Inappropriate claims are a major component of our workers' compensation problem. Up
to 25% of claims have some element of impropriety, ranging from patient
misunderstanding and honest mistakes to cost-shifting of unrelated problems into
the workers’ compensation system. There are also the issues of employee
resentment, unscrupulous service providers, and outright fraud. When health care
services are over-utilized, employers must foot the bill. However, employees
also suffer. The longer they stay out of work, the more likely they are to
perceive themselves as disabled. The more they stay at home, the harder it
becomes for them to return to the discipline of working eight hours a day. It
is often as important to know what kind of patient has the injury as it is to
know what kind of injury the patient has.
Injuries are often
managed in terms of objectively measured physical damages and limitations. Those
involved in the care of the patient become frustrated when that process works
for many, but not all, injured workers. The patients for whom that model does
not work become a source of bewilderment, annoyance, and frustration. The Psychological Aftermath of Work-Related Injuries
addresses not only the injured worker and family, but also the employers,
insurers and professionals involved in the complex processes that follow
injury.
Cases deteriorate for 5 primary reasons:
1.
The
patient is not providing complete or accurate information.
2.
The
employer is withholding important data regarding the accident itself.
3.
Insurers
are containing costs in the wrong areas and destroying trust.
4.
Health
care providers are not asking pivotal questions and are ignoring vital areas.
5.
Attorneys
are attempting to practice medicine.
Key Problem Areas
·
The
injury is viewed as a single event inflicted on an otherwise fully-functional
and healthy worker. This is, however, rarely-if-ever, the case.
·
Quite
often, those involved fail to explore how the employee’s history explains not
only the response to injury, but in many cases, the actual vulnerability to
injury itself.
Prior to, and at the time
of injury, each worker possesses specific intellectual, physical, emotional,
and motivational strengths and weaknesses which influence the course of care, pain
tolerance and acceptance of a disability role.
The Referral that Comes Too Late
Most patients who are
referred to my office have been out of work for 6+ months. The referral
question is often a. is the patient depressed; b. are there issues of secondary
gain; c. does this patient have PTSD, or d. is this patient a candidate for surgery
or SCS implant.
However, what I often
find upon examination is a de-conditioned person with marginal education and job
skills. Often there is a history of arrest ranging from DUI to spousal abuse
and more.
There may have been
frequent job changes without a specific career track. The patient feels that
the injury was preventable, coworkers were to blame, and that the “unsympathetic”
employer obstructed access to quality care.
To these patients, the
primary provider is seen as a tool of the insurer, and they believe their attorney
is competent to choose physicians, specialties and procedures.
The patient’s days
are spent tracking numerous medications, often supplementing them with
recreational and prescription drugs from family and friends. These may be mixed
with alcohol. There is poor quality of sleep at night, napping during the day,
no exercise, a high caffeine intake and impressive nicotine dependence.
While the patient may
once have needed psychological care in order to return to work, such care may
have been obstructed, or the referral was not made to a skilled clinician. The
resultant care may span many months without productive change while the patient
continues to deteriorate. As income dwindles, others advise the patient to maximize
complaints toward the goal of a larger financial outcome.
Becoming the Patient’s Target
The most destructive
element in claims management occurs when a patient targets a specific person
(typically the claims adjustor) as the enemy. This attitude can arise
from delays in authorization and financial compensation, and/or the belief that
their physician altered a diagnosis or recommendation after talking to an
adjustor. A patient with endless idle hours will value even minor changes and
events much more than will a claims adjustor with a full workload. Timely
communication is only a partial solution because the patient’s own history may
be characterized by recurrent broken trust.
The Legitimate Patient
The legitimate
and motivated patient is often overlooked in a system that is largely
adversarial. Reluctant to complain, they were most often a reliable worker and
a dedicated spouse or parent accepting responsibility for themselves and family.
They had high integrity, a strong work ethic and low tolerance for inactivity.
Their former life did not prepare them for the purposelessness of post-injury
existence.
Astute
physicians may note failure to improve despite compliance with medical care.
Since this patient is passively compliant, underlying depression may go
undetected, and thus no proactive movement towards diagnosis and treatment occurs.
The legitimate patient, however, will productively respond to brief and
targeted psychological intervention.
Requesting Psychological
Data
·
The nurse case manager is in the position to observe the patient
in different settings and act as a liaison between physician and adjustor.
·
The ATP can request psychological data to understand the patient
who does not recover as expected.
·
The claims adjustor can both request and authorize care and thus
maintain control.
Utilizing Psychological
Results
My objectives
when evaluating a patient are:
a. does this patient have a disorder arising from or exacerbated by injury;
b. what was the patient’s baseline functioning prior to injury;
c. what are the significant developmental, medical, educational, financial,
family and legal problems;
d. how is recovery psychologically obstructed;
e. what is the patient’s perception of the injury, care received and
anticipated,
f: what treatment, if any, is recommended, and can this patient benefit from
care?
If the
patient can benefit from psychological care, then the recommendation must be
time-specific, goal-defined care to minimize dependency and maximize the
patient’s return to productivity.
