National Trends in Workers Compensation

1
National Trends in Workers Compensation

• David C. Deitz, MD, PhD
• National Medical Director, CPS
• Liberty Mutual Insurance Group

2
Themes for this talk

• Liberty Mutual
• WC trends and concerns
• Some specific concerns
• Spine surgery
• Complex, high-cost claims
• Pain medicine and chronic pain
• Some partial solutions what payers are doing
• Guidelines, quality and outcomes in WC
• Questions

3
Liberty Mutual Group

• Privately held, founded 1912
• Multi-line Property/Casualty insurer, writing WC
  policies in all 50 states
• Long history of investment in safety, loss
  prevention and disability research
• Database compares favorably w/ those maintained
  by BLS, NCCI, NEISS
• (Murphy et al, Amer J Ind Med 1996 30130-141)

4
WC From a Payers View

• Medical costs now comprise 58 of WC losses
  nationwide (NCCI, 2006) about 65 in Montana
• WC medical inflation is higher than the CPI and
  the group health inflation rate
• Remains heavily driven by musculoskeletal care
• Costs continue to increase despite 10 year trend
  towards decreasing fatalities and decreasing
  severity of workplace injury (BLS data)
• WC has become very different from group health

5
Some key WC problem areas

• Growth of spine surgery over the last decade
• Expansion of passive physical medicine and other
  palliative treatments
• Medicalization of normal processes such as
  stress and aging
• The Decade of Pain and the rise of the chronic
  pain industry
• Medical dispute resolution primarily legal, not
  medical
• Disability and SSDI
• Cost shifting

6
Spine surgery a few facts

• Over the last 10 years, spine surgery rates for
  both Medicare and non-Medicare patients have
  tripled
• Driven primarily by lumbar fusion, which now
  accounts for about half of low back surgery (29
  in 1991)
• Fusion is associated with more complications and
  a higher failure rate than disc surgery
• Despite the dramatic increase in rates, there is
  no evidence for increased efficacy or improved
  outcomes from this operation, particularly in WC
  claimants

Deyo et. al. Spine 2005 301441-1445 Weinstein
et.al. Spine 2006 312707-2714
7
Spine Surgery - Montana

• For Medicare patients, Montana is far above the
  national average
• Lumbar disc surgery
• Billings, MT 4.5 (surgeries/1000)
• National average 2.1
• South Bend, IN 0.9
• Lumbar fusion
• Missoula, MT 3.0
• National average 1.0
• Grand Forks, ND 0.3
• No evidence that Montana achieves superior
  outcomes from these high rates

8
High Cost Claims
9
What is a complex claim?

• Catastrophic/multiple trauma
• Co-morbid illnesses which complicate an otherwise
  typical injury
• Injury or illness with medical complications,
  e.g. failed surgery, post-op infection,
  intra-operative heart attack, etc.
• Severe and/or chronic medical condition deemed
  compensable
• Unusual illness or exposure
• Significant psychosocial issues
• Recurrence or re-injury of prior WC injury

10
Some drivers of medical complexity in WC claims

• Aging workforce
• Medicalization of normal processes, such as
  stress and aging
• Consumerism in health care
• Cost-shifting from group health
• Medical advances treatments, diagnostic
  capabilities, drugs
• Expansion of palliative treatments PT to
  relieve pain, improve self-esteem, etc.
• Legal, rather than medical dispute resolution

11
High cost claims

• In WC nationwide, high cost claims account for
  disproportionate share of medical paid
• Avg med paid/claim may exceed 20,000/yr, with
  total medical expenses 500,000
• Only about 20 are catastrophic (head or spinal
  cord trauma, severe burns, etc. ) Remaining 80
  begin as soft-tissue claims
• 90 of noncats have evidence for chronic pain
• Multiple surgeries much more frequent, especially
  multiple spine procedures

Sources LMIG unpublished data Victor, RA.
Adverse Surprises in Workers Compensation Cases
With Significant Unanticipated Medical Costs.
WCRI, June 2005
12
High-cost claims make up about 3 of the WC open
inventory and over 50 of total medical case
reserves
-
Commercial Market WC- Medical Costs High
Exposure Claims as of 9/30/2005
13
Chronic Pain in WC
14
What is Chronic Pain?

