The Personal Physician's Role in Helping Patients With Medical Conditions Stay at Work or Return to Work

Best Practices in Documenting and Coding High-Value Care in Workers' Compensation Encounters-ACOEM Guidance Statement

ABSTRACT

Workers' compensation outpatient care requires attention to causation, functional assessment, work disability prevention, and return-to-work planning, elements not usually addressed in other types of outpatient encounters. Because these elements of care deviate from the usual pattern of ambulatory services, providers of workers' compensation care have faced challenges in billing and auditing practices resulting in underpayment when providing high-value care based on evidence-based guidelines. Recent changes in Centers for Medicare & Medicaid Services rules on documentation requirements for coding outpatient evaluation and management encounters offer an opportunity for occupational health clinicians to be paid appropriately for care that follows occupational medicine practice guidelines. There remains a need to define the elements of documentation that should be expected in delivering high-value workers' compensation care. This article provides guidance for documenting high-value workers' compensation care.

Short-term Disability Insurance, Return to Work, and the Responsibility of the Orthopaedic Surgeon

Millions of Americans are unable to work every day because of illness or injury. Many of these individuals have musculoskeletal issues and are under the care of an orthopaedic surgeon. Short-term disability insurance programs have been developed to address the financial burden experienced by workers who are temporarily without income. Private insurance companies and state-sponsored programs are the two most common forms. Most disability plans require verification from a physician that the worker is unable to work or is able to work in a limited capacity. Quite often, this responsibility falls on the orthopaedic surgeon. Our participation is important and substantial, yet we receive little instruction on the role that we play in this process. This article explains the history and development of short-term disability programs, describes the way they currently function in our country, and clarifies the role of the orthopaedic surgeon in the process.

The impact of major occupational injuries on professional reintegration. A Portuguese medico-legal contribution

Occupational injuries represent an enormous economic impact for victims, respective families, involved institutions and all the community due to professional outcomes. Thus, it is of the utmost importance that medico-legal personal injury assessment and the posterior follow-up of these victims, may allow their concrete damage repair, considering the victims' needs fulfilment and professional reintegration, whenever possible. The main objective of this study is to reflect on the role that legal medicine can play in promoting the professional reintegration of victims of major occupational accidents through the analysis of occupational injuries cases considering the medico-legal examinations performed. A retrospective study was conducted using medico-legal major occupational injuries cases (Partial Permanent Disability ≥40%). Data were collected from two medico-legal assessment moments: (a) personal injury assessment homologated by a labour court 4.8 years on average after occupational injury; (b) medico-legal follow-up for needs and/or Partial Permanent Disability adjustments performed 18.9 years on average after occupational injury. The final sample includes 103 cases. The results showed that in major occupational accidents, permanent long-term outcomes were principally associated with neurological (62.1%) and orthopaedic (52.4%) sequelae. Permanent professional damage parameters assigned by the labour court included Partial Permanent Disability (23.3%), Permanent Absolute Disability for Regular Work (41.7%) and Permanent Absolute Disability for Any Work (35%). Three-dimensional methodology is helpful in predicting Partial Permanent Disability and Permanent Absolute Disability for Any Work. However, three-dimensional methodology did not reveal correlations with Permanent Absolute Disability for Regular Work, and currently 65% of the victims who were considered able to work by the labour court are not professionally active. Thus, these major cases deserve a more detailed medico-legal approach based on concrete information about the professional reality of each victim, especially cases with an eventual Permanent Absolute Disability for Regular Work. Medico-legal Injury Assessment must be based on concrete aspects of the victim's professional reality and not only on permanent disability tables. This calls for an articulation between all institutions working with the victim of occupational injuries and legal medicine to promote recovery and the necessary measures to assure professional rehabilitation.

