Onsite Injury Prevention Services – Hire a New Watchdog
Honest Onsite Triage – Man’s Best Friend
Providing onsite early care services to employees can be a godsend. In its best spirit, it can save employees needless suffering, while saving employers needless expense. In my experience, seeing an employee onsite offers an opportunity to provide thoughtful, honest triage. As the practitioners who performed the Physical Demand Analyses and Ergonomic Analyses on employee job titles, we get a window into their job demands like no one else. We can quickly assess their present capabilities against their work requirements. We can make educated decisions as to where their best next step will be. We can even help sort out reasonable accommodations for any of their limitations.
Some will require only the basics of First Aid. Others may require more intervention. Some may only need to be placed in the optimal situation to allow healing to run its natural course. Others may be candidates for elevation into specialized involvement. In every case, it’s the thoughtful, honest triage that delivers the best of both worlds. When onsite or near-site practitioners have the job-security and freedom to practice ethically, most do so gladly. However, there are hidden forces that often cast a long shadow on this assumption. Allow me to explain…
There’s a Wolf in Sheep’s Clothing
Sadly, there’s a hidden reward system baked-in to the failing allopathic fee-for-service industry (we euphemistically call ‘healthcare’), and it drives perverse incentives. Known as the Resource-Based Relative Value Scale (RBRVS for short), it’s an opaque public / private arrangement dating back to the early 1990’s. An amalgam of AMA Specialty Societies, it conducts its business behind closed doors. Which would be fine in private ventures, but RBRVS drives the pricing of medical services we all must pay. It’s also heavily influenced by medical device manufacturers and pharmaceutical giants – both of whom are given a seat at a secretive bargaining table. RBRVS is a little discussed, rarely scrutinized partnership between the AMA and Medicare. In other words, a private business lobbying group influences the expenses to both the US taxpayer and our employers.
The criticisms against RBRVS are myriad – and valid. Instead of basing the pricing of medical and health services on outcome, they’re priced on professed input. Inducements are skewed toward a vested effort to overtreat, not toward effective results. Complicated and expensive interventions pay more, so they’re more often sought – even when they’re proven unnecessary. Value to the employee or employer is not factored-in to these costs. This divorces practitioners from a motivation to save employees undue stress and employers undue expense.
The most profit-driven practitioner is influenced to provide maximally complicated services over simpler, and often more effective ones. The thrust of funding in RBRVS is toward the specialist, where more expensive devices and pharmaceuticals can be justified. It’s not focused toward primary care – and certainly not toward prevention. Both of which are proven better investments. Prevention and cure cut short these baked-in revenue streams. Services that require more purported effort and specialty training lead to higher cost claims and increased income for specialty practitioners. It’s all a self-fulfilling prophecy. It’s also a self-perpetuating feedback loop.
The Specialty Society Relative Value Scale Update Committee (‘The RUC’ – for short) is for all intents and purposes, a privately-run outfit with public influence over our checkbooks. A clear example of incentivized regulatory capture. If that weren’t enough, The RUC is also – as mentioned – secretive in its dealings. The RUC’s deliberations directly influence public policy, yet it holds its meetings without public oversight. We’re not privy to see how the sausage is made. Meanwhile, The RUC’s data are effectively copyrighted by the AMA, even though its widespread use is required by statute. So – we’re stuck with it.
From The RUC’s proceedings, the AMA maintains a copyright over CPT coding. Those CPT codes then become our medical charges and costs. See how this works? This arrangement also allows a private entity to charge licensing fees to any providers who use RVU values with CPT codes when billing for services. That’s just about everybody who treats injuries and illnesses. What’s that worth? Well, the AMA receives upwards of $70 million annually from these licensing fees. Nice haul. All this would be fine, if it didn’t set Medicare (taxpayer) and insurance cost guidelines. But under this arrangement, we pay their price. We’re their captive audience.
When the Wolf Doesn’t Treat, the Wolf Doesn’t Eat
How does this all play out in a Work-Related Musculoskeletal Disorder (WMSD) scenario? Routinely, it looks like this: If it ‘happened at work’, an employee is triaged through the Occ Med provider. There, they undergo cursory examination and are often referred onward to a specialist consult. Many of these specialist group settings are carefully designed ‘one-stop-shops’. On its surface, this sounds like a good idea. However, many are arranged to engage in practice capture, keeping all billable events corralled under one roof for the specialty practice’s singular benefit.
These billable events usually follow an escalating standard of care, from conservative efforts to more invasive ones. That’s where things can go awry. Short of any outward signs of derangement there will usually be 1) orders for x-rays, 2) issuance of some ‘samples’ of prescription-strength NSAID’s, and 3) orders for in-house physical therapy. In these insular practice settings, the in-house physical therapy tends to consist of perfunctory ‘heat-it-up, beat-it-up, and ice-it-down’ delivery, prescribed three times a week for 3 or 4 weeks.
Upon no appreciable lasting progress, many an informed consumer declines more meds. We now know those powerful prescribed drugs have too many undesirable long-term side-effects on major vital organs in our bodies. Staying on them is not an option of interest to most of us, so the next rung up the one-stop-shop WMSD ladder is an injectable cocktail of corticosteroids and analgesics. The in-house physical therapy carousel is then remounted for another 3 or 4 weeks.
On the next follow-up, the stakes rise. In many cases, the injections work wonderfully – for a short while. Then they wear-off. Any pain symptoms often come back with a vengeance. This escalating progression of utilizing suppressive agents – such as NSAID’s or corticosteroids – often yields something known as ‘rebound effect’. When a suppressive agent is first applied then discontinued, pain symptoms can ‘rebound’ to a perception level even higher than their original level, before recalibrating. When this phenomenon is not explained to our WMSD worker, undue fear and suggestibility can ensue.
