Category Archives: Tools, Techniques, Methods & Money

June 28, 2016

Reduce ill-considered surgeries by using shared medical-decision making

Something called “shared medical decision-making” increases patient satisfaction while reducing utilization of elective procedures that are invasive, risky, of questionable value — and often high cost.   But it is rarely used today outside large health plans.

Do you know how shared medical decision-making (SMDM) differs from “informed consent”?  I didn’t until I attended a presentation by Ben Moulton from the Informed Medical Decisions Foundation. In brief, informed consent is a legal process that is supposed to protect patients and promote patient autonomy.  You’re probably familiar with it.  You get a form to read a minute before the doctor walks in to talk at you for a few minutes about risks and benefits of your up-coming test, procedure or surgery.  Then you sign the form after barely glancing at all the legalese.  In contrast, SMDM is a structured process by which a patient and a clinician share information with each other in a two-way exploratory conversation that prepares the patient to make a truly informed decision.  The INSTANT I learned about SMDM, I became an ardent fan.

(Please forgive the acronyms.  We have been doing a project with the military.  They constantly use acronyms in the interest of brevity.  I now find myself making an acronym out of EVERY multi-syllabic or multi-word term.  Here’s the latest one I learned:  BLUF which means “bottom line up front”.  In other words, instead of beating around the bush, the point of the memo or report is right here at the start!)

So here’s the BLUF:  Since the superiority of SMDM is now well-established among healthcare researchers and legal scholars, and many articles have documented its benefits to patients, to healthcare professionals, and in some cases to health payers, why isn’t it in widespread use every day and everywhere?   As soon as I heard SMDM existed, I began to wonder about what’s getting in the way of constant use?   I bet a combination of conflict of interest and pesky not-so-little logistical details like the lack of vendors, undeveloped operational mechanisms, and lack of fair payment for effort are the main reasons why.  And of course, a preference for costs later rather than costs today.  We gotta find a way around those obstacles!

BACKGROUND:

Ten years ago, a landmark article appeared that distinguished between informed consent and SMDM — then made a persuasive case for the latter.  Here’s the full citation:  King, Jaime S. and Moulton, Benjamin, Rethinking Informed Consent: The Case for Shared Medical Decision-Making. American Journal of Law and Medicine, Vol. 32, pp. 429-501, 2006.

First the authors described the two prevailing types of legal definitions for informed consent.   They wrote: “Currently, the states are almost evenly split between two types of standards for informed consent – the physician-based standard, effective in 25 states, and the patient-based standard, effective in 23 states and the District of Columbia.  Physician-based standards generally require physicians to inform a patient of the risks, benefits and alternatives to a treatment in the same manner that a ‘reasonably prudent practitioner’ in the field would.  On the other hand, patient-based standards hold physicians responsible for providing patients with all information on the risks, benefits and alternatives to a treatment that a ‘reasonable patient’ would attach significance to in making a treatment decision.”

The crux of the problem:   About one third of the time, the prevailing standard of care does not require the physician to do the treatment  (for example, the surgery is not the only treatment available, or is not required to save the patient’s life).  In that third of cases, in which the treatment or procedure is referred to as “elective”,  the intended outcome of the surgery is basically improved quality of life.  Thus, the decision whether to go ahead with the treatment really should depend largely on the values and preferences of the patient.  However, patients vary widely in how much information they want, their appetite for risk, their tolerance for various side effects and possible poor outcomes, and their confidence in their own decision-making ability.   Many of them will not feel prepared to make a good decision no matter how much information they get;  they want guidance or an out and out recommendation from their doctor.  Without knowing the patient’s  preferences and values, physicians are not able to give advice about treatment decisions tailored to the patient’s personal situation — and may inappropriately bias the discussion of alternative plans.

Then the authors defined SMDM:   “a process in which the physician shares with the patient all relevant risk and benefit information on all treatment alternatives and the patient shares with the physician all relevant personal information that might make one treatment or side effect more or less tolerable than others. Then, both parties use this information to come to a mutual medical decision.”  They also said SMDM must occur BEFORE the patient can give truly informed consent.

Here’s another problem:  Many physicians have trouble talking in lay language;  they tend to use big words and medical jargon.  And because medical visits are stressful, patients have trouble remembering the things the doctor tells them.   Moreover, most physicians do not have comparative factual data at hand about likelihood of success and specific side effects for the various treatment alternatives.  This has led to the development of decision aids – pamphlets, booklets and videos for patients that summarize information about procedures and treatments, their likelihood of success, what it is like to live with potential side effects and poor outcomes, and so on, all written in simple everyday language. Both the Foundation and its partner Healthwise have produced many of them.

Finally, the authors asserted that despite the “bureaucratic headaches, the enormous expenditure of financial and human resources, and the need for state by state adoption of new informed consent laws, the long-term benefits of shared decision-making and the use of evidence based decision aids to promote patient understanding of medical information to arrive at informed medical decision making far outweigh the costs for both patients and physicians.”

MY SIMPLISTIC ANALYSIS OF THE REASONS FOR LOW USE

Conflict of interest:
Some (or many) surgeons and interventionists of various kinds earn their living by delivering expensive services – and usually have convinced themselves believe those services are the best thing for the patient.   They often work for healthcare delivery organizations that want to drive revenue up – not down.   The whole team has a vested interest in making sure the patient says “yes” and understandably has less commitment to spending valuable time helping patients say “no thank you” to the operation or the treatment.

