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February 17, 2009

Pain as a Variable of Coverage

Dr. Scott Haig, an orthopedic surgeon, has a thought-provoking article in Time Magazine on returning to work after surgery. As those of us involved in workers comp know all too well, returning to productive employment is not simply a matter of healing. Motivation is obviously a huge factor, as is the lurking sense of entitlement that may accompany a work-related injury.

Haig cites a study conducted back in 1995, involving 103 patients who underwent rotator cuff surgery. The study focused on the type of insurance coverage. Where the injuries were work related and covered by workers comp, only 42% of the patients felt better and returned to work in the medically necessary time frame; by contrast, fully 94% of those covered by conventional insurance felt better and returned to work in a timely manner.

These differing results have little, if anything, to do with the quality of the surgery. It's a matter of motivation: people covered by conventional insurance are not making money during recovery; they need to get back to work to pay their bills, or back to whatever life requires them to do. By contrast, people on comp are being paid not to work. They may prefer life on comp to the working grind. They may not approach the return-to-work process with the same sense of urgency that others usually feel.

Chester's Pain
Haig goes on to tell the story of a cop named Chester. Haig performed rotator cuff surgery on Chester, who healed well and seemed ready for a return to light duty, which was readily available. Haig was scrupulous in cultivating a good relationship with Chester; he was confident of optimum results. But well into the recover process, Chester, accompanied by his aggressive mom, complained that light duty wasn't fair. "My sergeant had the same operation and he got six months off...[and by the way],I'm in constant pain."

Alas, despite the availability of appropriate light duty (answering phones), Haig realized that his return-to-work plan was doomed. "I knew the mess I was in. You can't argue with the complaint of pain. I could imagine the grimaces I would see when I examined his shoulder..."

Ultimately, Chester went back to work in four months and stayed on light duty for two more months. In other words, he got his six months, just like his sergeant.

As Haig concludes, the type of insurance coverage goes a long way to determine how much pain you feel. For those who qualify for comp with work-related injuries and illnesses, the pain just might reach the level where work of any kind is simply not not an option. At that point the pain is shared by the employer, who loses a productive employee for a longer period than is medically necessary, and faces increased cost of insurance through the experience rating process. When it comes to comp, there is plenty of pain all around, for sure.

Posted by Jon Coppelman at 11:54 AM Link to, Comment (4), or E-mail this post

Dr Haig sounds like the orthapedic surgeon who moved to my town and was more than happy to have me help him make contacts which helped his practice. All was well until he explained to me he did not believe any of his patients ever had pain after he treated them. Quite arrogent. The story gets better then he started having back problems which became severe enough he had a spinal fusion. He did come back to work but was obviously not sleeping well, fatigued and depressed. So depressed that he started telling me one day in the or how he wanted to kill himself. As a pain physician it was obvious he had severe chronic pain. Working, yes, but "obviously" the surgery sucessful, that is if you excluded his sufferring, considering he did believ like many people there was no such thing as chronic pain. The story in time as above is I do not doubt true but much more complicated then Haigs demeaning "story". Also his use of "facts" in my opinion is quite liberal which to me totally undermines the validity, but I am sure a great fairy tale, um sorry article.

Posted by: Judson Somerville MD at February 17, 2009 5:17 PM

We don't need to hear any more stories a la Dr. Haig.

I'd like to see more stories on how we can fix the problems with the comp. system that ruins the lives of injured workers and their families. Payments cut off arbitrarily; medical treatments delayed until they will do no good; incurred out- of-pocket expenses never repaid, job loss that might lead to a well paid worker dropping down to minimum wage; pitiful settlements for workers who cannot return to work and become the burden of taxpayers... You know, issues that are important to injured workers lives.

Posted by: Andrea at February 19, 2009 12:03 AM

Thank-you so much, Dr. Somerville, and I also very much agree with Andrea's comment. Dr. Haig reminds me of the 84 y/o "neurosurgeon" I just had to see for my 2nd IME just before my 2nd spinal surgery. He had basically written that I was faking my symptoms, yet my surgery the following week was more extensive than expected r/t not only a severe re-herniation, but multiple fragments indenting my dural covering. Yet he is due to testify, & calls himself a "practicing neurosurgeon" in my State, at 84? I am told he believes that all back injuries are pre-existing, therefore NOT compensable by WC. He had made up his mind before I even walked into the office. I am sure he would agree absolutely with the such of Dr. Haig. My pain continues to be more than moderate after 2 mos, at least when I try to actually do anything- yet I fear everyone will feel I am "faking it" a Dr. Haig. I was earning a high salary when my injury happened. I cannot return to the same kind of work...But I do need to work..No settlement, should there be one, will cover what I will have lost(future earnings). Being an RN, I know too many Dr's who do not believe that pts. really have pain, especially chronic-moderate or severe- with activity.

