In the year 2000, Congress declared a “Decade of Pain Control and Research” in response to rising instances of chronic pain among Americans. More than a decade later, though new treatments and drugs continue to proliferate, chronic pain still plagues the American population and the problem of prescription medication abuse has escalated. Part of the problem is that many chronic pain solutions are misguided, aiming for quick fixes that do not do justice to a problem as complex as chronic pain. Though the statistics are often lumped together for effect, there is a significant difference between having a chronically painful body part and a lifestyle disrupted by a chronic pain complaint.
Even with recent advances, uncontrolled pain and lifestyle dysfunction are on the rise; and evaluating chronic pain is an increasingly necessary skill among physicians and medical professionals. To properly identify and treat chronic pain, it is important to understand that pain is not a “vital sign” like blood pressure or temperature, but rather a complex biopsychosocial condition. An injured worker may transition from experiencing acute injury-related pain to chronic pain following a seemingly ordinary physiological trauma. Understanding the biological and psychosocial factors that cause or promote suffering in chronic pain is vital to providing effective treatment.
Three Interconnected Elements
Even as treatment options increase, uncontrolled or poorly controlled chronic pain cases remain on the rise because the condition is not treated in an integrated manner. During the progression from acute to chronic pain, biological, psychological and social components intertwine to create a unique, individual experience.
1. Biological: Biological pain responses may be the best understood component in chronic pain management, yet they’re still quite complex and difficult to treat. Physiological disturbances can stimulate pain receptors incorrectly, as in the cases of nociceptive and neuropathic pain. The nervous system can become sensitized and its ability to modulate pain adequately can fail. Pain may also occur due to old, poorly maintained injuries or to degeneration of the body with increasing age combined with lack of adequate physical fitness.
Finding and managing the biological basis for the pain is important, yet biological management alone won’t end a patient’s chronic pain. There is danger in overemphasizing the biomedical model (i.e. searching for a “pain generator” and extinguishing it). This approach often results in escalation of multiple medications and other interventions of questionable effectiveness. Medications that should work theoretically based on biology or laboratory results, or in carefully selected patients, often do not succeed when used in the masses or as a quick fix.
2. Psychological: Psychology can both affect pain and be affected by pain. One’s psychological state can impact one’s perception of pain, understanding of its meaning, behavior, and precision of reporting. Emotional components like catastrophic thinking and symptom magnification can make it difficult for a physician to properly diagnose and treat a disease, while pain-related anxiety, dependence, and addiction can be results of living with long-term pain. Many who experience pain deal with concurrent anxiety, depression, and substance abuse, among other conditions.
Clinicians who do not actively take into account these aspects of pain may incorrectly ascribe all of a patient’s distress to the pain and treat only the symptoms with little functional gain. The most effective treatments in managing chronic pain–therapeutic exercise, physical adaptation, independent self-care and healthy coping–take long-term motivation that is often difficult for many people to muster. This often requires a cognitive behavioral approach which reframes the pain dilemma and promotes a better sense of self-care and effectiveness (self-efficacy).
3.Social: Culture, lifestyle, and personal demographics can also contribute to chronic pain problems. The cultural milieu in which the patient moves can positively or negatively impact recovery, and lead to workplace problems and possible litigation. These social variables can both exacerbate chronic pain and create trouble during recovery, or, conversely, encourage a person with chronic pain to seek help and support. Though we have all heard of “secondary gains,” such as not having to work and financial rewards, as motivations to stay in the sick role, injured workers often experience “secondary losses,” such as loss of work identity and placing one’s life on hold, as well. The injured worker is often not conscious of either.
If the treating physician does not recognize each of the biopsychosocial components in his or her patient, instead choosing to focus on medical remedies only, the injured worker is unlikely to achieve the best outcome. Thus, many cases of chronic pain persist despite new medical innovations. We invite you to read our whitepaper titled “Addressing Chronic Pain Cases” to learn more about distinguishing chronic pain and the characteristics of a multidisciplinary treatment plan.
This week, Dr. Richard Adams, Paradigm’s medical director and brain injury specialist, provides us with his insights and the evidence for “disorders of consciousness” or “slow to recover” programs seeking to address the brain injured patient with low level of functioning. It is critical to understand the evidence for and prognosis of brain injury patients in these programs.