• Persistent pain of an unexplained nature lasting
  longer than 3-6 months
• Occurs beyond reasonable time for an injury to
  heal
• Occurs beyond the usual course of a disease
• Affects physical activity, work, family, and
  social life in a negative way
• Documented changes in neural architecture and
  processing in brain
• Strong emotional components
• May be unresponsive to usual treatments

15
How much pain?

• The National Institutes of Health estimates that
  pain costs over 100 billion/year in medical
  expenses, lost wages and lost productivity.
• National Institutes of Health, "The NIH guide
  New directions in pain research I," Washington,
  DC GPO, 1998.
• Over 75 million Americans suffer serious pain
  annually 50 million of those endure serious
  chronic pain (pain lasting 6 months or more)
• National Pain Survey, conducted for Ortho-McNeil
  Pharmaceutical, 1999
• One in eight workers loses 5 hours per week of
  productive time (excluding missed days) from
  pain. Combining reduced productivity while at
  work and lost work days 61.2 billion in
  estimated lost productivity for the year
  2001-2002. Stewart w et.al. Lost Productive time
  and costs due to common pain conditions in the
  US work force. JAMA 2003 290(18)2443

16
Chronic Pain in WC

• Statutes foster accommodation - to cure and
  relieve
• Loss of focus on function
• Emphasis on medical model rather than
  biopsychosocial model
• Concept of workplace injury leads to
  justification for perpetual intervention
• Pharmacologic end-game
• Narcotics
• Sleeping pills
• High-quality outcomes data for most interventions
  poor to non-existent

17
Top 10 Prescribed Drugs by Total Paid in WC
(19972002)

• 
  of Total Rx Paid
• Celebrex (anti-inflammatory) 7.6
• Oxycontin (painkiller) 6.6
• Vioxx (anti-inflammatory) 5.6
• Hydrocodone (painkiller) 5.4
• Neurontin (painkiller) 4.9
• Carisoprodol (muscle relaxant) 3.2
• Ultram (painkiller) 2.9
• Cyclobenzaprine (muscle relaxant) 2.4
• Ambien (sedative) 2.1
• Naproxen (anti-inflammatory) 2.1
• Analgesics comprise 54 of total WC drug bill

Source NCCI Research Brief, Oct 2004
18
The rise of pain mgmt

• Pain as the 5th vital sign
• Proliferation of pain mgmt specialists...

19
Pain Management Specialists
7000
200
Source Dr William Brose, Stanford Univ., Alpha
Omega Pain Assocs.
20
The rise of pain mgmt

• Pain as the 5th vital sign
• Proliferation of pain mgmt specialists...
• ...and pain mgmt societies

21
Professional Pain Organizations

• International Assoc. for the Study of Pain (IASP)
• American Academy of Pain Medicine
• American Pain Society
• American Academy of Physical Medicine
  Rehabilitation
• American Society of Anesthesiologists
• American Society of Regional Anesthesia and Pain
  Medicine
• American Academy of Pain Management
• American Society of Interventional Pain
  Physicians
• International Spine Intervention Society
  (formerly Spinal Injection)

22
The rise of pain mgmt

• Pain as the 5th vital sign
• Proliferation of pain mgmt specialists...
• ...and pain mgmt societies
• Data from Dartmouth Atlas clearly indicate a
  correlation between presence of specialty
  providers and increased likelihood of procedural
  intervention

23
Responding to New Challenges in Workers
Compensation Medical Care
24
Payer responses to WC issues

• Medical management talent
• Moving toward a group health model of approach to
  care
• High-Cost Claim Teams

25
The good news on chronic pain

• There is clear evidence that
• Focus on psychosocial issues (fear-avoidance,
  perceived disability) improves outcomes
• Interdisciplinary pain programs (IPPs) are
  superior to usual care, including injection or
  drug-based pain mgmt (multiple studies in medical
  literature)
• Earlier referral is best
• LMs experience confirms that IPPs produce both
  cost savings and better outcomes for injured
  workers

26
Payer responses to WC issues

• Medical management talent
• Moving toward a group health model of approach to
  care
• High-Cost Claim Teams
• Information systems
• Comparisons w/ group health benchmarks
• Allows better look at quality, outcomes
• Identify complex patients earlier
• Predictive modeling

27
Payer responses to WC issues

• Medical management talent
• Moving toward a group health model of approach to
  care
• High-Cost Claim Teams
• Increased focus on biopsychosocial approach
• Information systems - Medstat
• Comp w/ group health benchmarks
• Allows better look at quality, outcomes
• Identify chronic pain patients early?
• Predictive modeling
• Research
• Liberty Mutual Research Institute for Safety

28
Liberty Mutual Research Institute for Safety and
Health

• 50 years of occupational and safety research
• International reputation, chartered as separate
  institution from insurance claims and
  underwriting operations

29
Payer responses to WC issues

• Medical management talent
• Moving toward a group health model of approach to
  care
• High-Cost Claim Teams
• Increased focus on biopsychosocial approach
• Information systems - Medstat
• Comp w/ group health benchmarks
• Allows better look at quality, outcomes
• Identify chronic pain patients early?
• Predictive modeling
• Research
• LMRIS
• Focus policy debate on quality and outcomes as
  well as costs

30
Quality of WC Medical Care

• There is insufficient attention being paid to
  quality of care for property/casualty patients
• What kind of quality does this lead to?

