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December 2004


Workers' Comp: A Plethora of Opportunities

By David W. Clifton, PT

Workers' compensation (WC) represents a patchwork quilt of 50 separate and distinct state laws. Workers' compensation, unlike other insurance lines, is a legal not a medical system. Therefore, it is expected that every physical rehabilitation provider learn about the specifics of their state law if they are to fully participate in the prevention, treatment, and management of work-related illness and injury.

Rehabilitation's prominence is greater in workers' compensation when compared with other insurance lines. This is partly due to the prevalence of musculoskeletal cases. Musculoskeletal conditions account for 28% of lost work days with back disorders the number one cause of work-related disability.1 Sprains and strains are the most common injuries, accounting for 52% of all musculoskeletal conditions. Overexertion injuries are next at 43% of all cases. Overexertion injuries accounted for 25% of all wage and direct medical costs, according to Liberty Mutual, the nation's largest workers' compensation carrier.2

The Workers' Compensation Research Institute (WCRI) reported that the combination of physical therapy and occupational therapy accounted for 10% of total medical costs and 37% of all workers' compensation claims.3 The average rehabilitation claim in this WCRI study involved 14.4 visits at an average cost of $1,237. A National Council on Compensation Insurance (NCCI) data analysis revealed that in Florida, physical therapy accounted for between 8% and 16% of all WC costs and was involved in 35% of all claims.4

NCCI data suggest that the average treatment duration is four times greater in WC cases than in non-WC cases, 206.6 days versus 51.9 days, respectively. Jette et al noted that charges for WC-based physical therapy were 36% higher than non-WC cases.5 These and other data demonstrate the impact of rehabilitation in workers' compensation. However, this has invited intensified scrutiny of rehabilitation services that has resulted in medical fee schedules, enhanced utilization review including precertification of service, fee discounts, treatment guidelines, and aggressive management of preferred provider networks. It is important to point out, however, that PT- and OT-rendered care is seldom differentiated from generic physical and occupational therapy.

Few insurance companies use provider identifiers to differentiate therapist-driven services from those services provided by others using the CPT coding systems. This observation strongly suggests that therapists must do a better job of educating payors concerning their services versus services rendered by nontherapists. A failure to do so may further diminish the role of these services in the management of work-related conditions.

DISABILITY MANAGEMENT VS TREATMENT
Disability generally refers to the inability of a person to interact with their environment in a so-called normal or functional fashion. Obviously, in workers' compensation this means one's job station and/or work site. The goal in every WC case is to return the individual to gainful employment. Gainful employment is different from maximum medical benefit (MMB) or maximum medical improvement (MMI), a common goal in general or group health cases. Gainful employment recognizes a higher functional threshold than MMB or MMI. Gainful employment can imply a number of things: return-to-work (RTW) in one's previous job, a new job, a combination of jobs-from sedentary to heavy work-with or without reasonable accommodations.

RTW decisions require expertise that transcends the medical model typically followed by physicians who are well trained to assess and treat pathology, disease, and impairments. When pathology, disease, and impairments have become medically stable, one could reason that MMI has been achieved. However, this is an insufficient clinical outcome in workers' compensation cases that demand the injured worker achieve a maximum functional level determined by their condition, a variety of psychosocial factors, and critical job demands. Functionality assessments generally fall outside of the medical model and require expertise of those who assess function relative to environmental demands. This is essentially the domain of physical and occupational therapists-the functional experts.

Many WC cases require disability management, not treatment per se. Disability management is essential to RTW once an injured worker progresses beyond the acute stage of an injury or illness. This may require a paradigm shift for those therapists who principally focus on treating their patients. Persons under workers' compensation are not viewed as patients, but injured or ill workers, which in and of itself connotes the emphasis on work as a clinical outcome.

Disability management is a set of interventions designed to address the discrepancies between the individual's functional level and socioenvironmental demands. DM demands that rehabilitation providers look beyond treatment and consider physical, emotional, vocational, medical, and organizational factors that impact on employment.6

Optimal success in WC-based rehabilitation is predicated on blending medical skill sets with nonmedical ones, worker interventions with work-site interventions, treatment with management, and management strategies with prevention strategies.

