the recovery process and expectations, reinforcing proactive treatment to generate a positive outcome and shift the focus from pain to function. Early intervention promotes psychological as well as physical recovery, and often mitigates the need for pharmaceutical intervention, costly diagnostics, and potentially downstream surgical interventions (Sun E, Moshfegh J, Rishel CA, Cook CE, Goode AP, George SZ, JAMA 2018).

2) Misconception Two — Compartmentalized Care Controls Total Case Cost

Peter Deziel, Vice President of Rehabilitation, Concentra Occupational Health

In occupational medicine, employers and/or payers may look for cost-saving opportunities through compartmentalization of clinicians by picking and choosing non-integrated clinicians to manage transactional or per visit costs. While this may reduce the per-unit cost of care, it ultimately can create discontinuity of care, add to case durations, delay recoveries, and increase administrative costs to manage a mosaic of clinicians spanning primary care, specialty, and therapy services. These workflow inefficiencies, lack of clinical continuity, and delays in care drive lower patient satisfaction and increase indemnity, clinical, administrative, and total case costs over time.

Lack of clear communication between physicians and physical therapists, for example, could lead to unnecessary diagnostic testing. Often, a therapist can assess and successfully treat an injury without the need for diagnostic testing. Physician and therapy clinical collaboration is key to ensuring patients are receiving evidence based early intervention to optimize outcomes for patients with musculoskeletal injures.

Research has shown that asymptomatic individuals often will demonstrate positive findings in MRI (Schwartzburg, et al. OJSM 2016). “Unfortunately, once you snap an MRI and give a person an image of degenerative changes or partial tears, it often reinforces the perception of disability or inability to resume full function until the structural ‘damage’ is repaired, which can have consequences for recovery,” Deziel said.

Ideally, the physician and physical therapist work closely together, under one roof, collaborating to deliver evidence based early intervention when appropriate to optimize patient outcomes. For example, after the physician’s initial exam of an injured worker, the physician could walk the patient back to physical therapy and explain clinical findings to the therapist. The patient is integrated into the discussion and is witness to both clinicians collaborating and communicating toward an optimal treatment path, all with the patient engaged in the process. The injured worker could then begin rehab that same day to initiate the recovery process with confidence and clarity.

“You can really avoid the unnecessary use of diagnostics, pharmacy, and other costly interventions just by having more integration between physicians and rehab professionals on the front end. When managing musculoskeletal injuries in workers’ comp, strong clinician collaboration delivers better outcomes,” Deziel said.

Finally, close collaboration between therapy and medical clinicians can assist with rapid case closure once a patient achieves functional goals. For example, if a patient is prescribed six therapy visits, but meets all functional goals in four visits, the physical therapist can communicate in real time with the referring physician of goal achievement, walk the patient over for a final medical recheck, and potentially close the case immediately. There would be no need for the patient to finish out the last two therapy visits and attend a previously scheduled medical recheck in the future.

3) Misconception Three — Expertise in Occupational Medicine is not Essential to Manage Workers’ Comp Cases

One of the key differences between group health care and workers’ comp is the end goal of treatment. In workers’ comp, the ultimate endpoint is return to work and maximum occupational recovery and prevention of future disability. The same may not be true for a non-occupational medicine-based therapist, who may not have the same focus on incorporating essential job functions into the recovery plan and design a treatment plan specific to the environmental factors of the worker.

Take a warehouse worker who must be able to lift 75 pounds for his job and just suffered a back strain that renders him barely able to bend over. A therapist with expertise in occupational medicine might determine the worker is able to life 10 pounds and make an appropriate recommendation to the physician to adjust the work restriction to allow light or transitional duty, initiating that first step for the return-to-work process. A therapist without such expertise might not take this step, keeping the worker away from the job, and preventing a very tangible step toward regaining a sense of usefulness and progress.

Bureau of Labor Statistics reports nearly 33 percent of injured workers are associated with lost time from work. “In instances where a medical practice is only sporadically managing worker’s comp cases, the likelihood of driving lost time and not fully understanding causation and OSHA recordability can lead to costly case management,” Gallara said. “When clinicians specialize in occupational medicine, on the other hand, lost time ranges between 5-10 percent of cases vs. the 33 percent national average. There’s a huge emphasis on promoting transitional work duty, expediting return to work in a safe manner, and preventing future disability all while engaging key partners in the workers’ comp ecosystem.”

What to Look for in a Physical Therapy Partner

Look for a physical therapy partner that collaborates in real time with medical clinicians to treat occupational musculoskeletal injuries via an appropriate early intervention evidence-based model.  Understand the therapy providers primary patient population and determine treatment philosophy relative to early intervention, return-to-work planning, and long-term worker health promotion and occupational injury outcomes. Know how your therapy provider tracks metrics and whether those metrics are specific enough to help manage key occupational medicine cost drivers.

For employers and payers concerned about high physical therapy referral rates, Gallara noted, “the metric should spark a closer look at what’s driving injuries in the first place, rather than focusing solely on reducing therapy utilization. If a therapy partner is practicing evidence-based care, utilization should remain constant assuming the worker population has not changed.  If therapy utilization is creeping higher, it may be time for evaluation of factors such as low employee engagement, high turnover, changes in the work environment, forced overtime, aging workforce, etc. and the impact on their injury rates and recovery.

“It’s very important for employers and clinicians to partner to understand what’s happening from a workplace environment and safety standpoint as well as what workplace factors may be contributing to changes in therapy utilization,” Gallara said.

“At Concentra Occupational Health, 95 percent of our patient population is occupational medicine, so our colleagues are dedicated to caring for individuals who have suffered a workplace injury,” Gallara continued. “We have more than 850 therapists and well over 1200 medical clinicians who work in-house, as well as more than 600 contracted specialists who collaborate with our core clinicians to manage more clinically complex occupational injuries.”

“All three – the medical clinician, therapist, and the specialist are communicating together in real time,” Deziel added. “Because we have all these clinicians under one roof, we’re able to deliver coordinated care across the continuum while we concurrently engage the employer to generate the best outcome. We’re one of the few practices nationally that actually has an integrated care delivery model specifically focused for workers’ comp patients.”

To learn more, visit https://www.concentra.com/physical-therapy/.

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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]