Thursday, November 23, 2017

Beliefs, Protocols, Perceptions (5)

People are talking about workers' compensation, perhaps more today than ever. This is the fifth in an 11-post series (links to the others are at the end of this post), that attempts to overview various perspectives heard from system observers and participants. The point is that discussion is good, and if this series generates debate and interaction, all the better.

Injured workers beliefs - not informed or uninformed assumption

When injury or illness does occur, there are educational challenges. Some perceive that injured workers have preconceived perceptions and beliefs about what workers’ compensation is and how it operates. These notions are perceived as not accurately representing the systems. It is probable that selection of various adjectives has contributed to popular beliefs about workers’ compensation. Adjectives that describe system benefits based on “disability” as opposed to either “recovery” or a similarly encouraging outcome perhaps play a role in setting expectations or beliefs. 

There are expectations in the workforce that are perhaps unrealistic. Injuries, whether work-related or not, are unlikely to enjoy complete recovery. Return to a 100% capacity is unlikely for a great many people. Each person will be different. This will be likely in both the physical ability to recover, and in the mindset and beliefs about recovery. Some may perceive opportunity for recovery and return to function, and others may be more pessimistic about their potentials. The perceptions and beliefs may be affected by the existence and perceptions of comorbidities, including other medical conditions, reactions to treatment or modalities, and age.

Some hold the belief that employer behavior and actions, before and after a work accident, may influence employee feelings and perceptions. There are noted examples of successful programs maintaining employer/employee interaction post-injury. However, these are perceived by some as “large employer” processes. There is a perception that small employers represent a large proportion of the market, and that these employers are neither focused upon the post-injury communication/engagement, nor in a business position to appreciate the need therefore until an accident or illness thrusts them into workers’ compensation. 

Treatment protocols, a benefit or a burden 

Treatment protocols, or “guidelines” are published parameters that define presumptively appropriate medical care for the treatment of particular conditions or injuries. Several companies publish material based upon medical research and demonstrated scientific evidence of appropriateness and efficacy. Within the broad definition of guidelines, the concept of pre-defining appropriate prescription medication formularies might also be included. 

Medical treatment is science-based, and science continues to struggle with comprehensive understanding of all of our human intricacies. Studies have demonstrated that medical care outcomes in workers’ compensation are sometimes not the parallel of outcomes for similar injuries and illnesses in non-work settings. Some contend that patient incentives could play a role in these outcome disparities. Others contend that the benefit structure itself plays a role in these disparities, specifically regarding expectations and the participation of excellent providers. Still others contend that these disparities justify the control and certainty perceived by the advocates of opt-out. 

Some contend that volumes of regulation provide an answer to effective and efficient delivery of medical care in workers’ compensation. They contend that published structure would both speed the process of decision-making and promote consistency. Others conversely argue that the human body is demonstrably individualized and therefore argue that medical care should be left to the medical provider addressing a particular patient. They perceive treatment guidelines as burdensome and some refer to them derisively as “cook book medicine.”

Court decisions in recent years have demonstrated that our constitutional form of government does compel a measurement of burden attached to any adoption of guidelines in workers’ compensation. Though treatment guidelines are relatively new, the process of impairment (permanent outcome or effects of injury or illness) guidelines began in the 1960s and has become an accepted methodology for the assignment of impairment ratings. 

The American Medical Association (AMA) has published such guides for fifty years. Courts have concluded that legislatures can appropriately adopt a particular guide for impairment rating calculation/ determination and assignment. However, that adoption or delegation cannot be prospective, i.e. a legislature cannot today adopt an impairment guide that has not yet been published. In 2016 litigation established that an adoption of “the latest edition” of guides was inappropriate. Some courts concluded such language adopted whatever edition of the guides was “the latest” at the time of adoption. Another court concluded that such an adoption was vague and therefore unconstitutional on its face. 

