The current midterm election clearly has changed the political map from a local, statewide, and national perspective. There are those who believe that this change will solve every problem, particularly with respect to healthcare and by default Worker’s Compensation.
What Should Drive a Claim Decision?
Undoubtedly, winners of elections decide who writes the laws. What is not changed is the anatomy, physiology, the noted mechanism of injury, or the objective clinical evidence required to correct a medical condition that resulted from a workplace event. One of the (from my perspective) joys of Worker’s Compensation is that this is a particularly interesting intersection of multiple competing interests. Labor, employers, carriers, physicians, (in some cases) attorneys, regulators and that injured individual all approach each claim from a slightly different perspective. What is also noted is that an effective and properly functioning system requires decisions based on competent, objective, and independently confirmable medical evidence rather than any specific political identity.
Different Interests, Same Medical Facts
We all have our perspectives, and a natural flow is disagreement on how to best proceed. This particular issue is not evidence that the system is broken. The injured employee wants appropriate treatment and complete recovery. The employer wants a safe, productive workforce and predictable costs to ensure profitability. The adjuster simply wants timely and visibly defensible determinations. With every clinical record, there needs to be a conclusion supported by objective medical evidence, irrespective of where that evidence takes one. The physician wants the best for the patient. Attorneys advocate for their perspective. Regulators must balance access to treatment, “fairness” (when often there is none) and sustainability of the overall process. One of the basic difficulties is that different interests lend themselves to a different version of the facts.
Where Policy Shapes the Claim
Reasonable people may disagree about policy. If they did not, it would most assuredly take the fun out of politics, and the numerous memes I receive daily. What reasonable people should not have is a separate set of medical facts for the compensable injury sustained.
Changes in political control will affect Worker’s Compensation policy. Issues relative to benefit structures, access to care, presumptions, fee schedules, dispute resolution, and other topics most certainly will ensue. While political philosophy may influence what a jurisdiction chooses to do, evidence-based medicine determines whether the medical conclusions are truly supportable.
When a Claim Is Disputed, Start with the Injury
Straightforward claims should remain just that. However, when a claim becomes contentious, all parties should default to the basics. What was the actual mechanism of injury? What specific symptoms are a function of, or followed, that event? What objective data is noted supporting those symptoms? Does the diagnosis logically flow from the compensable injury sustained, and all of the pertinent clinical facts identified? The findings on imaging studies, are they related to the date of and actual injury sustained? Is there any measurable functional impairment? Are there any alternative rational explanations for the pathology noted? On balance, what is the most appropriate conclusion to be drawn?
As the findings on MRI do not vote red or blue. On their own, these findings do not establish causation either.
When Unanswered Questions Drive Up Claim Costs
Just like the outcome of this most recent election, contention within our ecosystem tends to become particularly expensive. When one cannot connect the pathology noted with the injury sustained, this obviously compromises claim file handling. Contention within a claim file becomes costly when:
- A symptom becomes a diagnosis without objective confirmation (e.g., pain)
- Changes on imaging studies are automatically attributed to the compensable event
- Degenerative pathology is mistaken for acute findings
- Ongoing treatment, without measurable functional improvement, is noted
- There is argument over the conclusion before agreeing to the underlying medical facts
Is the Claim Supported by Medical Evidence?
Resolving these questions early can reduce unnecessary treatment, extended disability, litigation, and claim expense. By contrast, prolonged diagnostic ambiguity could mean additional treatment, extensive disability, escalating attorney involvement, a delay in return to work, and greater difficulty in resolving the claim.
The goal here is not to automatically deny a claim, or treatment, only that all clinical facts need to be obtained, digested, and the most appropriate clinical decision be reached to the benefit of all parties concerned. An injured employee with a compensable injury deserves appropriate treatment as quickly as it can be delivered. At the same time, the employer deserves protection from treatment directed towards unrelated comorbidities. These positions are not mutually exclusive. The deployment of this standard is precisely where evidence-based medicine becomes valuable. It does not require the parties to share a political philosophy. It requires them to examine the same clinical evidence and explain how that evidence supports their conclusions.
The Standard Every Claim Should Meet
The most recent election has changed local, state, and national legislatures. This will most undoubtedly lead to changes in regulations, and the priorities of any particular policy. However, there should not be any change in how a specific shoulder, lumbar, or knee injury is addressed.
With every clinical record, there needs to be a clinical conclusion supported by objective medical evidence, irrespective of where that evidence takes one. To be clear, injuries do occur and they require the best possible treatment. Elections may change the rules. They should not change the medical facts. That should be the constant underlying standard.
