Friday, September 26, 2014

Hard Choices: Mental Illness vs. Medications

The recently released report and follow up webinar from the Workers' Compensation Research Institute (WCRI) shines more light on the complicated world of chronic pain.  (Full disclosure: PRIUM is a WCRI Core Funder... and proud of it).  WCRI doesn't take policy positions, they work hard to inject data and academic rigor into policy debates without taking a stance one way or the other.  As if often the case, however, the data in this report appears to speak for itself.

The report measures the utilization of modalities that should be used to support chronic pain patients in the healing process.  Physical therapy is the most common (moving from 87% of injured workers in chronic pain to 88%).  Still more work to do here - why are 12% still not getting PT? - but that statistic isn't particularly alarming.

Only 25% of injured workers in chronic pain are being monitored for compliance with drug therapy regimens.  From our vantage point, this statistic is slightly misleading.  We see pockets of extremely high and inappropriate utilization of drug testing among some physicians and virtually zero testing among others.  The net statistic is 25%, but we see a tale of two extremes in this area.  Again, this is our view from PRIUM - admittedly skewed by our focus on complex claims.

Finally, the dismal news.  Only 5% of injured workers in chronic pain go through psychological evaluation and only 4% receive psychological treatment of any kind.

We know why this is.  Adjusters: Raise your hand if you're willing to let a potential psych diagnosis get within 10 miles of any of the claims on your desk.  Seeing no hands raised, let's address the issue as candidly as possible.

On many long term complex claims, you are left with two bad choices: continue the meds or deal with the psych.  This is the proverbial "rock" and "hard place."  And years of training and bad experiences have left the work comp community with a clear answer to this quandary - under no circumstances are we to explore the psych.  Just pay for the meds, cross your fingers, and hope...

A favorite aphorism from one my business school professors comes to mind: "Hope... is not a strategy."

So what's the strategy?  I don't have all the answers, but here are a couple of ideas:

First, keep in mind that some modalities, like cognitive behavioral therapy (CBT), which are often used in support of the weaning process, do not necessitate or lead to psych diagnoses.  These are supportive and therapeutic modalities, not diagnostic.  And they can be billed under physical medicine CPT codes.  So don't freak out when you see a CBT recommendation.

Second, many treatment options require a psych eval to assess whether the option is viable for the injured worker.  Things like spinal cord stimulator trials, inpatient detox, and surgery often require (via medical treatment guidelines) a psych eval.  This can be complicated and you should consult with your supervisor and/or defense counsel on a case by case basis, but we've seen positive clinical outcomes as a result of a claims organization's willingness to choose the right clinical path, even if a psych eval has to be done first.

Finally, recognize the brutal fact that on some cases, the only way to reach resolution, the only way to for the injured worker to truly heal, is to deal with the underlying psychological issues faced by that person.  Note that according to the CDC, more than 60% of us experienced some kind of childhood trauma or abuse (verbal, physical, psychological, sexual, etc.)  We are a society of broken people.  Workplace injuries can trigger, exacerbate, or prolong our struggles with inner demons that have nothing to do with our non-specific low back pain.

I'm not declaring you should take on psych without regard to the potential consequences.  I'm simply suggesting that the first step to solving a problem is recognizing we have one.  And the second step is to have a real dialogue about the nature of that problem.

On Twitter @PRIUM1

1 comment:

  1. Michael,
    Thank you for your insightful and rigorous examination of difficult issues.

    Kevin Gregerson
    Program Administrator
    Union Construction Workers' Compensation Program