The traditional model of physical therapy is built on the patient-first principles of finding solutions to treat injured workers; however, it is marked by inefficiencies that can hinder patients from achieving maximum medical improvement (MMI). By outlining the pitfalls of the typical therapy model, industry professionals can bridge the gap between patients’ perception of pain and a successful treatment plan by clearly outlining the distinction between objective and subjective pain. In addition, they can give their patients the opportunity to reach MMI and return to work sooner – a benefit for all stakeholders.
In the workers’ compensation realm, pain is a seemingly universal concept that has two polar definitions.
Objective Pain: Also known as “good pain,” this is the pain experienced during treatment that leads to overall physical improvement. For example, the pain experienced after a rigorous physical therapy session is considered objective pain because it strengthens the injured muscle and surrounding tendons, ligaments, etc. to eventually achieve increased mobility.
Subjective Pain: Also known as “bad pain,” this is pain detrimental to one’s wellbeing. An example would be the initial pain felt immediately after a sprain, cut or injury occurs.
Prolonged physical therapy and its excessive resulting spend is unintentionally encouraged by the traditional care model – too many visits, overutilization, and treating unrelated pain are just some of the side effects. These factors can further perpetuate patients’ misguided perceptions of pain, and the inability to distinguish between objective (good) pain and subjective (bad) pain has limited the capacity in which physical therapy can be successful.
The proper identification of objective pain and supportive, yet educational, management of a patient’s subjective pain can return an injured employee to work through a course of treatment managed by multiple touch points. With patient buy-in, physical therapists can lead injured workers to MMI prior to completion of the physical therapy script, saving employees time and their employers’ money. By identifying and overcoming the shortcomings of the traditional model, injured workers can achieve MMI and return to work with a more efficient and cost-effective solution.
The typical physical therapy model consists of a treating provider prescribing a designated number of physical therapy appointments on a block system based on a number of visits allowed. Except for the injury factor, the number of visits is standard. Each injured worker represents a unique case – the same lumbar sprain injury can affect two people in entirely different ways. By this observation, care can never be standard.
In the same breath, because each injured worker is different, from the inception of treatment, a physician cannot know exactly how much physical therapy visits an injured worker will or will not need. To combat unnecessary spend, it is important to have a system of communication in place between the treating physician and the physical therapist, consisting of a series of updates as the injured worker progresses toward MMI. In today’s model, if a patient reaches MMI after 16 out of 32 prescribed visits, the injured worker will not be evaluated for MMI until the completion of the prescription. As such, the patient has to attend 16 unnecessary visits, possibly an additional eight weeks out of work if on lost time or temporary total disability, which equate to 16 visits that the employer would not have had to pay. While the industry may be historically focused on market discounts, the modern realization that less is more can yield significant savings.
Another factor that contributes to overutilization is the treatment of unrelated pain. Physical therapists develop a special relationship with their patients – one of the most valuable aspects of a successful therapy program. However, when their patients report pain they are experiencing, the therapist’s natural tendency is to find their patient relief. In many instances, this can lead to the treatment of a different body part, which is not covered under the prescribed physical therapy. While this may cause temporary relief for the injured worker, it results in additional fees for the employer and more time away from work.
In the workers’ compensation industry, “pain” (specifically subjective pain) has become yet another four-lettered word to which we have grown a tolerance. The two distinct types of pain are glossed over with quick fixes of narcotics and medical interventions. Prolonged physical therapy is just one of the contributors to the blurred lines differentiating good pain from bad pain.
Over time, some treating physicians have become less stringent to the differentiation of pain, indiscriminately accepting injured workers’ complaints and recording them within case notes for the adjuster to review. Inclined first to make the patient most comfortable, physical therapists cannot allow their patients to dictate their own care. Care (another four-lettered word) does not strictly equate to comfortable. By not discerning the differentiation, the entire model is discredited. If physicians are committed to the connotation of pain rather than its literal face value, a difference can be made. Injured workers can return to work. Employers can save money.
“Physicians have great difficulty in discerning soft tissue pain from neuropathic pain from psychosocial pain. In some cases, it may be a combination of one or more of the above or all three requiring multiple treatment plans. There is an overwhelming tendency for physicians to treat these cases with more and more drugs, unending physical therapy and, in too many cases, unnecessary and damaging surgery. Thus, longer TTD and higher disability ratings. A large percentage of chronic pain cases have a psychological component that can be assessed and treated through cognitive behavioral therapy. New CPT codes have been created just for this purpose. There is also new technology permitting neurologists and orthopedic physicians to differentiate between the three forms of pain noted above. We see very few adjusters and risk and claim managers even aware of the resources available to control this huge area of claims costs.”
Lockton Report, January 2014
In addition to national physical therapy guidelines, successfully enabling patients to take responsibility for their treatment can be just as important for their road to recovery. The traditional model assigns a sedentary role to the injured worker. They wait until their prescription expires to be told by their doctor to either undergo more physical therapy or be approved to return to work.
By obtaining patient buy-in at the forefront of care, the injured worker is invested in their own recovery. The physical therapist can work with each patient to set goals for MMI and return to work. Consequently, the injured worker, treating physician and physical therapist can more effectively fulfill return to work goals.
Should an injured worker show signs of not wanting to return to work or choose not to cooperate with their buy-in, the case can be flagged as there may be an unseen factor contributing to the injured worker’s perceived pain. In that way, physical therapy can serve as a gateway to other resources to help the patient alleviate their pain, whether it is skin deep or something deeper.
Because treatment is often driven by how the injured worker feels on any given visit instead of focusing on attainable goals for return to work and MMI, treatment can meander without achieving meaningful results or containing costs.
There may be comorbidities influencing the injured worker’s perceived pain, including depression or anxiety. Until these underlying factors are addressed, physical therapy can be a never-ending prescription and MMI may inevitably be unattainable.
An interdisciplinary approach can help these patient issues. Physical therapy serves as a gateway to an integrated program that uses a collaborative approach to help the patient recognize and manage subjective pain, allowing them to achieve MMI. In this new model, care is holistic, centering on the patient and not just the injury. Visibility into the entire episode of care can allow recommendations for supportive services like medication review, pain management and case management.
CorVel offers an effective approach to physical therapy focused on attainable goals for return to work and maximum medical improvement. Unlike typical programs, CorVel facilitates care for the injured worker’s specific diagnosis. By focusing on return to function, this patient-centric model ensures cost containment and delivers meaningful results.
CorVel avoids stagnation in improvement during recovery through a series of frequent touchpoints throughout treatment. Their clinical therapists review every initial evaluation and re-evaluate cases after every six visits. They hold providers accountable to providing quality care with a functional focus to yield better outcomes and appropriate utilization, in conjunction with the American Physical Therapy Association Clinical Practice Guidelines.
Through their process, CorVel reduces overutilization, risk of re-injury, and overall cost of care, while also returning the injured worker to wellness.
CorVel’s defined standards of care are:
In addition, CorVel has complete visibility into their clients’ programs including bill history, treatment calendar, and drug history, allowing CorVel to provide patient-centric care. With access to comprehensive data CorVel can also recommend other support services including medication review, pain management, and case management.
By focusing on the patient as a whole, CorVel provides effective long-term recovery for the patient and cost savings for the employer.