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John F. Marr
Vice President, Claims
Maine Employers’ Mutual Insurance Company
 If
you’ve been handling workers’ compensation claims for
more than just a few years, you’re bound to have suffered the
frustration of dealing with the scourge of the chronic pain claim.
More often than not, they are a mysterious soft tissue malady or
the aftermath of a failed surgery with no end in sight. The doctors
are fatigued and trying to pass the riddle to someone else. The
employer is convinced nobody cares or knows what they are doing.
In the meantime, there’s an injured worker who questions whether
life is worth living when you’re suffering such pain.
Over the years, we’ve seen the treatment come full cycle from
outpatient plans to inpatient clinics and back again. The costs
have gone up, but the success rate hasn’t changed much. Inpatient
programs run in excess of $30,000, and the cumulative costs of outpatient
programs aren’t much less.
In the end, the only winners are the practitioners who are reimbursed
regardless of the long-term outcome. Typically, at discharge the
injured worker will say he feels better and the provider chalks
it up as a victory and cashes the check.
The problem is that the injured party isn’t back to work,
and we are still sending weekly indemnity checks.
In recent years, a new wrinkle has been added to the pain management
process. We now have the medical community convinced that pain shouldn’t
be. If you can’t cure it, at least you can cover it up. Give
them endless scripts for Oxycontin, morphine pumps or like medications,
and send them away.
Paying for palliative drugs
At Maine Employers’ Mutual Insurance Company, in 1999, we noticed
a spike in the average amount spent for prescription drugs. We sifted
through the data. It didn’t take long to figure out we were
paying for palliative drugs as opposed to curative medicine.
To be sure, there was some effective medicine going on. However,
it was obvious there was a disturbing rise in the use of heavy-duty
narcotics. We continued to sift the data and found some cases of
abuse, and referred those to our Special Investigations Unit.
The majority of cases, not surprisingly, were legitimate but questionable
from the standpoint of practice. We detected a pattern of certain
doctors getting people into the use of strong painkillers early
on at the first sign of heightened discomfort. We noted that specialists,
once finished with the scalpel, were quick to refer patients on
to other practitioners to deal with the pain syndrome. Everyone
except the banker and the attorney was frustrated.
Growing tired of paying for programs that didn’t work, MEMIC
collaborated in further research with Peter Rousmaniere, a highly
regarded workers’ compensation activist of national renown.
After mining tons of data and examining hundreds of files that had
gone sour, we detected tell-tale signs that could be used to alert
us to adverse potential and the likelihood of a case being referred
to a pain management program. Armed with this knowledge, we decided
to take advantage of our strategic position in Maine and create
a tailored approach.
Mr. Rousmaniere used the research to formulate a specific practice
model and has created Pain Disability Management LLC. MEMIC is the
pilot site and Maine is the incubator.
MEMIC has the bulk of the comp business in the state, and the manageable
size of the population of Maine makes this a perfect match. In cooperation
with PDM we have created MEMIC’s Individualized Multi-Disciplinary
Treatment Program to deal with the problem and the expense of intractable
pain.
Early-warning signs
The plan and practice are simple. By paying attention to the early
warning signs, we make an early referral to the program. Some of
the common signs are:
•Prolonged use of narcotics.
•Searching for the “right” doctor.
•Personality swings.
•Sleep disorders.
The claim handler, along with the nurse case coordinator, is critical
in the early detection process since so many of the signs are objective.
However, we perform a data scan on a monthly basis to screen drug
usage and chart the injured workers to help alert the claim handler.
Once we have a concern, we set the plan in play.
The first step is to speak with the injured worker and make known
that we share a common objective: to get them over the pain, better
and back to a normal life style, including return to work. Oftentimes
it is necessary to persuade them to leave their current practitioner.
There’s an element of trust that must be gained to make this
work. They have to understand they are going to be the beneficiaries
of the process.
PDM has developed teams of clinicians with proven commitment and
experience in helping injured workers become more productive and
fulfilled in their lives. There are a multitude of specialists who
might be called upon. PDM coordinates the involvement and assures
that care is prompt, cohesive and the communication complete.
Crucial first steps
The first encounter with the IMTP is pivotal. The injured worker
is initially referred for a one-day assessment by a team of clinicians.
The worker is likely to be seen by a doctor of occupational medicine,
a physical therapist, a psychologist and other specialists as deemed
appropriate.
The worker completes special questionnaires dealing with pain issues
and goes through a series of simple tests. They meet with the team
of clinicians upon completion of the protocols and discuss the findings
and next steps. The team prepares an individualized treatment plan,
drawing upon a wide range of options to meet the patient’s
unique situation.
It is not a forgone conclusion that the team recommend an IMTP
for all or even most of the workers it assesses. The team might
recommend another direction, such as conventional work hardening,
further medical work-up on a previously undetected medical problem,
or simply return to work. Because the team is expert in treating
injured workers, it is fluent in all ways of recovery from injury.
An IMTP typically runs several hours every workday for about three
weeks to help break the disability cycle. The worker has to be motivated
and committed to attend every day, fully participating in the treatment
plan. Typical elements are individual and group activities, physical
therapy, counseling and self assessments. We encourage visits to
the worksite with problem-solving exercises included. On a daily
basis, the patient will record her or his experience with pain,
sleep and mood.
Much of the patient activity in an IMTP is behaviorally oriented
since pain experiences are intimately intertwined with daily mental
and physical activity. Upon conclusion of the program the injured
worker participates in an assessment of the program and develops
a plan for follow-up at work and home. Often it is necessary to
have retraining and job placement as part of the plan.
Setting the right direction
The benefit of an IMTP is one of taking control and setting the
direction. Experience teaches us that when we are unwittingly involved
in pain management programs, we seldom come away pain free. When
we set the pace, we usually win the race.
The IMTP may not be a panacea, but it is certainly better than
the bitter pill we’ve been forced to take with most typical
chronic pain management programs.
John Marr can be reached at jmarr@memic.com
or (207) 791-3410.
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