Slow to recover brain injury programs, previously known as “coma stimulation,” play an important, and sometimes ignored, role in the functional recovery of injured patients. The overall goal of this type of neurorehabilitation program is to provide an environment which maximizes functional recovery through the use of neurostimulation techniques, and medical management to prevent complications which can prolong potential neurological recovery.
The need has evolved over the last 20 years as the number of severe brain injury survivors has increased due to improvements in critical care management and rehabilitation treatment. While many of these survivors will go on to achieve significant recovery of function, as many as 10-20% will remain in prolonged states of severely reduced consciousness for a period of time or permanently. These survivors do not meet the criteria for admission to an acute rehabilitation facility (e.g. active participation in therapy for 3 hours per day with specific goals for functional recovery) due to their low level of cognitive functioning.
This has led to the development and growth of specialized programs staffed by therapists and physicians trained in neurorehabilitation. The programs are usually located in a variety of settings, including long-term acute care hospitals (LTACs), subacute congregate residential homes, subacute skilled nursing facilities and acute hospital transitional units.
Slow to recover brain injury programs provide systematic structure and goal directed interventions/strategies including range of motion exercises, positioning protocols and schedules, bowel and bladder management, and treatment of abnormalities of muscle tone (e.g. spasticity); management of heterotopic ossification; management of autonomic dysfunction; tracheostomy protocols for removal; maintaining optimal skin condition; protocols for assessment to evaluate change in physical as well as cognitive status; treatments to alleviate pain and/or physiologic sequelae of procedures involving noxious stimuli or interventions; and family/surrogate education and training in clinical management.
At this time, due to lack of evidence-based medicine, guidelines are limited regarding length of stay. However, many rehabilitative experts empirically recommend a length of stay for 6-12 weeks with 10-15 hours of structured therapy per week. If the individual has not shown cognitive improvement indicating potential to meet the admission criteria for an acute rehabilitation facility, then it is appropriate to transition the individual into a long-term environment. This does not mean there will not be further recovery, but it is unlikely the recovery would be to a level of functioning qualifying the individual for acute rehabilitation. Rehabilitative re-evaluations should take place at 6, 9 and 12 months before determining permanency.
The natural history and long term outcome of “slow to recovery” individuals has not yet been adequately investigated but clinical experience suggests that many of these individuals will recover to a level of meaningful activity which may not occur if not placed in the appropriate stimulating environment.
These programs continue to provide an enriching environment to maintain comfort, eliminate complications and optimize functional recovery. We need to move away from warehousing individuals who initially are at a low level of functioning until a sufficient amount of time has passed to allow for further recovery.
How do you measure the return on investment of medical case management effectiveness particularly for catastrophic and complex workers’ compensation injuries?
It’s a question all claims departments ask and one all case management providers will say they’ve answered.
But here’s the real proof:
Milliman, an independent consulting firm, examined a database consisting of more than sixty thousand acute catastrophic claims to evaluate how the workers’ compensation industry performs.
They concluded that the best case management efforts can significantly reduce lifetime costs and improve outcomes such as Release to Return to Work, Return to Work, and Return to Work Full Duty. For more about what Paradigm can offer, please view the video above or feel free to contact us.
Medically complex cases, including catastrophic injuries with post-acute medical needs, account for a very large portion of workers’ compensation claims costs. However, when claims managers seek to control volatility by helping the injured worker reach the highest possible recovery, they in turn reduce the risk of complications and lower long term medical care costs.
There are several factors responsible for driving the high costs in catastrophic and complex cases. First, there are the numerous ongoing risks that are inherent with these types of cases. Second, there is a considerable amount of medical care involved–significantly more than in other cases. Third, there are complications due to the increased number of settings in which care takes place and the increased number of providers and specialists that deliver care. These factors all increase the likelihood of errors that lead to increased expenses.
One example of this is the high incidence of complications associated with a traumatic brain injury. Figure A, below, represents the dramatic volatility that is inherent in these catastrophic injuries over time. Some of the more frequent complications driving increased medical need and costs include skin breakdown, hydrocephalus, seizure disorder, spasticity/contracture, impulsivity, pneumonia, meningitis, chronic pain, and the inability to live independently in the long term residential setting.
Figure A
Each risk is case-dependent and all can greatly increase the ultimate costs of the case. Poor management in the acute period can lead to a host of significant and expensive long-term complications, even when the initial costs appear to decline.