31
Quality of Care for WC

• There is minimal industry or regulatory focus on
  this issue
• Most studies of QOC have indicated that better
  care is cost-beneficial or at worst, cost neutral
• Duration of care for WC injuries may extend for
  years, or life.
• Many studies suggest treatment outcomes are worse
  in WC patients when compared with group health
• Few state systems collect medical/disability
  outcomes data, fewer have analyzed in detail
• Outcomes following administrative/judicial
  proceedings not tracked at all

Atlas SJ et al. JBJS 200082A4-15 Harris I
et al. JAMA 20052931644-1652
32
QOC Institute of Medicine Definition

• High quality health care should be
• Safe - avoiding injuries to patients from the
  care that is intended to help them.
• Effective - providing services based on
  scientific knowledge to all who could benefit and
  refraining from providing services to those not
  likely to benefit (avoiding underuse and overuse,
  respectively).
• Patient-centered - providing care that is
  respectful of and responsive to individual
  patient preferences, needs, and values and
  ensuring that patient values guide all clinical
  decisions.
• Timely - reducing waits and sometimes harmful
  delays for both those who receive and those who
  give care.
• Efficient - avoiding waste, including waste of
  equipment, supplies, ideas, and energy.
• Equitable - providing care that does not vary
  in quality because of personal characteristics
  such as gender, ethnicity, geographic location,
  and socioeconomic status.

IOM Crossing the Quality Chasm A New Health
System for the 21st Century. National Academy
Press, 2001
33
How can we get there?
34
Steps to Improve Quality and Outcomes in Workers
Compensation

• Support for better data collection, especially
  treatment outcomes
• Enforce link between EBM and quality
• Embed evidence-based practice in guidelines

35
Guidelines

• Why do we need them?

36
Potential Uses of Guidelines

• Precertification (traditional UM)
• Concurrent review
• Retrospective Review
• Physician profiling (network management)
• Quality assessment/improvement

37
Types of Guidelines

• Appropriateness of care typically, applied to
  procedure or service-based care such as PT
• Setting of care Inpt, Outpt, Office, etc
• Duration of care Inpt LOS, Disability
• Misc Assistant surgeon, rehab, etc.

38
Guidelines Why?

• Meet statutory requirements to precertify certain
  categories of treatment, e.g., surgery
• Intervene in ongoing care which is excessive or
  inappropriate
• Make payment decisions for care that has already
  occurred
• Evaluate duration of disability
• Make judgments concerning quality

39
Guidelines Common misconceptions

• Guidelines
• Are arbitrary
• Are financially-driven
• Lead to poor-quality, cookbook medicine
• Lag behind cutting-edge care and stifle
  innovation

40
Guidelines Discussion Issues

• Why do we need guidelines?
• Why cant we just do this with networks?
• Shouldnt we use guidelines developed by the
  specialty involved with the care?
• If guidelines disagree, how can any of them be
  valid?

41
Why do payers need guidelines?

• No uniformity in medical practice - many
  interventions proposed w/o evidence, but at
  increasing expense to system.
• Predictability in payment simplifies system for
  all stakeholders in our current healthcare
  model, bill adjudication is critical. (there are
  other models)
• Give me a viable alternative

42
Why cant we just do this with networks?

• Faulty assumption that poor quality or
  inefficient care is isolated to a few providers
  (the Berwick bad apples1)

1-NEJM 1989 320 53-56.
43
Why cant we just do this with medical provider
networks?

• Faulty assumption that poor quality or
  inefficient care is isolated to a few providers
  (the Berwick bad apples1)
• Insufficient data to profile specialty care
  effectively
• Small demonstrations show effectiveness (Bernacki
  20062) but scalability has yet to be proven

1-NEJM 1989 320 53-56. 2-JOEM 2006
48(9)873-882
44
Shouldnt we use specialty guidelines?