DISABILITY MANAGEMENT TRIAD
A disability management triad integrates treatment/management, education, and consultation.7 The treatment and management leg of this triad addresses rehabilitation and habilitation and principally focuses on injured workers' limitations and capabilities. The education leg focuses on learning more about the nonmedical attributes of the workers, especially psychosocial factors that have direct bearing on whether they return to gainful employment. Examples of nonmedical issues critical to success in workers' compensation DM include:
  • Educational level
  • Gender
  • Wage replacement
  • Time from injury to rehabilitation referral
  • Marital status
  • Attitudes
  • Job satisfaction
  • Presence of litigation
  • Preinjury employment status
  • Support level
  • Financial status
  • Availability of transitional or modified duty
  • Job seniority
  • Health benefits structure
  • Labor-management relations
Consultation represents the third portion of the DM triad. This area perhaps represents the greatest opportunity for rehabilitation providers. Injury prevention strategies, work-site management, and ergonomics are examples of consultation opportunities.

Because employers shoulder the burden of US health care costs, they are in search of alternatives to treatment. Managed care's promise of cost control has done little to prevent double-digit medical inflation. An aging workforce promises to further challenge employers. Rehabilitation as a sector can assist employers, but it will require a paradigm shift for some. Providers have traditionally been patient-centric in their focus and not particularly concerned with the work-site environment.

Rehabilitation providers can play a pivotal role in disability prevention by offering consultation services to employers. Many of these programs can be natural extensions of patient-based interfacement.


Table 1.
Table 1 illustrates a diversity of skill sets that rehabilitation providers can offer within a DM program.7

There is overlap between prevention and consultation programs; however, in this context consultation implies that employers have already experienced problems and require abatement. Prevention, as the term implies, connotes minimization or elimination of workplace injury risks.

Participation in integrated disability management programs may require providers who step beyond the clinical realm. These providers are more likely to survive poor reimbursement cycles or intensified scrutiny of rehabilitation services. These providers will be better positioned as valuable resources to employers that are seeking alternatives to treatment.

Those providers who continue to treat within their own offices may be viewed (by employers) as isolationists and, subsequently, play an insignificant role in work-related disability management. A failure to collaborate with employers under workers' compensation may deny providers other opportunities as well. Lukes and Wachs opine that "in an effective disability management program, efforts are made to keep employees healthy and safe in all aspects of their lives, not just work. Disability management begins before any injury or illness occurs, before anyone is disabled. It is a proactive, anticipatory strategy."8 Providers who assist employers with workers' compensation may enjoy opportunities to consult in other health and wellness programs.

FROM CLINICIAN TO CONSULTANT
Rehabilitation providers, should they desire, have many means with which to convert their skills, knowledge, and experience into consultation opportunities. Again, consultation in this context refers to non-treatment-oriented services. Employers can benefit from outsourced expertise in the following areas: ergonomics, provider panels, functional job analysis (FJA), functional capacity evaluations, and medicolegal.

ERGONOMIC COMMITTEES
Many employers have safety and health or ergonomic committees composed of diverse stakeholders. In some states, eg, Pennsylvania, employers receive discounts on workers' compensation premiums in exchange for ergonomic committee development. Physical and occupational therapists have competencies in a number of areas of importance to employers. These include but are not limited to musculoskeletal, biomechanical, injury mechanism analysis, and therapeutic exercise. Those providers with a keen interest in ergonomics can achieve specific certifications in this specialty area.

WORKERS' COMP PANEL SERVICE
Most state WC acts encourage and permit the establishment of a preferred panel of WC providers who must be used by injured employees for time frames that are state-specific. Some states may preclude the participation of a physical or occupational therapist, but this can be ascertained by reading one's state WC law or act. In those states that preclude direct rehabilitation provider participation, it is advisable to determine which orthopedists, neurologists, or general practitioners are listed. Participation on WC panels facilitates early intervention and possibly opportunities for employee screenings, employee and management education and training, ergonomic analysis, functional job analysis, and other prevention or consultation services.