My question is:  How can we get around this obstacle?   Why can’t managed care companies or health/disability/workers’ comp payers find qualified third party vendors who can engage patients in shared medical decision-making conversations when the treating physician can’t – or doesn’t want to?   The company Health Dialog does that – but last time I talked with them, they are only set up for bulk sales to healthplans.    I haven’t yet run across an organization that will do onesie and twosie shared medical decision conversations on request.   In workers’ compensation and disability benefits programs, that option is the only way this will fly.

Scarcity and cost of materials, logistics, and lack of delivery mechanisms:
1.    Materials to educate and prepare the patient for shared medical decision-making are available only for a limited number of procedures.  It takes time and expertise to prepare them, and since they are based on the latest scientific evidence, they must constantly be updated.  For example, when I looked last, the Foundation had no package for spine fusion surgery, though they did have them for laminectomy and spine MRI.
2.    Medical offices that buy the materials used to educate and prepare the patient for a shared medical decision-making conversation can’t bill for the cost of the materials.  There is no CPT billing code expressly designed for it, and if the provider bills under a similar-appearing code, it often won’t be paid.
3.    Physicians who conduct “real” shared decision-making conversations in their office aren’t paid for the time.  There is no CPT billing code expressly designed for it, and if the provider bills under another code, it often won’t be paid.
4.    Medical delivery organizations that have especially trained staff on hand to conduct these conversations can’t bill for the time they would spend doing it.   Non-physicians can’t bill health payers for the time they spent on these conversations.  There is no billing code expressly designed for this service, and if the provider bills under another CPT code, it usually won’t be paid.

GOTTA FIND A WAY TO MAKE THIS WORK

Many studies have shown increased patient satisfaction when SMDM occurs.  In addition, Group Health of Oregon reduced healthcare costs by 40% by putting SMDM in place throughout their group practice HMO.  (They didn’t have to worry about getting paid for doing it because Group Health is a prepaid health plan that employs its own physicians.  Increasing patient satisfaction strengthens their business, and any dollars they save stay in house)

Those of us who contract with vendors and operate provider payment mechanisms really ought to get ourselves in gear to remove the barriers to widespread adoption of SMDM.   Drs. Ian Hargreaves and Victor Montori from the Mayo Clinic summarized the situation in an article in Health Affairs entitled “Shared Decision Making: The Need For Patient-Clinician Conversation, Not Just Information,” They wrote: “The patient and clinician must jointly create a course of action that is best for the individual patient and his or her family. The larger need in evidence-informed shared decision making is for a patient-clinician interaction that offers conversation, not just information, and care, not just choice.”

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June 22, 2016

Psychiatrist says we should use food to treat anxiety and depression

Dr. Drew Ramsey is a well-trained psychiatrist at Columbia in New York.  He grew up on a farm in Indiana.  When his patients weren’t getting well despite “evidence-based” psychotherapy and drugs, he starting wondering what was missing.  Then he started thinking about the link between what we eat and the health of our brains.  He figured out where all the latest nutrition research is pointing us, and started using food as part of his treatment plan for his patients — with good results.

Makes sense to me.  The brain consumes more energy than any other organ in the body. Obviously, a brain that isn’t getting what it needs in the way of nutrients will not function at its best.

So, one question to ask when we see someone who is not performing at their best mentally is:  are they eating right?   Which brings up another, much bigger question:  why are inquiries about nutrition not part of EVERY medical interview of sick people?  Why aren’t recommendations about foods that foster healing part of EVERY medical treatment plan?  Besides feeding the brain, nutrition is critical to healing injured tissues.

For years I’ve read about how doctors don’t learn nutrition.  It didn’t bother me because I DO know it.   My parents raised me to be a mother/wife and to be responsible for making sure I know how to feed my family well and keep them healthy.  I am also the main cook in our household.   But …. EVERY doctor should know what I know, and should keep it on the front burner.  And here’s the weird part.  Nutrition really ISN’T part of the medical culture.  Even though I’ve always known how important nutrition is, it hasn’t been part of what I talk about with people who are sick and need to get well.  Wow.  What a realization.  How stupid.

Dr. Ramsey has done at least two TedX talks, Brain Farmacy and Brain Food at the End of Your Fork.  He has a website, a blog, and three books.  Check it all out.  To me, his basic ideas make a lot of sense, and the nutrition stuff he’s saying is pretty solid, based on my own reading.  All in all, this seems like sensible stuff from the practical son of an Indiana farmer — who turned into a scientist, physician, psychiatrist and now educator.

(One concern: he may be getting swept up in the Dr. Oz fame whirl.  I hope he will avoid becoming faddish and commercial, pandering to the demands of TV fans who demand new woo woo immediate magic cures every day. So let’s go catch him now, in case he gets spoiled.)

I just ordered his Happiness Diet book to see if it’s a good patient education tool. Just THINK of all the people who are having trouble getting well.  Their medications aren’t working, they can’t tolerate their medications; therapy isn’t working, they don’t like their therapist.  I wonder how many could help heal themselves by thinking of food as therapy– and start making their brains healthier by eating nutritious (and delicious) food!

Do tell me what you think after you look at all of this stuff.