• Not necessarily
• While stakeholder buy-in is valuable, no data
  indicate that specialty guidelines developed in
  absence of data are any more effective in
  promoting better care that other guidelines
• Redefinition of evidence tailored to needs of the
  specialty

45
Evidence-Based Guidelines from the Council on
Chiropractic Practice

• Guidelines Mission Statement
• Needs of and Rights of our Patients
• ????The first endeavor of the panel was to
  analyze available scientific evidence revolving
  around a model which depicts the safest and most
  efficacious delivery of chiropractic care to the
  consumer.
• ????The guidelines were developed to protect the
  right of any patient ----including children and
  asymptomatic patients ----to obtain
  subluxation-based chiropractic.
• http//www.ccp-guidelines.org/files/CCPA.pdf

46
Pain Guidelines?
47
Table 1. Designation of levels of evidence Level
I Conclusive Research-based evidence with
multiple relevant and high-quality scientific
studies or consistent reviews of
meta-analyses Level II Strong Research-based
evidence from at least one properly designed
randomized, controlled trial or research-based
evidence from multiple properly designed studies
of smaller size or multiple low quality
trials. Level III Moderate a) Evidence obtained
from well-designed pseudorandomized
controlled trials (alternate allocation or some
other method) b) evidence obtained from
comparative studies with concurrent controls and
allocation not randomized (cohort studies,
case-controlled studies, or interrupted time
series with a control group) c) evidence
obtained from comparative studies with
historical control, two or more single-arm
studies, or interrupted time series without
a parallel control group. Level IV Limited
Evidence from well-designed nonexperimental
studies from more than one center or research
group or conflicting evidence with inconsistent
findings in multiple trials Level V
Indeterminate Opinions of respected authorities,
based on clinical evidence, descriptive studies,
or reports of expert committees.
Boswell, MV et al. Pain Physician 2005 8 1
47.
48
When guidelines disagree....

• Guidelines rarely disagree when evidence is
  available.
• Points of divergence are always emphasized by
  guideline opponents (the glass is never 9/10
  full)
• Back care guidelines developed in Europe,
  Australia, NZ and the US are in substantial
  agreement

49
The real problems

• Over-emphasis on the lack of evidence issue
• Dissemination of evidence/best practices
• Provider resistance to using guidelines, which
  leads to....
• Poor compliance with best practices, which leads
  to...
• Deficient quality of care

50
The lack of evidence problem

• Get over it. There will never be enough.
• It gets better and better each year
• The dissemination problem is much bigger
• Lack of evidence is a poor rationale for
  including WC patients in unproven or experimental
  treatments and there is evidence for that. WC
  patients have consistently worse outcomes than
  group health patients across a spectrum of
  procedures (Harris I et. al. 2005 JAMA 293
  1644-52)

51
The dissemination problem

• Long cycle between evidence for a best practice
  and actual adoption of that practice in provider
  community
• Examples abound in spine care
• Lack of activity prescription for acute LBP
• Narcotic use for acute LBP

See Crossing the Quality Chasm, IOM 2001
52
The Compliance Problem

• Providers dont like guidelines
• Providers dont follow guidelines
• Physicians viewed guidelines as providing
  helpful information, but constraining their
  practice and not helpful in making decisions for
  individual patients.
• Providers consistently overestimate their
  compliance with best practices
• But....

Tierney WM, et al, J Gen Intern Med 2003
18967976
53
Interventions to improve provider use
of/compliance with guidelines are only modestly
successful

• Results on education, feedback, and economic
  incentives all mixed
• Latest Cochrane review suggests audit/feedback
  results quite modest in affecting provider
  behavior
• Its the economy
• Providers are not paid for not performing
  interventions
• Interventions which combine directed feedback
  with economic incentives/disincentives are more
  effective in changing behavior (pay for
  performance)

54
Guidelines Can Improve Outcomes

• Adherence to best practice guidelines led to
  lower admission rates for heart failure1
• Better guideline compliance was associated with
  lower mortality for community-acquired pneumonia2
• Exercise/activity prescription for chronic low
  back pain, as recommended by multiple guidelines,
  produced better outcomes3

1 Komajda et al. Eur Heart J 2005 26
1653-59 2 Menendez et al Amer J Resp Crit Care
Med 2005172757-762 3 Liddle et al Pain 2004
107 176-190
55
Steps to Improve Quality and Outcomes in Workers
Compensation

• Support for better data collection, especially
  treatment outcomes
• Enforce link between EBM and quality
• Embed evidence-based practice in guidelines
• Create environment for guidelines to work

56
Steps to Improve Quality and Outcomes in Workers
Compensation

• Support for better data collection, especially
  treatment outcomes
• Enforce link between EBM and quality
• Embed evidence-based practice in guidelines
• Create environment for guidelines to work
• Measure

57
Steps to Improve Quality and Outcomes in Workers
Compensation

• Support for better data collection, especially
  treatment outcomes
• Enforce link between EBM and quality
• Embed evidence-based practice in guidelines
• Create environment for guidelines to work
• Measure
• Seek systematic reform

58
Systematic Reform

• Improvements in medical quality must rely on
  system changes (IOM, IHCI)
• All stakeholders must be involved
• Employers
• Employee representatives and/or unions
• Providers
• Payers
• Government Legislative, Regulatory
• This is not easy

59

• Thats all....