Predictors of Temporary Profile Days Among U.S. Army Active Duty Soldiers

Introduction

More than 40,000 soldiers cannot deploy every year, which undermines readiness. The medical readiness of soldiers is a critical component of the overall operational readiness of the U.S. Army. Acute musculoskeletal injuries (MSIs) are the greatest threat to medical readiness. Medical providers place soldiers on temporary profiles to facilitate treatment and recovery of acute MSIs. Poorly managed temporary profiles negatively impact a soldier’s work attendance, resulting in the loss or limitation of over 25 million workdays annually. Upgrading the electronic profile system and implementing the Army Medical Home has led to improvements in managing temporary profiles over the last decade. The Army Medical Home encompasses care delivery platforms, including the Patient-Centered Medical Home (PCMH) and Soldier-Centered Medical Home (SCMH). The structure of U.S. Army PCMHs and SCMHs differ in ways that may affect care processes and patient outcomes. Temporary profile management is an important soldier health outcome that has not been studied in relation to the U.S. Army’s PCMH and SCMH structures or care processes. Access to care, continuity, and communication are three care processes that have been described as essential factors in reducing lost workdays and functional limitations in workers after an acute injury. Understanding the impact of the medical home on temporary profile days is vital to medical readiness. This study aimed to (1) compare temporary profile days between the U.S. Army PCMHs and SCMHs and (2) determine the influence of medical home structures and care processes on temporary profile days among active duty U.S. Army soldiers receiving care for MSIs.

Materials and Methods

This was a retrospective, cross-sectional, and correlational study guided by Donabedian’s conceptual framework. We used secondary data from the Military Data Repository collected in 2018. The sample included 27,214 temporary profile records of active duty U.S. Army soldiers and 266 U.S. Army PCMH and SCMH teams. We evaluated bivariate and multivariate associations between outcomes and predictors using general and generalized linear mixed regression models. The U.S. Army Medical Department Center and School Institutional Review Board approved this study.

Results

Total temporary profile days ranged from 1 to 357, with a mean of 37 days (95% CI [36.2, 37.0]). There was a significant difference in mean temporary profile days between PCMHs (43) and SCMHs (35) (P < 0.001). Soldiers in PCMHs were more likely to have temporary profiles over 90 days (OR = 1.54, 95% CI [1.17, 2.03]). Soldiers in the heavy physical demand category had fewer temporary profile days (P < 0.001) than those in the moderate physical demand category. Age, sex, rank level, physical demand category, profile severity, medical home type, the “explain things” communication subscale, and primary care manager continuity were significant predictors of temporary profile days.

Conclusions

Excessive temporary profile days threaten medical readiness and overall soldier health. Aspects of the medical home structure and care processes were predictors of temporary profile days for musculoskeletal conditions. This work supports continued efforts to improve MSI-related outcomes among soldiers. Knowledge gained from this study can guide future research questions and help the U.S. Army better meet soldier needs.

The Value of the Patient-Centered Medical Home in Getting Adults Suffering From Acute Conditions Back to Work: An Integrative Literature Review

Acute conditions are the leading cause of work restrictions and missed workdays, contributing to over $27 billion in lost productivity each year and negatively impacting workers' health and quality of life. Primary care services, specifically patient-centered medical homes (PCMHs), play an essential role in supporting timely acute illness or injury recovery for working adults. The purpose of this review is to synthesize the evidence on the relationship between PCMH implementation, care processes, and outcomes. In addition, we discuss the empirical connection between this evidence and return-to-work outcomes, as well as the need for further research.

Ineffective Communication: The Uninformed Injured Worker

BACKGROUND

Effective communication has been demonstrated to impact patient health outcomes, specifically in improving symptom resolution, safety, function, and emotional well-being, and to lower malpractice claims. I hypothesized that the communication process with patients with Workers' Compensation is inadequate.

METHODS

Prospectively, claimants presenting for an independent medical evaluation or an impairment rating were assessed concerning the education that they received with regard to their claim. Basic principles were based on the Utah Labor Commission Employee's Guide to Workers' Compensation and an employee information sheet.

RESULTS

There were 556 consecutive claimants assessed. None of the participants expressed any familiarity with the employee information sheet. Although there was a mean of 12 months since the date of claim to the evaluation, 536 participants (96.4%) were effectively unaware of the principles surrounding their claim; of these participants, 6 had attorneys and 23 had prior industrial claims. Of the 3.6% of participants who had received the State Employee Guide, 5 had a prior evaluation with the medical director of the Labor Commission, 6 had located the information online, and 9 had been provided information by their nurse-case manager. Even with this information, the context or importance of the information was not well understood. There were 16.4% of participants who were aware of the mileage compensation. Two claimants were aware that the insurer, not the employer, was responsible for managing the claim, 2 claimants were aware that their claim was open for life, and 1 claimant was aware that claimants could change physicians.