This is usually the time WMSD sufferers are guided toward an in-house MRI machine. It’s a device that’s been described within certain circles as a ‘money-printing machine’. Injured workers go in one end, and money comes out the other. There’s commercial inducement to keep the machine running within the specialty practice group setting. Afterward, the routine in-house physical therapy regimen is once again ordered until the next follow-up visit. This time it’s with the surgeon, who is often partner in the entire group practice enterprise.
In this visit, the surgeon explains the MRI findings – and all too often – recommends in-house surgery. It’s frequently scheduled at the in-house surgical center (remember: ‘One-Stop-Shop’). Afterward, post-operative in-house physical therapy is yet again prescribed – this time for 4-6 or more weeks – depending on the surgeon’s discretionary (and preferred) postoperative protocol. What’s more, in-house issuance of various and sundry ancillary durable medical goods and add-ons are thrown onto the mounting pile of expenses for good measure.
Let’s tally up the tab: Our WMSD employee entered the one-stop-shop specialist group months back. Since then, our worker has been ‘churned’ through in-house physical therapy, in-house diagnostics (x-rays, MRI), an in-house surgical center, in-house durable medical goods, and in-house add-ons. They’ll come out months later, after tens-of-thousands of dollars have been run-up on the employer’s health insurance or workers comp expense account. Realize authorization processes can slow this whole event down even further, sometimes stretching out over the better part of a year. That means extended episodes of modified-duty and / or lost-time at work. In so doing, important Key Performance Indicator (KPI) metrics are crushed, while insurance and work comp premiums are driven up ever further. As mentioned earlier, it’s all a self-fulfilling prophecy, and a self-perpetuating feedback loop.
Seems the Cat’s Finally Out of the Bag
Thanks to efforts made through disparate outfits such as the United States Preventive Services Task Force (USPSTF), The American Board of Internal Medicine’s Choosing Wisely Campaign, and OSHA Safety Pays website, alternatives to this rush toward overtreatment are becoming clearer. Nowadays, there are experts whose goal it is to drive prevention as a worthy practice model in and of itself, only relying on reactive intervention when all else fails. It’s a more integrated standard of care, and it’s catching-on at major universities and employers nationwide.
For the disturbing reasons and examples outlined above, it’s important to scrutinize all our onsite and near-site practitioners. For the sake of our workforce and our employers, we need to make sure their motives are pure. Holding them accountable to KPI like lost-time injury resolution and OSHA-recordable injury rate reduction is a good start. Defining and monitoring their triage ratio is another valuable metric for a glimpse into their profit motive.
We CAN Teach an Old Dog New Tricks
When evaluating practitioners, there is a way to separate the wheat from the chaff. In my direct onsite experience, we pitted specialist group practices against one another. Through our referral network, we sent similar cases to different groups in different towns, with surprisingly diverse results. The group practices who compressed our lost-time and got our workers back sooner (and in better shape) were rewarded with more of our future referrals.
The one’s who were either inept or seemed to suffer from a corrupting commercial influence were squeezed off or sent packing. The upstream model of WMSD gatekeeper is an extremely powerful one, when used properly. It’s a funnel that can drive better behavior among the downstream practitioner neighborhood – starving out the bad actors while rewarding the good ones.
Quite often, the combined disciplines of Physical Therapy, Occupational Therapy and Athletic Training can be the most solid source of gifted onsite practitioners. They form a sturdy, 3-legged stool. Those whose motives are truly aimed toward practicing preventive care are worth their weight in gold. These are expert musculoskeletal gatekeepers who – when freed from the corrupting influences of the RBRVS structure – have motivations that are grounded in prevention, performance, assessment and recovery. Unencumbered by the oppressive strictures of the RBRVS and the CPT coding scheme, they are open to provide the best value for the best price to the most employees and employers.
Hiring a New Watchdog
Many properly trained PT / OT / AT’s make perfect upstream triage specialists and musculoskeletal gatekeepers. They can assure only the most deserving cases will be escalated to the next level of care. They invert the antiquated, perverse-incentive, referral food chain. With our knowledge of the unwholesome enticements described above, it’s imperative to our employee health and employer finances that individuals working among us have no ‘skin-in-the-game’ of an RBRVS / CPT Code-driven system that rewards their overtreatment.
Our new 21st century injury prevention management will be geared toward Environmental Health and Safety best practices. Outcomes outperform input. Leading indicators outstrip lagging ones. Restructuring the practices of Physical and Occupational Therapy along with Athletic Training will accelerate. All for the better. Conservative WMSD and injury management will dovetail neatly with prevention medicine. And exercising the WMSD gatekeeper role soberly and astutely will serve every worker, every employer and every practitioner. It’s a better model grounded in continuous improvement. As a nation, we can no longer afford to ‘practice-to-the-code’ for the profit of the few. The stakes have never been higher to do the right thing. So, let’s do the right thing. Let’s hire a new watchdog at work.
A little about our author, Matt Jeffs DPT PSM CEAS –
Dr. Jeffs is a health and safety performance advisor for national and international firms. He’s also a seasoned ergonomics educator here at The Back School. Years ago, he excelled as a big-wave surfer and an experienced ocean lifeguard – with numerous rescues – prior to earning both his clinical undergraduate and doctoral degrees in physical therapy.
With well more than 13,000 working hours onsite across US industrial settings performing physical demand analyses, ergonomic analyses, post-offer employment testing, onsite job coaching, onsite injury triage, rapid return-to-work rehab benchmarking and more, Dr. Jeffs is sometimes lightheartedly known as the ‘Mike Rowe (from Dirty Jobs Fame) of Physical Therapy’. You name it, he’s tried it. And he’s learned something from every experience along the way.