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June 17, 2016

Free webinar on getting off opioids next week — offered by CIRPD

See below for the topics and schedule for a series of (free) summertime webinars sponsored by  the Canadian Institute for Relief of Pain and Disability (CIRPD).  They’ve got some excellent and expert presenters lined up.   The first one is on a technique for reducing dependence on opioid medications — on Wednesday next week!

I have been on the CIRPD board for a couple of years now.  I am impressed with their focus on educating professionals alongside patients as well as their efforts to build a web portal to expedite translation of evidence from academic researchers to real world practitioners.

I am certain there OUGHT to be an analogous organization here in the USA.  One reason why CIRPD manages to survive is that it has kept getting annual grants from the British Columbia government’s “gaming” revenue.  Seems like a good use of that money!

See much more at www.cirpd.org — where you can also register for one of the webinars shown below.  Here’s an idea:  Put the ones you like on your calendar now!
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Upcoming (free) CIRPD Webinars

Targeting Pain and Prescription Opioid Misuse with Mindfulness-Oriented Recovery Enhancement (MORE)
Eric Garland, Ph.D., LCSW – Associate Dean for Research and Associate Professor in the University of Utah College of Social Work
Dr. Eric Garland will discuss his research on the clinical benefits and neurobiological mechanisms of Mindfulness-Oriented Recovery Enhancement, a novel therapy designed to target chronic pain and prevent opioid-related problems.
DATE:            June 22, 2016 – 11:00am PDT / 2:00pm EDT

Keeping the Boom(ers) in the Labour Market: Can Existing Workplace Policies and Accommodations make a Difference?
Monique Gignac, PhD – Associate Scientific Director and a Senior Scientist at the Institute for Work & Health
Dr. Gignac will discuss current research on understanding the interplay between accommodation and chronic diseases so employers can better retain older workers.
DATE:            June 8, 2016 – 11:00am PDT / 2:00pm EDT

The Be Well at Work Program: Managing Depression, Absenteeism, and Presenteeism in the Workplace
Debra Lerner MS, PhD – Director, Program on Health, Work and Productivity, Tufts Medical Center
Dr. Debra Lerner will discuss current research on how depression in the workplace affects levels of absenteeism and presenteeism. She will also present strategies for working with employees with depression.
DATE:            June 15, 2016 – 11:00am PDT / 2:00pm EDT

The Difference Gender and Sex Make to Work Disability Outcomes
Mieke Koehoorn, PhD – Professor and Head, Occupational and Environmental Health Division, University of British Columbia
Gender and sex can have an impact on the outcomes of workplace disability. Dr. Mieke Koehoorn will discuss recent research on how gender and sex affect disability outcomes and will provide some practical steps for handling the differences.
DATE:            July 13, 2016 – 11:00am PDT / 2:00pm EDT

Exercise Management for Chronic Fatigue Syndrome – The Evidence and Current Approaches
Suzanne Broadbent PhD – Senior Lecturer, Clinical Exercise Physiology, Southern Cross University
Dr. Broadbent will provide an over view of exercise management for Chronic Fatigue Syndrome and discuss current research describing the most effective types of exercise practices to use.
DATE:            August 23, 2016 – 4:00pm PDT / 7:00pm EDT

Pain-related Distress: Recognition and Appropriate Interventions
Tamar Pincus PhD – Professor in Health Psychology, Royal Holloway, University of London
Many people who live with chronic pain report that they also suffer from low mood, irritability, and withdrawal from activities and relationships. Dr. Tamar Pincus will discuss new research which helps distinguish whether these behaviours are based in depression or pain-related distress.
DATE:            September 20, 2016 – 8:30am PDT / 11:00am EDT / 4:30pm UK

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June 5, 2016

Want to hear my “personal elevator pitch” — and create your own?

I recently developed a brief answer to the question “what do you do?” after watching a 2013 TEDx Talk on “How to Know Your Life Purpose in 5 minutes” by Adam Leipzig.  He called it a personal rather than business version of “an elevator pitch”.  (NOTE: When you’re trying to raise venture capital or make a big sale in business, the elevator pitch is the quick summary you can deliver to a prospective funder or client in the time it takes for the elevator to reach your floor.)

Want to come up with your own personal elevator pitch too?   Get a piece of paper and then watch Adam’s TEDx talk.  His talk isn’t perfect and the process felt kind of forced and dorky — but I went along and did what he asked us to do, including answering out loud. I think I was willing to do so because he started by talking about his 25th college reunion, how unhappy most people were, and how the happy ones differed from the unhappy ones.  And then the actual exercise was surprisingly meaningful and very quick.

Afterwards, Adam pointed out an important feature of the kind of answer he had us design:  it makes most listeners want to ask a follow up question:  “HOW do you do that?”   And then there is an opportunity for a real conversation.

Here’s my answer to the question about what I do (as of spring 2016):

“Because of what I do, people feel inspired to make changes for the better — and because they also feel more willing, prepared, and confident, they actually start doing things in a new way.”

So now, are you curious HOW and WHERE and WHEN I do that?

Doing this exercise was really satisfying.  I keep a copy of my answer handy.  That single sentence has made me feel clearer and calmer inside about the unusual commitments and drive, talents, and unearned gifts with which I was endowed by my maker (thank you God or random chance).  I can feel deep in my bones how much I love serving as a channel through which the new energy that creates better outcomes is released.  Sometimes I think of myself as a “midwife for possibility”.