The trajectories for Paradigm-managed cases are quite different when it comes to costs for all types of medically complex cases because we prevent or mitigate the medical complications commonly responsible for poor outcomes and high costs.
Figure B (below) represents cumulative medical expenses for all types of catastrophic injuries.
Three simple actions can help claims professionals and treating medical achieve the highest possible clinical outcomes, reduce the risk for outbound volatility and control the overall claim costs:
Figure B
1) Engage top tier medical specialists to consult with claims staff and treating physicians
2) Map a detailed care path to the best-case recovery
3) Closely manage the case according to the care plan
Claims professionals understand the importance of properly reserving workers’ compensation claims. Yet, despite the attention given to complex large loss claims associated with catastrophic injuries, accurate reserving is a big challenge.
In a May 2009 industry survey by Wilson Associates titled “Catastrophic Injury Management in the Workers’ Compensation Industry,” respondents provided the following answers when asked what tools were used to estimate reserves for catastrophic cases:
Individual Judgment 48%
Internal Guidelines 19%
Third-Party Experts 11%
Predictive Model 6%
Other 12%
These results explain a great deal about why so many catastrophic cases are under-reserved.
The predominant use of individual judgment has many limitations, the most important of which tends to be the small sample sizes of comparable cases. Catastrophic injuries vary greatly from one case to the next. Differences in the patient’s age, weight and other factors make enormous differences in cost projections. It is rare to have large enough pools of comparable cases to make these distinctions and accurately predict total costs.
In addition, there are other factors that are often responsible for less-than-adequate reserve setting. These include:
Lack of access to credible data. Very few external resources exist to use in benchmarking comparable cases, and claims professionals often find it difficult to access their own data for predictive purposes due to system limitations.
More volatility than expected. The costs associated with intensive care, multiple surgeries, the involvement of multiple specialists and high medication needs can often be highly unpredictable and require probability-adjusted estimations for the complications that can occur through missed handoffs and medical treatment.
Unrealistic durations (often too short). Many project expenses for only the acute period of care and grossly underestimate the complications that can and do occur years later as the body ages and the prior trauma causes ongoing complications and spikes in medical costs.
Abundance of optimism. Often there is the hope or expectation that “this claim” will recover without complications, yet, the statistical reality is that with catastrophic injuries, the abundance of optimism principal rarely holds.
Abundance of pessimism. Conversely, one may believe that “this claim” is so severe that the patient will die and therefore not require traditional services; again, statistically, the abundance of pessimism is not borne out in medical evidence.
When you understand these five potential pitfalls and seek out professional guidance and expertise, it is possible to accurately set reserves for complex large loss cases. What resources have you found helpful when setting reserves for this type of case?
Did you know 13% of the American workforce experiences a loss in productivity annually due to pain? And that loss of productivity cost employers over sixty billion dollars last year? It’s true.
Chronic pain is a huge, complex problem. But, with a comprehensive, targeted approach you can reverse the downward spiral and get injured workers healthy and back to work.
Employers large and small face the challenge of rising healthcare costs and the devastation caused by catastrophic workers’ compensation claims. For the average employer, 6.2% of the claims result in 49.9% of lifetime medical costs. The best way to address the unique issues associated with catastrophic cases is through the use of effective complex case management.
When “one of our own” has been severely injured, the employer’s focus is on trying to ensure the best recovery possible. Positive medical results are not only the best thing for the injured worker, but they also benefit the company by reducing the likelihood of costly complications and long term care. Unfortunately, what works for the majority of injuries is inadequate for catastrophic injuries, and only specialized care management will provide the desired results.
Catastrophic and complex injuries require a comprehensive care management model involving medical experts, high quality providers and an experienced clinical support infrastructure. While wrapping an expert team like this around a mildly injured person may be too much for the most frequent claims, it is necessary for these complex claims. This is where employers benefit the most from having a partner like Paradigm involved from the onset of the case.
Paradigm’s focus is on the best possible medical outcomes, which ultimately translates into substantial savings for clients. We strive for the best possible recovery, including restored function and quality of life, and a release to return to work. When you do the right thing for the injured worker, the results follow. We know that our proprietary Systematic Care ManagementSM model achieves five times better results than the industry benchmark for release to return to work, five times better for return to competitive work, and 13 times better for return to work full duty. Likewise, significant savings can be achieved in addressing unresolved legacy cases.
