April 24, 2015

Red Herrings

Cost Containment
, Pharmacy

A new whitepaper by Keith Rosenblum, a Senior Strategist for Workers’ Compensation Risk Control for Lockton, discusses evidence-based medicine, its foothold in the marketplace and how it could help reduce the spend attributed to chronic pain cases in workers’ compensation.

The paper, titled “Red Herrings and Medical Overdiagnosis Drive Large – Loss Workers’ Compensation Claims,” notes that 20-25 percent of all loss dollars are attributed to low back injuries. This high spend results from the all too standard practices of assigning MRIs and CT scans to such injuries. However, while these high-cost imaging services boost spend, there is no correlation when it comes to resulting outcomes from these diagnosis mechanisms. Additionally, pain medication only serves to drive costs even higher.

Rosenblum calls for “innovative models in diagnostic technology that may ensure more accurate diagnosis and treatment.” Citing that red herrings, a medical references that refers to a diagnosis based on inaccurate criteria, creates a sense of false certainty and in turn a dependency on certain, often expensive treatments, when the true pain could originate from somewhere else – for example, the brain.

He cites one study in which “85 percent of all people who developed chronic low back pain had changes in brain regions dealing with reaction processing rather than initial sensation. This suggests that most (not all) of the time, it’s about the brain processing and not about the body damage.”

Rosenblum also refers to CorVel’s Chronic Pain Identification and Intervention Model, citing an example in which the “employee-centered” model has a nurse at the front-end of targeted claims to identify any potential signs that the claim could develop into something more complex due to bio-psycho-socio-economic factors. “If recovery stalls and chronic opioid therapy, spinal injections, or surgery are even anticipated, the underlying diagnosis may be reassessed,” Rosenblum said in the paper.

It is a widely known industry fact that a small percentage of claims accounts for a vast majority of the costs. Rosenblum concludes that adjusters must be proactive before approving aggressive treatment plans and should consider any potential bio-psycho-socio-economic factors that may be present.