 

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May 18, 2016

It’s time to establish accountability for job loss

My report on Establishing Accountability to Reduce Job Loss After Injury or Illness (commissioned by the US Department of Labor’s Office of Disability Employment Policy) was originally conceived as a simple effort to lay out the rationale for adding work and participation in life to the list of positive health outcomes.  (I suspect that I was asked to write it because they thought a physician like me would focus on medical practitioners and the healthcare delivery system.)

Almost immediately, it became obvious to me that in order to make a solid contribution to the on-going public dialogue about health outcomes, the paper would have to explore the meaty issues of explicit expectations, accountability, metrics, credible data, rewards for best practices, and incentives for both participation and performance.

Soon after that, the absurdity of discussing expectations and accountability for the healthcare system alone became obvious —because organizations in other sectors of society play a role in the SAW/RTW process, each of which has enough discretionary power to support or thwart it.

Thus, over time, the purpose of the paper shifted to answering this question:  What has to happen in order to engage the professionals at the front-line  — the ones who work directly with affected individuals and make discretionary decisions about how much effort to make and for what purpose — so they start making a real effort to help people stay employed?

Who are those front-line professionals?

(1) Healthcare professionals.  Most of us view our purpose as making accurate diagnoses and providing appropriate treatment.   We are generally not trained to assess work capacity and prevent work disability.  Yet our opinions about work have considerable weight under law, regulations, insurance policies and traditional business practices.  We generally don’t spend much time and energy thinking about issues outside the exam room.

(2) Workplace supervisors or HR professionals.  Their focus is the business of the organization, producing its goods or delivering its services,as well as abiding by company policies and applicable laws. They can decide how much effort to make to help the employee stay at work and keep their job.  With rare exceptions, they are neither aware of the preventable nature of most work disability, nor are they trained how to negotiate and arrange stay at work or return to work plans, identify alternative temporary tasks or reasonable accommodations.  And they are not incentivized to do so.

(3) Claims/benefits administrators.  Their focus is administering the benefit programs correctly, establishing eligibility, compensability, meeting deadlines, making payments, and other requirements. In between these duties, they decide how much effort to make to help the beneficiary/claimant. Like the workplace professionals, with only rare exceptions, they are neither aware of the preventable nature of most work disability, nor are they trained how to negotiate and arrange stay at work or return to work plans, identify alternative temporary tasks or reasonable accommodations.  And they are not incentivized to do so.

Job loss is the third worst outcome of an injury or illness

As I thought about these players and those who influence their behavior, the biggest realization dawned more slowly:  job loss is a potentially devastating secondary consequence of a health-related employment disruption or a failed SAW/RTW process — because it often leads to permanent withdrawal from the workforce.  In fact it is the third worst outcome of a health condition, the other two being death and loss of limb or core functions like sight and hearing.

Yet we have not seen it that way.  Unlike death and serious injury, job loss is generally not noticed.  It’s actually a hidden outcome.  The frequency with which it occurs can only be estimated indirectly — because it is untracked and thus invisible.  When someone loses their job due to long-lasting illness or injury, they often end up leaving leave the workforce permanently, becoming dependent on public benefits programs like SSDI.

Some years ago, a senior Social Security Administration official commented to me that SSDI is the largest insurance fund IN THE WORLD and yet it has no risk management program, no loss prevention program.  Private sector insurance companies view these as core functions of their organizations.  They know they must identify and take steps to reduce risks and mitigate losses in order to meet their responsibilities and stay solvent.

In my view, government should be likewise obligated to take steps to protect SSDI (and the taxpayers who fund it) from the economic consequences of the dysfunctions, inadequacies and gaps in the upstream social structures and programs — because their failures end up on public benefit programs.

Government will make a major contribution to reducing demand on SSDI by:
(1) establishing policy that job loss/withdrawal from the workforce is a very unfortunate outcome of a health problem and should be avoided whenever possible,
(2) enabling all parties to see more clearly when it happens by requiring reporting of these events; and
(3) establishing consequences of some sort when involved organizations are non-responsive (negative incentives such as financial penalties, loss of privileges, or public exposure) or do take appropriate action (positive incentives such as credits, privileges, or favorable publicity).

This combination of outcomes visibility and accountability should then start to shift how parties in the private marketplace choose vendors and suppliers.

How will things look different when there IS real accountability for job loss?  

Implementing the broad range of actions recommended in the Establishing Accountability report will require a significant long-term effort because of their comprehensive, complex, and varied nature.  Taken as a whole, these actions have the potential to create truly transformational change.

Success will mean that more workers living with adult-onset chronic conditions and impairments (acquired disabilities) will be able to stay fully and productively engaged in their own personal, family, and community life; protect their household’s standard of living; remain economically self-sufficient contributors to their local area economy; and avoid dependency on government programs—which will in turn protect their future health and well-being and improve their children’s future prospects.  At the national level, success has the potential to stem the tide of declining labor force participation, lighten taxpayer burdens, and bolster the nation’s social fabric and the vitality of the economy.  All in all, the initiatives proposed make good use of limited government resources.

