Thanksgiving is upon us and our thoughts begin to drift away from the workplace, but a compelling article in the New York Times by health writer Gina Kolata brings us abruptly back to work. The article cites a new study, published in the Journal of the American Medical Association, that raises serious questions about the reliance on surgery for treating herniated discs. The basic findings are startling:
People with ruptured disks in their lower backs usually recover whether or not they have surgery. Surgery appeared to relieve pain more quickly (emphasis added) but most people recovered eventually and that there was no harm in waiting. Patients who had surgery often reported immediate relief. But by three to six months, patients in both groups reported marked improvement. Doctors once feared that waiting would aggravate the condition; this study shows that waiting does not have any negative effect on the eventual outcome.
Sciatica occurs when the soft gel-like material inside a spinal disk protrudes through the outer lining of the disk like a bubble on a bicycle tire. That compresses and inflames a nerve root that forms the sciatic nerve. Doctors often associate the condition with a traumatic incident - lifting - which often enough occurs at work, making the condition work-related. (The predisposition for sciatica may well be genetic - it tends to run in families. But given a work-related cause, comp will pay the bills.)
Ruptured discs are associated with excrutiating pain. (For a very personal perspective, see our posting from a year ago.) The pain can feel like a burning fork in the buttocks. Or it can be a searing pain down the back of a leg. It can be so intense that some people cannot walk. Some cannot sit. In my case, I could barely crawl.
Surgery is certainly a viable option. The operation is quick and generally effective. It involves gently pushing the compressed nerve root away from the herniated disk. Then the surgeon makes an incision in the disk and deflates it. The nerve returns to its normal position, the inflammation goes away, and the pain often disappears.
So in the world of workers comp, where ruptured discs are common, what should we do: perform surgery or wait it out?
The Comp Perspective on Pain
Ultimately, the choice of whether to have surgery is up to the injured employee. And this difficult decision comes down to two fundamental issues: pain and time. In our frequent postings on pharmacology, we note the abundant reliance on narcotics in the workers comp system. People naturally avoid pain and are quick to take medications that make them feel better - even though the medications themselves can have a debilitating impact on recovery.
Injured workers experiencing pain have to perform a difficult calculus: how long can I tolerate the pain? Is it worthwhile to risk surgery, to make the pain go away sooner? Is it worth the risk to stifle the pain through powerful medications, under the assumptions that (1) the pain will eventually go away and (2) I will not develop any problems with the medications themselves?
The Comp Perspective on Time
Then there is the time issue: in the comp system, injured workers get paid to wait. They collect indemnity (usually 2/3 of their average weekly wage, tax free) for the duration of the period where they are unable to work. (We can assume that few workers with severe back pain will be able to take on a modified duty job at work.) So avoiding surgery might actually prolong the time away from work.
There is one other important factor involving time: during a prolonged period of disability - during the wait to get better - injured workers can get used to the idea of being paid not to work. Indeed, indemnity appears to offer a perverse incentive: as long as the pain lasts, I get paid not to work. As soon as the pain goes away, indemnity checks stop and I have to go back to work. For people who don't love their jobs (or their supervisors), the seduction of the indemnity check can be very powerful.
Cost Benefit Analysis
The researchers involved in this study are not concerned about workers comp. Nonetheless, they are interested in the cost effectiveness of surgery compared with waiting. Although the complete analysis has not been published, Dr. Anna N. A. Tosteson of Dartmouth, an author of the study, said that Medicare paid a total of $5,425 for the operation and that private insurers might pay three to four times that. But that's just the cost of surgery. What about the impact of indemnity? For an average worker receiving an indemnity check of $600 a week, $10,000 (estimated cost of the surgery) equates to four months of indemnity.
So from a policy perspective, should insurance carriers start to push back from the surgery option? I don't think so. Given the risk of prolonged disability when people are being paid not to work, given the heavy reliance on narcotics for dealing with pain in the comp system, surgery might still be the preferred option. In comp, time is of the essence. Because surgery speeds the return to work, it might well be the preferred path to recovery.
Enough talk about back injuries. Let's talk real turkeys instead. Here's wishing all our readers a wonderful and safe holiday.