Whether an employer is large or small, self insured, or carrying a low or high deductible, all employers benefit from improved outcomes, better quality of life for injured workers, improved return to work rates, and lower overall costs.
For more on what employers should know in complex case management, please watch our webinar on the topic featuring leaders from Donatos Pizza and DHL.
The use of narcotic medications for chronic pain treatment can have expensive and harmful side-effects, including drug addiction and multiple system impairments. The use of pain medication needs to be carefully monitored and steps need to be taken to help patients avoid or recover from narcotic addiction.
Narcotics are abundant and come in multiple forms. Some of the most commonly prescribed include Codeine, Hydromorphone, Dilaudid, Morphine, Fentanyl, Oxycodone, Methadone, and Oxymorphone. Narcotic usage has reached epidemic levels, and each year there are more deaths from prescription drugs than illicit drugs. This creates a conundrum for medical professionals. While these drugs have a legitimate place within the realm of medical care, medical professionals must strive to maintain a balance between treating pain and avoiding addiction in their patients. The sales promise in the 1990s that there is no ceiling dose for opioids (dose beyond which there is no additional pain relief) has been proven quite wrong and minimized the dangers of toxicity.
A recent study by the California Workers’ Compensation Institute found an increased number of claims associated with opioid use, as well as increased payouts associated with opioids. This problem is no surprise to those in the workers’ compensation industry.
Assessing Likelihood of Addiction
Addiction is a primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations. It is characterized by a loss of control, compulsive use, continued use despite harm, and cravings that result in excessive use of a drug for purposes for which it is not medically intended. In chronic pain, patients may convince themselves that the these behaviors are solely due to the pain symptom(s). A condition called opioid-induced hyperalgesia (increased pain with increased dose) may further confuse them.
The first step in preventing addiction to prescription opioids is to be keenly aware of patients’ risk factors. The known risk factors for addiction to any substance are good predictors for opioid abuse. Risk factors include past cocaine use, history of alcohol or cannabis use; lifetime history of substance use disorder; family history of substance abuse; history of legal problems and drug and alcohol abuse; tobacco dependence; or history of severe depression and anxiety.
Even in patients without any known risk factors, opioids function in such a way that they facilitate addictions. They eliminate the body’s own endorphins, which cause the endorphin system to shut down, leading to hyperalgesia and hypersensitivity to pain, ultimately resulting in increased opioid use to eliminate pain.
Early Warning Signs
Awareness of patients’ early warning signs for addiction is crucial. These signs include complaints that more medication is needed; drug hoarding; making specific drug requests; early refill requests; openly acquiring more pain medication from other providers; and not adhering to other recommendations for pain therapy. If these warning signs are ignored, the problem will escalate.
Comprehensive Treatment
The inherent challenge with weaning narcotics in patients with chronic pain is the chronic pain itself. Often demonstrating a tangle of various physical complaints along with both correct and false beliefs about pain, chronic pain patients will continue even ineffective drugs as a means of “doing something.” The potential harms of the medications are ignored, or at least accepted, in exchange for an elusive, simple, and effective solution. Therefore, unlike weaning narcotics in non-pain patients, it is necessary to address a person’s beliefs about pain and their coping mechanisms, and to enhance their ability to utilize proven methods to rebuild their strength, flexibility, endurance and to self-administer pain relieving modalities. Effective intervention requires a comprehensive complex case management approach, focused on optimal clinical recovery, restoration of function and community reintegration. Therefore the goals when tapering an individual off opioids should focus on decreasing medications and toxicity, improving quality of life, restoring optimum levels of function, reducing or eliminating the need for addictive pain medications, and enabling them to become independent of the healthcare system related to their pain management.
The best solution is to taper the use of narcotics and stimulate the body’s own natural pain management mechanisms. Tapering is a slow process and may require medications to help control symptoms of withdrawal. Stimulating the body’s natural pain management mechanisms can be done in a variety of ways including stimulating the release of neurotransmitters through activities such as exercise, massage therapy, acupuncture, meditation, and therapy.