The ultimate success of the initiative will hinge on the ability of Federal policy leaders and supporters to create and sustain real multi-stakeholder buy-in and enthusiasm for achieving the future vision described in the paper.   A good next step is for the federal and state governments to decide whether and where to start.  It will take time and effort to achieve consensus among key stakeholders that this kind of initiative is necessary, timely, and deserves priority for person-power and funding.  Once that preliminary groundwork is laid, more detailed planning work can get underway.

Whoever you are, I hope you read the Establishing Accountability paper and agree that change and action is needed.  If my suggested recommendations spur you on to creative thinking, you do NOT need to wait for the government to act.  You can start factoring these issues into your decisions about who to collaborate with now.

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May 16, 2016

New study: adherence to guidelines leads to better outcomes

One of the issues raised at the multi-stakeholder Work Comp Summit I attended in Dallas last week (more on that later), was this question:  “Are Treatment Protocols and Evidence-Based Guidelines a Benefit or a Burden?”  Evidence-based medicine (EBM for short) and evidence-based treatment guidelines have been controversial in some quarters, especially when they don’t support popular (and lucrative) treatments.  Skeptics have pointed to the lack of “real world” proof that following these guidelines actually does produce better outcomes.

As a near-miraculous coincidence, we have HARD FACTS to contribute to that discussion as of today. A landmark paper has just been published that will / should attract wide attention — particularly in the regulatory and commercial marketplaces.  The new study says it is describing the development of a methodology for assessing the impact of treatment guidelines — but in so doing it has produced the first tidbits of hard evidence that adhering to EBM treatment guidelines significantly improves outcomes of work-related injury claims, in terms of both medical cost and duration.

There’s an easy-to-read article about it entitled Study Supports Benefits of Evidence-Based Medicine in this week’s on-line Workers’ Comp Forum published by Risk & Insurance.  According to that article, the researchers believe this is the first scientific proof that consistently applied treatment guidelines are more effective in treating injured workers — when compared to non-evidence-based care. If you’re a details type, read the original article entitled A New Method of Assessing the Impact of Evidence-Based Medicine on Claim Outcomes.  It’s in this month’s issue of the Journal of Occupational & Environmental Medicine.

To the methodologists and kvetchers among us – any comments on this merits of the methodology they used?  Do we have an opportunity to IMPROVE the methodology?  And just in case there are any advocates of EBM among us, anyone want to yell YAHOOOOOOO? I do!

The study was supported in part by AF Group, formerly Accident Fund Holdings Inc which owns a family of workers’ compensation companies and is itself a for-profit subsidiary of Blue Cross Blue Shield of Michigan.  It was AF Group’s workers’ comp claim data that was analyzed using ODG’s treatment guidelines.

ACOEM membership includes a subscription to JOEM, so if you know an ACOEM member, ask them to get the article for you.   It may be simpler to purchase your own copy on JOEM’s website.    The authors are Hunt, Dan L. DO; Tower, Jack MS; Artuso, Ryan D. PhD; White, Jeffrey A. MS; Bilinski, Craig MS; Rademacher, James BA; Tao, Xuguang MD, PhD; Bernacki, Edward J. MD, MPH.   Dr. Bernacki works at both the University of Texas and Johns Hopkins University, and has done some superior research in the past on questions of real practical interest.  The full citation is JOEM: May 2016 – Volume 58 – Issue 5 – p 519–524 doi: 10.1097/JOM.0000000000000718.

I sure wish this study had been done based on ACOEM’s Occupational Medicine Practice Guidelines which are the clearly superior product from my (informed) point of view.  That’s the NEXT study that should be done.

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May 8, 2016

Key but hard-to-find esoterica in evidence-based medicine

Mother’s Day Brunch is over, and I am feeling appreciated and loved, though a bit bored and lonely now that the “kids” have left for home.   So I’m catching up on stuff.

I went back to finish reviewing a draft practice guideline via an on-line questionnaire.  The authors wrote that I was selected to participate because of my particular field of expertise.  I started but didn’t finish the questionnaire last month.  When I logged in again today, the software jumped me straight to a question that asked whether I agree with a statement that begins: “There is OCEBM Grade C supporting evidence that ……”

This terminology was only semi-famliar to me, so I Googled OCEBM which wasn’t much help.   I still haven’t found the criteria for Grade C (which implies there exists criteria for Grade A, B, and maybe other grades beyond that too).    More Googling will probably help.  But to be truthful, I decided to give up on this effort.   When the researchers asked me to participate, they didn’t tell me the survey has SIXTY FIVE questions each of which seems to require a whole lotta cognitive work including evaluating a set of brief descriptions of the scientific literature pertaining to the subject of each question.   I am NEITHER an academic type nor a methodologist (a person who critiques the experimental design and analytical methods used in research).

HOWEVER, while Googling around I did find a document  entitled “Understanding GRADE: An Introduction” that MAY BE USEFUL to you.  It was for me.  It succinctly describes  (in LESS than 1,500 words) the steps that developers of systematic reviews and practice guidelines should use to assess and rank the quality and strength of evidence supporting a particular practice or treatment.  This method is widely used in appraising scientific studies.  Worth a read – particularly if you are confused by competing guidelines.

Methodology is KING in evidence based medicine — if the scientific quality of a study sucks, you shouldn’t view the results as reliable/valid/believable — no matter how much you love them.  So if you’re like me and not a methodologist yourself, you need to make sure that the committee that produces an “evidence-based guidelines” has members who really do know that stuff.

