How to separate appropriate advanced care from treatment that has drifted beyond the accepted injury.
Every time I sit down and watch television, there are always new medications, procedures, and innovative technology to address clinical issues. However, it has been my experience that injured employees do not always read the fine print for these clinical interventions, and they feel that this is absolutely necessary to address the sequelae of their compensable event. As one having recently undergone a multiple level lumbar fusion surgery (and yes, even as an orthopedic physician associate, I knew this procedure was necessary), my feeds became cluttered with a number of YouTube videos on the procedure. At that time, I also noted that there were a number of alternative surgical interventions already developed.
When High-Cost Treatment Requires Closer Scrutiny
The question becomes: would this potential six-figure surgery receive appropriate intensive scrutiny, or perhaps, is the need for these $25,000 a month medication protocols required to address pain complaints or other issues?
To be clear, the issue here is not the price tag. The issue to be resolved is what is the extent of the compensable injury, what particular objective clinical findings are noted to support the suggested treatment, and is this treatment appropriate for the injury and demonstrates a significant chance at marked functional improvement? Understanding that good quality care can be expensive, it is also understood that poor care can be equally, if not more so, as expensive. The key determinant is whether or not the treatment is clinically justified relative to the compensable injury sustained.
When Advanced Treatment Is Appropriate
As noted, expensive does not mean excessive. Having undergone a complex fracture of my distal radius with displacement, requiring multiple pins and screws, as well as surgical plates, this fracture was very expensive to treat. Other considerations would be rotator cuff repairs in those individuals requiring a reverse total shoulder arthroplasty. Or perhaps a significant multiple level trauma or a severe crush injury. Treatment for each of these described interventions is not cheap.
Each intervention would require specialized care, hospitalization with surgery, extensive imaging studies, and in a number of cases extensive post-procedure rehabilitation. Getting that injured employee back to the maximum functional level is the primary driver. To accomplish that goal can be expensive.
Identifying Treatment Drift
All that being said, one must be cognizant of “treatment drift.” We often see injured individuals who wish to pursue excessive amounts of physical therapy without measurable gain or improvement in the overall clinical situation. Having moist heat, therapeutic ultrasound, or other comparable measures to address a simple lumbar strain can evolve into years of modalities and pain management interventions. This becomes unnecessarily expensive. The American College of Physicians guideline recommends superficial heat for acute and subacute low back pain and finds insufficient evidence for therapeutic ultrasound. (Qaseem A, et al. Ann Intern Med. 2017;166(7):514-530, PMID 28192789)
Similarly, when multiple body parts are added outside the parameters of the reported mechanism of injury, or there are repeat injection protocols with no identified significant improvement or benefit, these are examples of “treatment drift.” They should create red flags ensuring appropriate investigation.
Three Questions to help Avoid Treatment Drift
If there is a red flag, there are three questions the claim file handler should ask. First, does the treatment match the reported mechanism of injury? It is the mechanism of injury that drives the diagnosis and this diagnosis drives the appropriate treatment plan. If the answer is no, appropriate review is indicated. Second, what are the specific objective clinical findings to support continuing care or additional interventions? As part of your red flag handling, look at the physical examination findings, the diagnostic imaging studies, what current functional deficits are present and has any improvement been identified. Third, any clinical intervention or treatment should create measurable progress. Is the work capacity improving, activity tolerance increasing, and is recovery advancing? Each of these items should be answered.
Understanding Escalation vs. Overtreatment
And to be clear, escalation of treatment does not automatically mean “overtreatment.” If there are any questions, a quick phone call to your trusted medical advisor should be completed asking the question about the treatment. The treatment may be wholly warranted, and you may not be current with the Journal of Bone and Joint Surgery. Having this clinical conversation can establish if there is appropriate or excessive treatment. The challenge is to distinguish between these two separate situations prior to incurring accelerated cost exposure.
Let The Clinical Review Guide the Claim
Medicine is advancing on a daily basis. New treatments, and surgeries, better medications, all are out there. And each comes with a significant expense. The highest quality care is not always inexpensive. However, the lowest cost option is not always appropriate. Effective claim file management requires clinical discipline, and you need to obtain the appropriate information to support your determination. As with everything, the standards of evidence-based medicine should be the overriding concern.
The question is not whether treatment is expensive. The absolute question has to be if the treatment still belongs to the compensable injury that you are managing.
