To The Editor:
The Orthopaedic Forum article entitled "Workers' Compensation:
Avoiding Work-Related Disability" (82-A: 1490-1493, Oct.
2000), by Melhorn, is timely and the suggestions are well intentioned.
However, I am afraid that they will fail to make an impact on the
problem worker for several reasons.
First, most physicians see their role as patient advocates, and
by extension, they take the patient’s report of work-related
pain at face value. Practicing physicians tire of disputing their
patients’ strongly held beliefs for some greater social
good, but Dr. Melhorn argues that such dispute is actually in the
patient’s best interest, since earlier return to work and
rehabilitation prevent disability, and I agree. However, some Workers' Compensation patients
will not accept that approach and may "doctor-shop" or
become angry at the physician’s efforts to return them
to work earlier than the workplace requires.
Second, many of these workers have no health insurance other than
Workers' Compensation and so may report the onset of their
pain as occurring on the job, rather than when treatment would not
be covered by insurance. A physician can seldom differentiate work-related
soft-tissue injury from injury occurring elsewhere. Some form of universal
safety-net health insurance (twenty-four-hour coverage) would perhaps
avoid some of this cost-shifting.
Third, pain and suffering are more generously compensated within
most of our compensation systems if they are permanent. This fact
may be emphasized to the worker by his or her attorney and may create
more permanent pain and suffering than would otherwise exist. There
may be subconscious somatization due to the power of suggestion,
without any overt malingering or conscious intent.
Fourth, although there is more certainty as to the anticipated outcome
in cases of injury to the hand or extremities, in cases of musculoskeletal
pain, particularly spinal pain, there are fewer guidelines that
the treating physician can use when projecting outcomes. Pain in
others cannot be measured, and our crude measures of range of motion,
neurologic function, and anatomy may have little relationship to
the subjective symptoms experienced by the patient. When examining
the same patient, we see a large variation in the impairment rating provided
by different treating physicians and chiropractors as a result of
these assessment difficulties.
Fifth, in our state of Florida, the reimbursement for treating
workers is so poor that many of the orthopaedic surgeons who could best
negotiate the legal and administrative minefield of the system choose
not to treat injured workers except in emergency situations, since
much of the money collected in premiums paid by employers seems
to be consumed by attorneys’ fees and other administrative
costs. I suspect the same may be true in other states to a greater
or lesser degree. Attending to the twelve specific steps that Dr.
Melhorn lists on page 1492 of The Journal, along
with the other "para-clinical" matters peculiar
to Workers' Compensation patients, makes such patients
far more expensive to treat. As noted in Dr. Melhorn’s
article, each state has a different system in place.
The fundamental ills of the Workers' Compensation system remain.
Until we are able to measure pain in others and to determine with
objectivity who can work and who cannot, compensation systems for
pain and suffering will be fatally flawed. I look upon the compensation
system itself as the problem and suspect it creates much pain, suffering,
long-term disability, dependence, and expense, despite all good
intentions.
M. Melhorn replies:
I would like to thank Dr. Bellamy for his comments regarding my
article. Dr. Bellamy has mentioned five concerns regarding the impact
of Workers' Compensation on the outcome of treatment for
the patient with work-related injury. I originally addressed only
one part of the equation for improving outcomes in compensable work-related
injuries—avoiding work-related disability. I selected this approach
because, as physicians, we have the best opportunity to improve
the outcomes for our patients with work-related disability without
the complex issues introduced by the other participants in the system.
The doctor-patient relationship allows physicians to immediately take
the high ground for patient advocacy. Although a separate article
could be written in answer to each of Dr. Bellamy’s points,
I would like to offer an abbreviated summary.
Workers' Compensation system: Although
Workers' Compensation is described as a system, it is actually
the sum of many parts, separate jurisdictional programs that include
the fifty states, American Samoa, Puerto Rico, and the U.S. Virgin
Islands.
Causation: Linked to the idea of employer liability
is the term "causation." Causation is a critical
issue in work-related and liability cases and therefore the evaluating
physician is often asked to consider this issue. Because causation
has a very vague definition, interpretation can often lead to cost-shifting
(that is, injuries or illnesses occurring in the nonwork environment
may be reported as work-related), as described by Dr. Bellamy. Occasionally,
the medical opinions that address the issue of causation may not
meet the needs or expectations of the injured worker (patient) or
those of his or her attorney, and a search for a more favorable
second opinion (doctor-shopping) may occur. Hopefully, the opinions
are based on good medical science and not on financial considerations
and therefore the second medical opinion would support the first.
Participants: Recognizing all of the participants
in a Workers' Compensation suit is crucial to obtaining improved
outcomes of treatment. The participants include the injured worker,
physician, employer, insurer, lawyer, union, and Workers' Compensation commission.
As described by Dr. Bellamy (his third concern), our current compensation
system rewards individual patients who do not return to work and
those whose condition is permanent, rather than encourages patients to
return to work early with appropriate financial support from the
employer and the insurer.
Pain: Clinically, physicians cannot prove or
disprove the existence of pain. Pain is a subjective interpretation
that is influenced by learned experience and cultural norms. Pain
that does not resolve or that progresses in the absence of activity
is abnormal. The diagnosis and treatment of pain are among the most
challenging problems facing the orthopaedic surgeon1.
Disincentives for physicians: Physicians who
deal with the patient throughout the whole work-related injury process (treatment,
recovery, return to work, and psychosocial issues) will often increase
their overhead costs while reducing their revenue2.
While it is true that reimbursement for Workers' Compensation
is low in some states, it is also higher in others. Each state has
specific guidelines for requesting reimbursement that may help to
offset overhead costs for additional reports and communications
with the employer, insurer, and case managers. The decision to treat
the patient with work-related injury should remain a personal decision
for each physician.
Change for the better: Changing Workers' Compensation
for the better will not be easy. As physicians, we need to start
where we have the most influence—with the issue of avoiding
work disability. Then we can progress, on the scientific foundation
of outcome results, to change the focus for the other participants.
This will require input from our professional organizations like
the American Association of Orthopaedic Surgeons, our professional
journals like The Journal of Bone and Joint Surgery,
and our continuing education courses like the American Academy of
Orthopaedic Surgeons’ annual course in November 2001, entitled "Occupational Orthopaedics
and Workers' Compensation: A Multidisciplinary Perspective." (Details
on this CME course are at http://www3.aaos.org/mastcaldb/buildcme.cfm.)
As physicians, we must expand our focus from the narrow treatment
of a specific injury to treatment of the whole patient, who may
come with a variety of psychosocial problems. We must make return
to work an explicit goal of treatment, recognizing that there are
other participants in the system who can affect our patients’ recovery,
and we must challenge some of these to change their attitude from
one of antagonism to one of cooperation.