In theory, I like the idea of wide participation of experts in development and review of practice guidelines.  But based on my (limited) experience with development of the ACOEM practice guidelines for occupational medicine, the work is so hard, detailed, and time-consuming that it tends to be done by a small group of committed experts who put in a TON of hours, and then send their finished product out for comment.  Part of the reason why I felt so uncomfortable reviewing the practice guideline today is that there was so little background information and context provided to me as a reviewer.  Like:  (a)  what were the 65 questions going to be like; (b) how long would it take me; (c) where are they in the development process, and (d) what use is going to be made of the on-line reviewers’ input?

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November 19, 2015

Early EVENTS influence outcomes: You have power to make good things happen!

Few people realize how important early EVENTS are in determining the eventual outcome of a work disruption due to a health problem, particularly the most common kinds of conditions:   low back pain and other kinds of muscle and joint sprains and strains, depression, and anxiety.

Let’s call this a poor outcome:  a failed medical recovery that results in over-impairment and excessive “disability” accompanied by work absence and loss of employment that could have been avoided.  And let’s call this a good outcome:  the fullest possible medical recovery with the least possible physical or mental impairment and the smallest possible impact on the rhythm of everyday life, including minimal lost work time and continued employment.   Do you agree?

Here’s the exciting “so what” about this news that EVENTS influence outcomes:  all three of the professionals who respond to an individual CAN influence what some of those EVENTS are going to be.  Those three professionals are:  the treating doctor, the workplace supervisor, and the benefit claims handler.  This news means that each of them actually has some POWER to nudge things in a good or bad direction!!

See below for a brief description of why early events are so important, and how the experience of  people destined for lucky or unlucky outcomes differs.  In fact, these ideas are some of the main concepts of the work disability prevention model.  (NOTE:  The scientific articles that support the  evidence-based concepts are briefly noted in parentheses.  Their full literature citations appear in the list of References in our report that recommends the establishment of a nationwide Health & Work Service.)

When a working person’s life is disrupted by a new or changed illness or injury, the first few days and weeks after onset are an especially critical period.  The likelihood of a good long-term outcome is being influenced, either favorably or unfavorably, by some simple things that either do or do not happen during that interval (Bowling 2000; Cornelius et al. 2011; Franklin et al. 2013; Loisel and Anema 2013; Nicholas et al. 2011; Shaw et al. 2013; Waddell and  Burton  2004; Waddell,  Burton,  and  Main  2001).  It  is  the  optimal  window  of  opportunity  to improve outcomes by simultaneously attending to the worker’s basic needs and concerns (Shaw et al. 2013)  as  well  as  by coordinating  the  medical,  functional  restoration,  and  occupational  aspects  of  the situation in a coordinated fashion (Wickizer et al. 2011).

The  way  the  episode  unfolds  over  time  in  all  dimensions — biological,  psychological,  social,  and economic — can have a big impact on the outcome. Events that occur can either mitigate or aggravate existing  risk  factors  in  the  situation,  leading  to  better  or  worse  outcomes.  There  are  usually  many opportunities to actively influence the course of events immediately after onset of a health problem (and  many  fewer  opportunities  later  on),  but  today  there  are  few  resources  devoted  to  finding  and exercising these opportunities.  Most of the current attempts to steer situations to a better outcome are made long after the best opportunities have passed by.

The best opportunity for basic intervention appears to last about 12 weeks or three months (DeWitt 1995; Franklin et al. 2013; Hashemi et al. 1997; Johnson and Fry 2002; Loisel and Anema 2013; Turner et  al.  2008)  although  some  data  shows  it  ending  by  6  months  (Rumack  1987;  Waddell  and  Burton 2004). A modest set of simple services —that embody an immediate, systematic, pro-active, integrated, and multidimensional approach — can mitigate the potentially destructive impact of common injuries, illnesses, and chronic conditions on quality of life among the working population (Burton et al. 2013; Hill et al. 2010; Iles, Wyatt, and Pransky 2012; Kendall et al. 2009; Lagerveld et al. 2012; Loisel and Anema  2013;  McLaren,  Reville,  and  Seabury  2010;  Mitchell  2012;  Nicholas  et  al.  2011;  Shaw  et  al. 2013; Sullivan et al. 2005; Turner et al. 2008; Waddell and Burton 2004; Wickizer et al. 2011).

This new approach will allow people to avoid the kind of adverse secondary consequences of medical conditions that they too often experience today (Institute of Medicine 2001; Dartmouth 2008; Franklin and  Mueller  2015).  Those  consequences  are  not  usually  obvious  until  months  or  years  later,  after unfortunate things have happened. The unlucky ones have received sub-optimal health care, been left with undertreated or iatrogenic impairment, become dependent on opioids, found themselves socially isolated, lost their jobs, withdrawn from the workforce, lost economic independence, and ended up on long-term disability benefits programs or SSDI in order to survive (Darlow 2011; Franklin et al. 2008; Franklin et al. 2014; Franklin and Mueller 2015; Habeck, Hunt, and VanTol 1998; Nguyen et al.)

CLARIFYING KEY TERMS

Figuring out where the opportunity to improve outcomes actually lies will be easier if we first clarify some terms that are often used carelessly or that mean different things to various audiences.