CONCLUSIONS

Workers' Compensation programs were designed to expedite care and treatment while decreasing the adversarial environment for workplace injuries. Yet delays and confrontational events continue to be experienced by the injured worker. This often results in the impression that workplace injuries have worse outcomes for the same diagnosis. The lack of effective education with regard to the rights and responsibilities of the claimant may also lead to this poorer outcome. Given studies showing the benefits of patient education in preventing malpractice claims and improving health-care outcomes, it is suggested that improved patient education for the injured worker is warranted and may lead to improved outcomes with diminished adversarial events.

Disability Evaluation and Treatment for Patients With Psychiatric Disorders

Primary care physicians (PCPs) are often asked to perform disability evaluations for patients with psychiatric disorders, which are now a leading cause of disability worldwide. After acknowledging the limitations of disability assessments for all conditions, this review aims to provide PCPs with practical knowledge to inform their assessments and interventions with a focus on patients with depression. After the disability definitions and programs in the United States are reviewed, a pragmatic approach to assessing function and discussing return to work is offered. Individualized assessment is key, and functional recovery rather than symptom relief should be prioritized. Finally, evidence-based interventions for enhancing the likelihood of return to work are considered. We believe the principles of functional assessment and recovery lend themselves to ready adaptation for use in other psychiatric conditions and chronic somatic syndromes, including chronic pain. The key principles of this approach are as follows: 1) a patient is not categorically disabled, but has specific limitations in specific contexts; 2) graded, work-oriented rehabilitation with tailored problem-solving strategies are essential; 3) involving a multidisciplinary team in coordinated care optimizes functional recovery; 4) return to work is an iterative process aimed at restoring meaningful function in a stepwise fashion; and 5) the relationship between symptoms and function is bidirectional. PCPs can use these principles to plan optimal recovery paths for psychiatrically ill patients presenting with a wide array of biopsychosocial realities.

Toward Effective Work Accommodations for Depression: Examining the Relationship Between Different Combinations of Depression Symptoms and Work Productivity Losses

OBJECTIVE

Heterogeneity of depression experiences has led to suggestions that interventions focus on depression symptom combinations rather than depression severity alone. Our analyses explore the question, "What is the relationship between different combinations of depression symptoms and work productivity losses?"

METHODS

These analyses use a population-based sample of 2219 working adults. Using the PHQ-8 items, cluster analysis methods were used to identify depression symptom clusters. The Work Limitations Questionnaire's four work productivity loss dimensions were regressed on the identified depression symptoms clusters.

RESULTS

The symptoms clusters of workers with mild to moderate depression had significant but similar work productivity losses. However, the symptom combinations within these clusters of workers varied.

CONCLUSION

To create effective work accommodations, attention should focus on the combinations of depression symptoms and specific job characteristics rather than severity alone.

Health Care Expenditures and Length of Disability Across Medical Conditions

Objective:

To describe the relationship between the length of short-term disability (STD) and health care spending.

Methods:

Medical claims for insured US employees on STD were evaluated to describe the distribution of disability durations and health expenditures across major diagnostic categories and common medical conditions. Correlations between health expenditures and disability durations were examined.

Results:

The most expensive 10% of cases accounted for more than half of total health spending. The longest 10% of cases accounted for more than one-third of total disability time. Only one-third of the most expensive cases were also among the longest in duration. Disability durations were moderately correlated with medical spending and this relationship was modified by comorbid conditions and age.

Conclusion:

Psychosocial barriers, in addition to biomedical factors, should be considered to achieve optimal functional outcomes and well-being of patients.

Practical approach to a patient with chronic pain of uncertain etiology in primary care

Chronic pain of uncertain etiology often presents a challenge to both patients and their health care providers. It is a complex condition influenced by structural and physiological changes in the peripheral and central nervous systems, and it directly influences, and is modulated by, psychological well-being and personality style, mood, sleep, activity level and social circumstances. Consequently, in order to effectively treat the pain, all of these need to be evaluated and addressed. An effective management strategy takes a multidisciplinary biopsychosocial approach, with review of all current medications and identification and careful withdrawal of those that may actually be contributing to ongoing pain. The management approach is primarily nonpharmacological, with carefully considered addition of medication, beginning with pain-modulating treatments, if necessary. In this article, we present a primary care approach to the assessment and management of a patient with chronic pain where the cause cannot be identified.