Thus, any adoption of treatment guidelines would likely involve some similar burden related to the investigation and adoption process, characterized as “system” burden, in a macro sense. Thereafter, as medicine advances, a state would potentially elect to update such guidelines periodically thereafter. Those efforts at determining the need for updating and the appropriate adoption of each iteration would also result in some degree of system burden, and financial expense. 

There are also those who perceive such guides as imposing burden on a micro level, in each particular doctor patient relationship. They contend that diagnostics or treatment could be indicated by a guide for a condition or complaint, but the provider in that case might find same unnecessary or superfluous. Despite the perception of being unnecessary, the provider might nonetheless order such care or testing in order to satisfy the guidelines requirement. Critics contend this would add unnecessary cost, “direct” cost for services and “indirect” in delay of either other dare or return to work. Thus, there is concern that unneeded, or ill-advised, care may be rendered, or needed care may be declined upon the authority of such guidelines.

Prescription medication “formularies” are listings of regulatory pre-approved medications for treatment of workers’ compensation injury or illness. To be approved for such listing, medications have to have demonstrated qualities that may include efficacy, cost-effectiveness, and disinclination to addiction or other negative side-effect. Advocates assert that such a regulatory pre-approval process can speed the delivery of medication following an injury or illness, and that with rapid instigation of care recovery is enhanced. Critics of formularies denounce the limitation of individual decision-making by medical practitioners, and some voice the same “cook book medicine” derision applied to treatment guidelines. 

Perceptions and education 

There are many people integrally involved in workers’ compensation, including attorneys, employers, physicians, regulators, therapists, and vendors. There is no shortage of astute, informed, and active professionals. Recent years have led to greater professional specialization. Although there are some available news sources focused on workers’ compensation, the breadth and depth of their capacity is limited. The broader marketplace is less informed regarding developments, changes and challenges, until news spreads. Dissemination of information is often dependent upon word of mouth, email chains, and social medial. 

Some believe that the systems are in need of better sources of information and education. These would perhaps counter existing misperceptions. Such education could be focused upon issues raised in this report, including: system failures, real or perceived; injured worker beliefs about workers’ compensation; Claims handling; medical ignorance; identifying inappropriate activity; expectations of full recovery; and roles of various system participants. 

Admittedly, many will engage information and education only when needed. That is, it is likely that most employers and employees will continue to have minimal interest in workers’ compensation until and unless a work-injury, or allegation thereof, occurs. There is a general consensus that the systems would benefit from more input and participation by broad categories of employers and by employees. But there is doubt that such interest can be easily engaged.

There is a wealth of knowledge in the employment marketplace, which might be of great benefit and value in the structuring of benefits and procedure. Unfortunately, it is perceived that interest in workers’ compensation, and motivation to voice perceptions and ideas, tends to flow primarily from industry and system insiders, and those already affected by the systems. The involvement and engagement of the broader workplace populations is minimal and difficult to motivate or inspire. 

There is perceived value in engaging the workplace in a broader context. Systems would benefit from the involvement and contributions of a greater variety of both employers and employees, addressing concerns and structure of this “safety net” before it is needed in a particular instance or situation.

Other posts in this series:


(2) Benefit adequacy, Regulatory complexity, Delays in treatment even if compensable

(3) System failures, Incentive is different in WC and group health, Systems are persistently adversarial

(4) Staffing and training of the workers’ compensation professions, Permanent partial compensation, Opt out movement

(5) Injured workers beliefs - not informed or uninformed assumption, Treatment protocols, a benefit or a burden, Perceptions and education

(6) Vocational rehabilitation, Ability versus disability, Methodology of claims handling

(7) Medical ignorance, The critical point in a claim, People who are acting inappropriately

(8) Misclassification, Unrealistic expectation of full recovery and youth, Federalization

(9) A new national commission?, Employee participation in the conversation, Occupational disease

(10) Lawyers in the system, Competition between states, Roles and delineation

(11) Single payer, Outliers, Conclusions