DOING THE “RIGHT THING” FOR THE CLAIMANT IS ALSO THE MOST COST-EFFECTIVE

Without a clear clinical picture, treatment decisions for workers' compensation cases are often difficult. Surgeries, spinal interventions, opioids, stimulators, or intrathecal pumps are not always the best approaches. They may cause physical deterioration and drastically increase our expenses. Here are some suggested alternatives:

1. Occupational or rehabilitation physicians (physiatrists) should perform initial evaluations. This physician should typically treat acute injuries with non-opioid medications, recommend physical therapy as soon as possible, and refrain from excessive diagnostic testing. Avoid orthopedic surgeons or interventional physicians at this state.

2. There should be clear clinical reasons for any early diagnostic testing. Acute injuries in the first two weeks rarely require spinal interventions, opioids, or sophisticated imaging studies. A diagnosis is made by the physician via examination, using specific criteria. Testing confirms or rules out the physician's diagnosis; it rarely makes it. X-rays, for instance, are seldom helpful except for suspected bone fractures. Unfortunately many doctors request them because it has become a patient expectation: "The doctor didn't even X-ray me."

3. MRIs are needed if the examination suggests neurological injury requiring surgery. Often doctors request repeat MRIs without new neurological findings. Why? "My pain is worse." Pain can indeed worsen for multiple reasons, but MRIs will not likely clarify them. Again, claimant pressure: "My doctor didn't even order a new MRI."

4. After two weeks with no improvement, it's time to consider psychosocial issues. What about secondary gains, family support, disability history, previous psychiatric issues or addiction? Is the claimant following the physician's instructions? What about job satisfaction or performance? Is the employer adapting to the claimant's restrictions?

5. At this point, any procedure - surgical or not - must have clear clinical explanations and detailed expectations of outcome. They should address improvement of pain, but must include functional goals and life quality improvement. Some examples of expectations and functional goals are:

• After surgery, the patient will walk 1-2 miles without assistive devices
• Will return to work in one month with some restrictions
• Pain scores will decrease from 7-8 to 2-3
• Spinal interventions (epidural injections) no longer needed
• Opioids not to be resumed. Important: patients awaiting surgery should be weaned off narcotics. Surgeries performed on patients taking narcotics have a greater chance of failure.

6. If there are indications of delayed recovery, claims administrators should consider conservative approaches not formally "covered" under worker's compensation, which might help the injured worker improve. Properly monitored services like aqua therapy, acupuncture, limited gym membership, or even short chiropractic care are relatively inexpensive options. These can be helpful and far better than opioids or additional surgeries.

7. Finally, what about the claimant with multiple unsuccessful surgeries/procedures, heavy narcotic use, severe functional decline, major psychosocial issues, or poor life quality? For them, it is time to consider a Functional Restoration Program. While this can be an expensive option, it may be cost-effective in the long run, because at this point the claim itself is injured and slowly but drastically hemorrhaging dollars.