FUNCTIONAL JOB ANALYSIS
Functional job analysis serves an important purpose in WC cases. Since the ultimate goal is safe but expedient RTW, an FJA can provide the blueprint for both program design (eg, work hardening, work conditioning) and functional capacity or capability evaluation (FCE). Employers seldom receive on-site visits from attending physicians, therefore opportunities exist for therapists who offer FJA as a consultative service that produces alternative revenue as well as critical data.

FUNCTIONAL CAPACITY EVALUATION
FCE is well established as a rehabilitation intervention. However, most FCEs are done as a component of patient care or an extension of a work hardening or work conditioning program. Relatively few therapists offer FCEs as an independent evaluation of disability. As a result, insurers and employers often principally rely on independent medical examinations (IMEs) for disability determinations and completion of physical capacity forms.

An IME, when augmented by an FCE, can provide two expert opinions, a physician's and a physical or occupational therapist's. This assures that the entire disablement model is addressed from pathology to disease, impairment to disability, and disability to handicap. Physicians are generally trained in the identification of pathology, the diagnosis of disease, and assessment of impairment. However, PTs and OTs are experts in the assessment of disability, which is not purely a medical decision. There is enormous opportunity for FCEs not only in workers' compensation, but also in disability insurance (short-term and long-term disability), in Social Security cases, and under long-term care policies. This last category, long-term care policies, requires that a distinction be made between activities of daily living (ADL) and instrumental activities of daily living (IADL).

MEDICOLEGAL SERVICES
Medicolegal consulting opportunities for therapists abound in workers' compensation. Rehabilitation literature searches at the bequest of insurers, employers, or attorneys represent one such opportunity. Expert testimony to establish the medical necessity and reasonableness of physical or occupational therapy represents a second untapped opportunity for many. The provision of medicolegal expertise can be considered one of the hallmarks of professionalism. It can also assure that a peer-to-peer process is guaranteed during utilization review/management and legal testimony.

A UNIQUE OPPORTUNITY
Disability management in workers' compensation offers a unique opportunity for physical and occupational therapists who recognize the value of offering nontreatment services that are natural extensions of one's education, training, experience and skill sets. DM encompasses treatment, management, education, and consultation and offers a hedge for therapists during difficult times.

David W. Clifton, PT, is president of Dolphin & Associates, Media, Pa, and a member of Rehab Management's editorial advisory board.

REFERENCES
  1. Watson Wyatt Worldwide Third Annual Report: Staying@Work, 1998/1999, Bethesda, Md, Watson Wyatt Worldwide. Available at: www.watsonwyatrt.com. Accessed June 6, 2000.
  2. Roberts S. Employer priorities don't match most costly worker injuries. Business Insurance. 2002;36(153):77.
    3. `
  3. Eccleston S. Overview of state workers' compensation medical care initiatives. Presented at: Workers' Compensation and Managed Care Challenges and Opportunities in a Changing Health Care System, Agency for Health Care Policy and Research (AHCPR), Chicago, July 30-August 1, 1997. Available at: www.ahcpr.gov. Accessed June 6, 2000.
  4. Medical Expenditures in Workers' Compensation: Utilization of Services Drives Cost. Boca Raton, Fla: National Council on Compensation Insurance; 1994.
  5. Jette AM, Smith K, Haley SM, et al. Physical therapy episodes of care for patients with low back pain. Phys Ther. 1994;74:101-115.
  6. Shrey D, LaCerte M, eds. Principles and Practices of Disability Management in Industry. Winter Park, Fla: GR Press; 1995.
  7. Clifton DW. Physical Rehabilitation's Role in Disability Management: Unique Perspectives for Success. Philadelphia: Elsevier Saunders; 2004.
  8. Lukes E, Wachs JE. Keys to disability management. American Association of Occupational Health Nurses (AAOHN) Journal. 1996;44(3):141-147

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