Work Disability vs. Disability
In the world of employment and commercial insurance, the word  “disability” is carelessly used.  In this world, the correct term is often “work disability” –which means absence from or lack of work attributed to a health condition.

According to the ADA, disabilities are impairments affecting major life functions (such as work).  Having a disability need not result in work disability.  This is a core concept embodied in the Americans with Disabilities Act. Similarly, having symptoms or a diagnosis need not (and usually does not) result in work disability.

Medical Recovery vs. Functional Restoration
Medical recovery refers to the resolution (disappearance or remission) of the underlying pathological process. Functional restoration refers to reestablishing the usual rhythm of participation in everyday life including the ability to go about one’s regular daily business: performing necessary tasks and enjoyable activities at home and work, and participating fully in society. Functional restoration often accompanies medical recovery, but not always.  Even when medical recovery is not possible, restoration of function often is.   In some cases, it may require separate and specific professional attention.  Functional restoration may include rehabilitation (broadly defined), the successful use of assistive technology, adaptive equipment, and/or reasonable accommodation in the workplace.

Anticipatory  programs  that  ensure  the  right  things  happen  from  the  start  and  include  early identification of those needing extra support are the simplest and most effective way to prevent later adverse secondary consequences of these conditions. A professional needs to provide the following services throughout the immediate response period (which typically ends with stable RTW or 12 weeks post onset).  These services are not generally available today, especially to lower-wage workers and those who work for small firms:

  • oversee and champion the affected individual’s stay-at-work and return-to-work (SAW/RTW) process until it is successful.
  • conduct a quick initial assessment and planning session that considers the individual’s entire situation, screens for known risks for poor outcomes, helps the individual and/or employer make a  SAW/RTW plan and  support them  in  carrying  it  out;
  • drive towards the best outcome by:
    — expediting and coordinating external medical,  rehabilitative  and  other  kinds  of helping services, including referrals for specialized services as needed to address remediable obstacles in a variety of life domains;
    — facilitating communications among all involved parties, ensuring they get the information they need so everyone has a shared picture of the situation and the goal;
    — taking a problem-solving approach with affected individuals, treating physicians, employers, and payers.

If RTW has not occurred by the time the 12 week period has ended, that should trigger a hand-off  to another professional with broader expertise for a deeper assessment which is likely to reveal the need for a different strategy, revised goals, a new approach, or the involvement of other disciplines.

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October 26, 2015

Medical “red herrings” lead to over-treatment & leave patients suffering

When I give a presentation, my goal is to give a gift to the listeners — some new information, perspective, or insight they might not have had before.  I spend time beforehand, imagining how they see the topic now, what they might be thinking, and how I should structure my talk to take them from “here” to “there.”

It’s very gratifying when they send signals that they “got it.”   The funnest [sic] part about public speaking is seeing people’s eyes light up or heads nod as I speak, or having them come up all excited to talk to me afterwards, or when they send an email — or when they write about what they heard.  It’s particularly graifying when the article a reporter writes matches up with what I hoped they would notice.  All those things were true last week when Keith Rosenblum (a senior risk consultant from Lockton), Dr. David Ross (a neurologist and developer of the NP3 diagnostic testing method) and I gave a presentation at the SIIA (Self-Insurance Institute of America) conference last week.  Our audience was a small group of professionals who work for companies (employers) that are self-insured for workers’ compensation.  Our topic was “How Medical Red Herrings Drive Poor Outcomes and Big Losses— and What You Can Do to Stop Them” .

And in particular, here’s a shout-out to reporter Robert Teachout (wow, a rhyme!) for really GETTING what we were trying to get across in our session.   Robert’s article appeared last Friday in HR Compliance Expert.

Dr. Ross taught the audience about the latest definition from pain experts on the essential nature of pain:  it is an EXPERIENCE put together by the brain after it analyzes and interprets many things.  Pain is NOT a sensation in the body.  He also described why and how “objective findings” on MRI often lead doctors to over-diagnose structural spine problems and provide over-aggressive treatments — because the actual source of the pain lies in soft tissues or the brain itself.

My job in the session was to point out this obvious but often overlooked fact:  doing surgery on the wrong problem is not going to make the patient’s pain and distress go away.  And I introduced the audience to the idea that there are other very common causes of prolonged back pain, distress and disability (summarized as biopsychosocioeconomic (BPSE – bipsee) factors) that may mimic or worsen noxious sensations coming from the spine.  Screening for and dealing with easy-to-treat BPSE factors BEFORE resorting to aggressive testing and treatment makes more sense than waiting until AFTER you’ve subjected the patient to those potentially harmful things.  That’s because MRIs, opioids, injections, and surgeries increase the patient’s certainty that their problem is in their spine while at the same time failing to relieve their pain AND causing side-effects and additional problems.    Keith recommended that employers / claim organizations start screening for the presence of a variety of BPSE factors — and get them addressed — BEFORE aggressive, potentially destructive and definitely expensive treatment even begins.  Screening methods can include simple things like questionnaires, or fancy things like the NP3 testing methods.

In addition, even when surgery IS needed, it makes sense to screen for complicating BPSE issues and address them BEFORE surgery as well as during recuperation — because having clear indications for surgery and being a good surgical candidate doesn’t mean a person is free of the kind of BPSE issues that reduce the likelihood of a good recovery.