Posted by: Barbara at February 22, 2009 12:28 PM

Let’s pretend that from our safe and lofty position on this Summit, all the visionaries in attendance discovered a safe place buried deep within the cutthroat workers’ comp jungle where each affected group involved in this safari would find their individual Shangri-La. Beyond the dense smoke and foggy mirrors of second-opinions, peer/utilization review, retrospective hospital bill audits and never-ending record reviews; treacherous three-card Monty attempts to find-the-lower-premium; quicksand bog of paralysis by analysis and countless strategies littering the rainforest landscape with unfunded legislative mandates and other ‘comprehensive solutions’ designed to eradicate the serpentine-like rising costs contributing to choking off and polluting the business environment to the point of extinction. Not too mention the anaconda of run-on sentences …

After much discussion, it was agreed that the time for action was NOW. The land was too contaminated to rehabilitate, let alone restore and recover. The visionary leaders agreed to assemble a revolutionary new concept called the Telescope-of-Hope (ToH) and dialed in on a fixed point on the horizon where they believed Workers’ Compensation Shangri-La was located. In order to gain consensus to rally the troops, they invite each representative from the various stakeholders to come and see for themselves.

At that moment, the Telescope of Hope had been inadvertently and unfortunately transformed into the Kaleidoscope of Chaos (KoC). Each stakeholder who stepped up to the ToH adjusted the viewfinder by just one click and then moved on ~ satisfied the utopian scene identified by the visionary leaders was made even more beautiful because of their ‘insightful’ input.

The visionary leaders’ Telescope of Hope never moved from the originally agreed upon fixed point on the distant horizon, yet their Vista of Victory had been lost forever. Why? Because each constituent representative who looked through the ToH adjusted the view to fit their own ideal image for the Garden of Eden and, from that point forward, no two stakeholders could ever agree what Nirvana looked like.

This was not the first time a calamity like this occurred. The Tower of Babylon was never completed after each constituent’s “voice was heard”. When Moses led the mass exodus out of slavery from Egypt, he had the distinct advantage of Divine Intervention when He parted the Red Sea to evade Pharaoh’s army. One would think that act, on its own merits, would generate a lifetime of loyalty, however, non-committed people forget. It’s always, “What have you done for me lately?” So, it’s easy to understand why Moses wandered aimlessly in the desert for forty years until the original Chosen Constituents died off before he delivered their beneficiaries to the Promised Land. Perhaps the ultimate example of passive-aggressive servant leadership … but I seriously digress.

It’s not the big things that keep us from getting to the Promised Land. It’s the little things constantly challenging our worldview. As we go through life relying on our individual moral compass guided by our personal values, beliefs and ideals; our professional constituency’s stakeholder paradigm is driven and defined by its own mission, vision and values of those we serve, lead or follow.

Employers must acknowledge their role in this crisis. Regardless of their current posturing – they are not victims. Employers are the ONLY ones who can actually change their status quo. The greatest problem facing occupational health professionals may be one of our own making. We may have inadvertently ‘helped’ our employer-clients become corporately co-dependent. By consistently framing the workers’ comp problem in a manner that triangulates the power shift labeling the employer and injured employee as the persecuted, we (providers) help perpetuate the myth that employers are powerless from managing their destiny. And to make matters worse, we are now struggling with the concept of leading an intervention with an unwilling participant who refuses to acknowledge their behavior as a mitigating factor in their ongoing financial misery.

Employers have a duty to pay for any injuries and/or illnesses their employees may experience while performing their jobs. They also have a duty to provide a safe workplace and minimize the risks their employees may be exposed to while performing their jobs. So, it stands to reason that the most cost effective risk management strategy available to employers is a comprehensive absence management program beginning with recruitment, orientation, safety/prevention training, ongoing skills improvement, post-injury transitional duty assignments and an array of other programs designed to help employees become accountable for their actions, behaviors and decision-making.

The chief executive and senior management team must be role models demonstrating their commitment to transforming the workplace culture from what it is to what they want it to become. There is no room for lip service or empty promises in this quest for excellence. And there cannot be any of the usual abdication of corporate responsibilities and accountabilities to any third party. As they pay for the band, they call the tune. The time has come for Corporate America to step up and replace their wishbone with a backbone.

Posted by: Tom LeClair at February 26, 2009 9:14 AM
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