Effective treatment must be multi-faceted and customized to the patient, and best practice requires measuring outcomes and monitoring for durability. While there are definite challenges to narcotic tapering in chronic pain management, it is possible.
Workers’ compensation claim offices nationwide are plagued with thousands of unresolved complex large loss claims that could benefit from complex case management. These are persisting claims with mounting expenses due to ongoing and escalating medical complications and often pharmaceutical misuse or abuse. These claims may stay open for years and if not settled, the medical costs may be open for the lifetime of the injured worker. These ongoing medical costs may even be seen as a fact of life for individuals monitoring the file and not viewed as a priority for medical management.
Fortunately, there is now a solution for cases with ongoing or escalating medical costs. A 2009 research study by Milliman, Inc., shows that proper medical management of legacy claims can lead to better clinical outcomes and a 29% average reduction in lifetime projected reserves.
Milliman is one of the world’s largest independent actuarial and consulting firms. In this study, they looked at aged large loss claims with significant incurred costs. The study included pre- and post-Paradigm management projections of long term costs as determined by Milliman. The reductions included a number of cost elements including physician services, pharmaceutical expenses, attendant care and future medical and indemnity benefits.
In cases managed by Paradigm Management Services, the study found a 49% reduction in lifetime costs for spinal cord injuries, a 14% reduction for traumatic brain injuries, and 29% reduction for other diagnoses such as severe burns and amputations. The average reduction in all cases managed by Paradigm was 29%.
Visit our website for a white paper titled “Innovations in Reducing Reserves” with additional detail on this study and our proven outcomes. You may request the complete study by writing to Robert Briscoe at Milliman Inc., RR3 3117 Park Lane, East Stroudsburg, PA, 18301, or e-mailing bob.briscoe@milliman.com.
If you would like to refer a case to Paradigm Management Services, feel free to contact us at 800-942-1725 or join our social communities.
Depending on the extent and location of an injured worker’s burn, there can be a negative impact to virtually every system in the person’s body. Possible complications after the initial injury, and the complexity of treatment, make burns very difficult and expensive to treat. A workers’ compensation-related burn injury can end up costing a payor millions of dollars. In fact, Paradigm has seen cases where the acute hospital costs approached $20 million. To achieve the best medical and financial outcomes possible, one should apply a comprehensive complex case management approach, focused on optimal clinical recovery, restoration of function and reintegration, when treating severe burn injuries.
Comprehensive Care for Burns
The successful treatment of severe burns requires a coordinated team of specialists from multiple disciplines, and specific surgical expertise on the long term management of burn wounds. The current standard of care for acute burn wound management involves daily evaluation and management by physicians and other members of the care team. Critical care services are often necessary as part of daily care for patients with extensive or complicated burn injuries.
Patients frequently require multiple surgical interventions. As part of the ongoing care, there are both active medical issues and premorbid medical diseases to manage. Those issues can range from correcting simple metabolic and electrolyte abnormalities to significant cardiovascular disease interrupting the healing process. Burn patients are at a continual risk for complications such as disfigurement, scarring, infection, chronic pain, cataracts, and psychological issues, including depression. Complications can significantly delay and prevent the desired medical and financial outcomes.
Systematic Care ManagementSM
Paradigm uses a comprehensive, expert-driven approach known as Systematic Care ManagementSM to successfully improve medical outcome levels associated with severe burn wounds. The key components of this strategy are the use of medical experts, the selection of top providers, and leveraging a custom-built catastrophic care infrastructure. This process relies on the oversight and coordination of care by a skilled burn physician and onsite nurse case manager to create a plan in advance that outlines the key aspects of care and risks that must be mitigated. Getting injured workers to a specialized burn center will help implement all aspects of care from medical to long term care to equipment and transportation.
Using data and proprietary models to identify risks and optimize care paths specific to injury components and co-morbid conditions is also critical to the medical management system. Through the use of this approach, better medical outcomes are possible.
Return to Work Outcomes
One measure of the clinical effectiveness of an acute and long-term care plan is the return to work status of a burn victim. A recent article published in the Journal of Burn Care and Research (2010; 31: 692-700) provides evidence supporting the efficacy of Systematic Care Management for burn patients. In the study, Paradigm’s burn patients were matched as closely as possible to a national register of burn patients. Despite the Paradigm set of patients having more severe burns, the Paradigm return to work rate was more than twice the industry average.
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