"No single injury management relationship is more important than the one established with the occupational clinic." That's a phrase workers' compensation professionals keep saying, but do we really understand how to make the occupational clinic relationship work? What are the key advantages to building a relationship with the occupational clinician and how do we move that experience from good to great? What can occupational physicians do to change the way workers' compensation stakeholders view their importance in the injury management process?
Most employers and injured workers view the occupational clinician as the "workers' comp doctor." This implies that the physician is working for the employer or the insurance carrier. It also creates a negative view of the medical treatment provided at the clinical setting.
"We have to dispel the myth that occupational medicine is not quality medicine," said Dr. Richard Spirer, medical director for Physician Health Centers. "There is an underlying perception that the medical care is different because we are treating workers' compensation injuries. The fact is that we are trained and qualified physicians who happen to be treating injured employees."
Dr. Spirer is correct. Consciously or subconsciously, we often add a negative connotation to the medical treatment received in the workers' compensation system. We often overlook the fact that these physicians are board certified and have extensive experience in emergency medicine in or outside of the occupational environment. The American College of Occupational and Environmental Medicine (ACOEM), which represents more than 5,000 occupational physicians, said that their members are knowledgeable and capable of treating job-related diseases, recognizing and resolving workplace hazards, instituting rehabilitation methods, and providing well-managed care.
Adjusting Mindsets
To change the perception and dispel the myths about occupational clinics, we must evaluate how stakeholders interact with the physician and provide key guidance on building a proactive and results-driven relationship. At the onset of the injury, employers must understand their roles in helping the physician discern the dynamics of the injury. Physicians are increasingly pressured to expound, interpret, and determine whether the resulting injury was caused by the accident. Questions such as "Is the employee really injured?" and "Did the mechanics of the accident really cause this injury?" need to be answered.
In our haste to send the injured employee for medical treatment, employers often overlook the key process of painting the accident picture for the physician. This can only be done by providing the doctor with a copy of the first report of injury along with any supporting documentation related to the accident.
"Causation, Causation, Causation – its imperative the employers give the treating physician enough information at the onset of the injury so they can determine if the injury diagnosis is related to the occupational accident," said Dr. Michael Webb, southeastern regional medical director for Liberty Mutual. "Physicians need to be comfortable calling it as they see it. The carrier and the employer want the truth about if the injury was directly related to the occupation. Tell us right away so we can manage the claim appropriately."
In other words, treating physicians do not have a crystal ball. Employers must communicate the dynamics and mechanism of the injury immediately so that the physician can evaluate the causation and start the injured worker on his way to recovery.
Good to Great
"The best treatment must be coupled with the best outcomes," said Dr. Seth Feldman, medical director for Medwork 84 and Medstart. "The key aspect of utilizing an occupational clinic is the assurance that it will provide excellent treatment to the injured worker while balancing the needs of the employer. It is imperative that the occupational physicians make the correct diagnosis and create a progressive treatment plan that is focused on helping the injured worker recover quickly."
It is fair to say that one of the major systemic roadblocks for occupational physicians, employers, and injured workers is the delayed implementation of the treatment plan. Delays in authorizing follow-up diagnostic testing, physical therapy, and referrals to specialists can lead to frustration, and it undermines the tenet of the occupational clinic.
Dr. Spirer expressed it best when he said, "Delays in implementing treatment protocol must be minimized at all cost," and Dr. Feldman added that "delays in getting authorization for diagnostic testing or physical therapy results in delayed diagnosis, delayed return-to-work options, and a longer disability cycle — a snowball effect."
If the purpose of the workers' compensation system is to get injured employees immediate medical treatment so they can return to their pre-injury status quickly, we must find ways to translate that urgency into the treatment authorization process.
The building blocks for creating a great occupational clinic experience extend beyond medical treatment and must include an open dialogue between the physician, the injured worker, and the employer. It also means including advocates like the nurse case manager, who is often underutilized and may not be added to the injury management process early enough.
"Even seemingly minor injuries can benefit from case management," said Dr. Spirer. "Physicians have a vested interest in working with case managers because they help them implement the treatment plan efficiently, effectively, and immediately."
In addition, nurse case managers help injured workers navigate the often complex injury management process and aid in commuting with employers and insurance carriers. Therefore, it's unfortunate that they are an underutilized advocate.
Recognizing Weak Points
Beyond medical treatment authorizations, there are two other hot-button items that concern occupational physicians: Non-existent return-to-work programs and rushing the treatment process.
The resounding message from occupational physicians is that employers must have return-to-work programs that keep injured employees working versus sending them home to dwell on their injuries. Both Dr. Feldman and Dr. Spirer expressed the same message: "No return-to-work policy leaves treating physicians with few options for keeping injured employees motivated to work." Employers must be open and willing to explore all options that keep injured employees at work.
Additionally, stakeholders must recognize that there may not be a quick treatment plan since each individual will progress differently. The goal has to be helping the injured employee recover. This does not mean that injured employees won't exhibit symptom magnification or attempt to manipulate the system. It simply means that occupational physicians are here to determine what's real, what's not, and find a way to communicate recovery to the injured worker, the employer, and the insurance carrier.
Frank, candid, and definitive communication with the injured employee can aid in the recovery process. Having the same open conversations with the employer can dispel the notion of too much treatment. "Physicians must to be willing to have open and honest communication with the injured worker," said Dr. Spirer. That statement was echoed by Dr. Feldman, who said, "How physicians communicate the recovery process is critical. We must help injured workers understand that they can and will get better, but it may take some time. We have to help employers recognize that, too."
Physician Heal Thyself
The most challenging aspect of workers' compensation is always medical management. As an industry, we cannot have a lopsided view of the occupational clinic. While no relationship is perfect, it is critical that we continue to reflect and create ways to move this important relationship from mediocre, to good, to great. Each of our panel members was asked what it would take to improve the occupational clinic experience, and their answers came as no surprise.
"Occupational physicians should practice evidence-based medicine," said Dr. Webb. "Occupational medicine is the gateway, the key component of the workers' compensation process. Physicians must be willing to utilize all of the resources available to them, including the ACOEM Practice Guidelines and ACOEM's Preventing Needless Work Disability by Helping People Stay Employed, as well as the Official Disability Guidelines (ODG). These resources will aid in the physicians' understanding of the workers' compensation disability management process. Beyond that, nothing is more important than picking up the phone and communicating with the adjuster, employer, or nurse case manager."
"Occupational physicians cannot change perception without producing better outcomes," said Dr. Spirer. "In a results-driven world, employers want to see positive outcomes, they want to understand why the employee is receiving treatment, and they want to know that the physician has a treatment plan that is being evaluated and revised at every appointment. Employers must be confident that the physician is working to get the injured employee back to work successfully. We must practice 'cutting edge' medicine that includes documentation that supports our treatment protocol."
"We must ask ourselves why employers choose our facility, and the answer must be because we offer quality medical treatment, provide sound diagnosis backed up by diagnostic testing if necessary, and supply a one-stop convenient alternative to the emergency room," said Dr. Feldman. "Beyond that, we must do what is in the best interest of the injured worker, as we balance the employer's desire to get the injured employee back to his pre-injury status."
"Occupational clinics are here to stay," concluded Dr. Webb. "They will remain a key component of the injury management process. For that reason alone, we must strive to maintain our integrity and to move the bar from good to great by increasing positive outcomes."
Margaret Spence, CWC, RMPE, is president of Douglas Claims & Risk Consultants, Inc. and ReturnToWorkResources.com in Boca Raton, Fla. She may be reached at 561-795-3036 or Margaret@MargaretSpence.com.
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