I sent Robert, the reporter, a compliment via email that read:  “Robert, you did a remarkable job of capturing the salient facts, important implications, and key take home messages from our session.”  I hope you will read his article — and that you’ll send him a note if you found it informative or helpful

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October 22, 2015

Star rankings for doctors who deliver better outcomes in workers’ comp

I was in the audience for a presentation on “outcomes based networks” in workers’ compensation while at the SIIA conference this week (Self-Insurance Institute of America) in Washington DC.   The two presenters were from Sedgwick (which I believe is now by far the largest workers’ comp claims administrator [claims payer] in the country — servicing mostly self-insured employers) and from Multi-Plan (a huge PPO).

The bottom line is that Sedgwick is now putting INDIVIDUAL treating physicians into ranks, from 5 stars (most preferred) all the way down to 1 star (least preferred) .  HOWEVER, many physicians cannot be ranked because the “n” (number of cases for which the payers have data) is too small to analyze with any statistical confidence at all.  The star ratings are NOT generally shared with the physicians — but I bet doctors who know the rankings exist can ask pointed questions about where they stand.

The two speakers have been deeply involved in developing the data sets and metrics to assess physician performance.  They have also been responsible for packaging that information so people who need to know where to send patients can quickly find the best available nearby doctors.  (I am an informed listener on this topic, having developed a physician “report card” myself with less sophisticated data tools in the late 1990’s.)

The presentations were fascinating, both because of what the speakers DID say, as well as what they DIDN’T say.  The four most important things they DID say (if I heard correctly) were that:
•    Sedgwick’s clients, claims adjusters, and case managers who are making referrals / recommending physicians to care for work-related injuries now have access to a user-friendly website that automatically lists doctors within certain geographies IN ORDER OF STAR RANKING (though the ranking itself is not displayed).  Reality check:  Some locations simply don’t HAVE any super-top-ranked providers.
•    Employers who are able to get most or all of their employees to 4 or 5 star doctors have DRAMATICALLY BETTER RESULTS in terms of medical/functional outcomes, disability duration and cost, including higher patient satisfaction/lower litigation rates.   These employers are seeing roughly 15-20% improvement in the parameters of interest.  I heard later that these are mostly California results.
•    The highly ranked doctors are happy to get the referrals and have NOT been asking to be compensated better when it has been confirmed that they are the best.  The highly ranked doctors also tend to be the ones who do a lot of work comp — so they are attuned to the critical issues that need to be managed.  Personally, I think those who DO deliver the best results SHOULD thrive and prosper as a result — not just get more patient volume.  MANY doctors already feel maxed out!
•    A nice endorsement for occupational medicine specialists in general.  The speakers consider “occ docs” as “primary treating” providers (along with urgent care, internists and family practitioners) rather than as specialists (e.g. orthopedists, pain management).  In general, occ docs rank high.  The speakers said it was because of our specialty’s philosophy of care that puts high priority on employing evidence-based techniques for medical treatment and preventing needless work disability in order to optimize patient outcomes and control total episode costs. They said it’s not a sure shot — there are SOME duds in our specialty — but both speakers agreed that as a rule, occ med physicians are among the best.  (They only mentioned occ med because I specifically asked the question –and that was because I suspected what the answer would be –and wanted the audience to hear it!)

The three most important things I DIDN’T hear the speakers say were:
•    How OFTEN the employers/adjusters/case managers are ACTUALLY choosing docs based on rankings.
•    What FRACTION of all doctors in any given geography they actually are ABLE to rank.  (In other words, how many cases have Sedgwick’s employer clients actually been SENDING to each doctor.).  I wouldn’t be at all surprised if it’s less than 25% of the doctors.  I suspect the unranked doctors’ names are NOT presented first.
•    How many cases the doctor has to have treated before ranking them makes sense or is fair. Very few payers are going to have the volume of information available that Sedgwick and Multi-Plan do.  Buyer beware:  TPAs and networks that want to keep up with the Joneses may CLAIM to have ranked providers — but it takes a large number of cases AND considerable statistical sophistication to do this ranking stuff accurately and fairly.   One catastrophic injury could make even a great physician look bad without appropriate adjustment.   The speakers both acknowledged that getting accurate data and analyzing it in a fair manner has been a big challenge, and that their capabilities for doing so have improved rapidly over the last 5 years.

This IS the wave of the future.  Physicians who discover they are low ranked should find out why — and do their level best not to be defensive, but rather learn and improve from the experience.  Buyers of /payers for services absolutely do have the right — if not the duty — to select suppliers based on the best information at hand about who will meet their legitimate needs.   And physicians are suppliers in their eyes.

Sedgwick got started building their Outcomes Based Networks after participating in a Cornerstone Conversation co-hosted by the American College of Occupational & Environmental Medicine (ACOEM) and the International Association of Industrial Accident Boards & Commissions (IAIABC).  This was a four-way conversation among a small group of key stakeholders:  ACOEM leaders, large payers, large employers, and state regulators on what needs to happen in order to improve access to high quality healthcare and improve outcomes for injured workers, and to reduce unnecessary costs for employers and payers.  A joint project undertaken by ACOEM and IAIABC as a result of that meeting was the production of a Guide to High Value Physician Services in Workers’ Compensation.  You may find the observations and suggestions made in this succinct document helpful — whether you are a chooser, a recommender, a payer or a physician-supplier of medical care services.

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