Development of an Occupational Health Safe Return to Work Prototype Application and Ergonomics Dataset for Agricultural Tasks

Serious, restrictive, non-fatal injuries are commonplace in large animal agriculture including in pork and dairy production. Primary care clinicians often have few resources to facilitate workers’ return to work and have difficulties communicating work restrictions/limitations to workers and their employers. This project developed SafeReturnToWork.org, a web-based platform to aid physicians and farmers in farmworkers’ timely and safe return to work. This prototype characterizes the duties of dairy and pork workers, and facilitates the creation of applicable light duty job assemblies for farmers and farmworkers by physicians and other healthcare providers. Guided by interviews and focus groups with physicians, farmers, and farmworkers, the system was developed for use with workplace injuries that could eventually link to human resource department systems, an electronic health record, or expand to other industries beyond agriculture.

Economic Evaluation and Systematic Review of Publicly Available Workers' Compensation Practice Details and Mod Rate Calculators Applied to Upper Midwest Agriculture

Background: Agricultural employment is one of the most dangerous occupations in the United States. Workers' compensation coverage requirements for agricultural work vary from state to state, and experience modifier rates (E-mods) affecting insurance premiums sometimes vary drastically across state lines and according to claim severities and farm sizes. We proposed to develop an interactive software application that would educate farmers on the impact of employee time loss on annual E-mod factor change specific to their geographic location and farm size.Methods: We conducted a comparative analysis of workers' compensation formulations, including E-mods among Upper Midwestern states. We performed sensitivity analysis of the formulas to claim amount and payroll to highlight differences related to claim severity and to farm size.Results: The state to state variation and remarkable complexity of these formulas was confirmed. E-Mod factors are shown to increase substantially across states with both claim size and payroll, though are found to be similar across Wisconsin and Minnesota which were examined in detail.Conclusions: The findings confirm that creating a nationally applicable interactive educational software tool for farmers and ranchers to view hypothetical rate changes by inputting on-farm injury scenarios represents a significant challenge and that educational outreach coupled with the use of commercial software, especially as less costly options become available, may serve the role of minimizing misunderstandings by current producers as may other informational sources.

Insurers' Influences on Attending Physicians of Workers Sick-listed for Common Mental Disorders: What Are the Impacts on Physicians' Practices?

Purpose In many jurisdictions, general practitioners (GPs) play an important role in the sick-leave and return-to-work (RTW) process of individuals with common mental disorders (CMD). Since it is insurers that decide on workers' eligibility for disability benefits, they can influence physicians' ability to act. The nature of these influences remains little documented to date. The aim of this study was therefore to describe these influences and their impacts from the GPs' perspective. Methods Semi-structured interviews were conducted with GPs having a diversified clientele (n = 13). The interviews were audio-recorded, transcribed verbatim and analyzed according to thematic analysis principles. Results The results indicated that the GPs recognized insurers as influencing their practices with patients on sick leave for CMDs. The documented influences were generally seen as constraints, but sometimes as enablers. The impacts of these influences on the GPs' practices depended on the organizational characteristics of their work context (such as limited consultation time) and other characteristics of their practice setting (such as lack of timely access to consultations with specialists). Conclusion The results brought three major issues to light: the quality of the information sent to insurers by GPs, the respect shown (or not) for workers' care preferences, and the relevance of the specialized services offered to support workers' RTW. These issues in turn reveal potential risks for workers, risks that need to be identified and recognized by all parties concerned if we are to come up with possible solutions.

Using Electronic Health Records and Clinical Decision Support to Provide Return-to-Work Guidance for Primary Care Practitioners for Patients With Low Back Pain

OBJECTIVE

The aim of this study was to describe the process by which a group of subject matter experts in the area of return to work developed a resource tool to provide clinical decision support (CDS) for primary care clinicians.

METHODS

A common musculoskeletal disorder, low back pain (LBP), was selected, pertinent literature reviewed, and specific recommendations for action in the clinical setting developed.

RESULTS

Primary care practitioners (PCPs) are routinely expected to create work activity prescriptions. The knowledge base for a CDS tool that could be embedded in electronic health records has been developed.

CONCLUSION

Improved clinical support should help prevent and manage work limitations associated with LBP not caused by work. The proposed decision support should reduce administrative burden and stimulate PCPs to explore the role of occupation and its demands on patients.