Workers' comp: Perfect fit for chiropractic

Journal of the American Chiropractic AssociationJul 2000

Workers' comp: Perfect fit for chiropractic

 

According to the National Safety Council, work-related injuries in 1998 cost America more than 80 million lost workdays, at $62.9 billion for wage and productivity losses, $19.9 billion for medical costs, $25.6 billion for administrative expenses, and $12 billion for other employer costs.1 Industries experiencing the highest average number of lost workdays include grocery stores, public safety, hospitals, banking, agriculture, beauty shops, and food service.2

All 50 states have enacted workers' compensation laws. While in most states, workers' compensation insurance coverage is mandatory, it is voluntary in Texas and New Jersey. Different from health insurance, workers' compensation insurance is a no-fault insurance that covers injuries on the job or illnesses resulting from the job. It requires no deductible and pays all approved medical bills. That sounds good, but troubles arise when managed care bureaucrats, industry management, health care professionals, and a multi-cultural workforce try to understand and comply with the broad spectrum of laws.

"There's a lot of confusion out there, especially with the medium-sized employers where the human resource manager also wears the hat of safety manager and accountant," says Fiona Fletcher, DC. "They don't fully understand their responsibilities as employers. I recently had a case where a safety manager from a plant did not know that his personnel were allowed to see chiropractors for work injuries. We had to clarify that."

In some states, one insurance company runs the entire system; in others, several insurance companies are in charge; and in a few, workers' compensation is totally state-run. The system is complex, but gradually improving. For example, many states have attached "right to choose" clauses to their workers' compensation laws. As more employers and employees understand that they have access to the physicians of their choice, chiropractic benefits.

"When South Dakota passed a workers' compensation law that gave people the freedom to choose their doctors, that really helped our profession," says Scott Munsterman, DC. "Our patients were finally able to come see us first. Before that, the employers had the right to choose."

Another advantage of "right to choose" laws is that they allow chiropractic doctors to begin treatment sooner-for better results. "You can more effectively treat patients and manage their recovery that way," Dr. Fletcher adds. "We still see many patients three months down the line because they have not had the results they expected with medical care, or they still have a lot of back pain because their medical doctor took a casual attitude, assuming that rest and time would heal everything. Then again, sometimes I see patients who have had too many medications and invasive procedures that can result in iatrogenesis or medically induced problems that we have to deal with above and beyond the initial injury."

In spite of the fact that chiropractic has proven effective in reducing pain and returning employees to work sooner, medical biases persist. Dr. Fletcher states that even though Minnesota gives employees access to providers of their choice, most seek their employers' advice after an injury. Employers generally recommend the family physician. Most patients she sees immediately following an injury have had previous experience with chiropractic, either personally or through family and friends.

America's medical bias becomes particularly evident with companies that have international investments, says Robert Sherman, Esq., general counsel for the Ohio State Chiropractic Association. The Japanese, for example, advocate the most cost-effective health care provider while their American counterparts lean toward medical doctors. Over the past five years, however, he finds that the effectiveness of chiropractic treatment and the resulting cost savings to employers and insurers are helping to reverse traditional thinking.

"We can get rid of these artificial barriers to access if we can demonstrate our cost-effectiveness in treatment and return to work. Employers are looking for every competitive advantage. While they may discriminate against chiropractors today, if the data show that chiropractors return patients to work faster than any other provider, the artificial barriers limiting chiropractic access will fall. If using chiropractors makes them money they'll use chiropractors, even if they don't like them."

A number of studies comparing medical and chiropractic treatment for workrelated back injury, the most prevalent work-related injury treated by chiropractic, offer promising results. One study concluded that chiropractic offered consistent 2-to-1 superiority,3, and another found that treatment costs in cases managed by chiropractors increased only 12 percent between 1986 and 1989, while treatment costs in cases managed by medical physicians increased 71 percent during the same time period,4. Next to back injuries, doctors interviewed for this article report that the most common injuries they treat are postural-type strains to the neck and upper back and repetitive strain injuries, such as carpal tunnel syndrome and tendinitis.

Anthony L. Rosner, PhD, director of research and education at the Foundation for Chiropractic Education and Research (FCER), predicts increasingly favorable outcomes for chiropractic due to the improved design of clinical trials and research. "[D]ramatic changes are in evidence," he writes in the book Contemporary Chiropractic. "Regarding back pain as assessed by a U.S. government agency, the Agency for Health Care Policy and Research (AHCPR), chiropractic appears to have vaulted from last place to first. According to the 1994 monograph Acute Low Back Pain in Adia, an AHCPR clinical practice guideline, the strength of the evidence found to support manipulation was rated sufficiently high to place this intervention among the first two options (together with the use of analgesics and nonsteroidal anti-inflammatory drugs [NSAIDs]) to be considered from 22 different types of interventions reviewed."5

Over the past 10 years, Dr. Munsterman has seen a steady increase in the use of doctors of chiropractic by the general population. During that same period, he also has seen a consistent rise in the number of patients who are referred to doctors of chiropractic for workers' compensation injuries by medical doctors.

"We are experiencing better relationships," he says. "In our practice, we have an orthopedic clinic set up next to our clinic, so we have open referrals back and forth between the two. The orthopedic surgeons will refer into our rehab program, as well as for care either before or after surgery. And, of course, we do likewise. If we're at a plateau with a patient or it looks like a surgical case of a non-contained disc, for example, well refer to them."

Dr. Fletcher, who has been in practice for five years, also has watched respect for chiropractic grow in the medical community. "Medical doctors or anyone else in the health care field who are willing to look at the evidence, especially recent research, are starting to refer to me. It's more pronounced in the younger generation of medical doctors who may have been exposed to chiropractic and alternative health care during their training, though it is still mostly limited to lowback pain, with some for neck pain and chronic headaches. I believe referrals for other conditions that chiropractic treats, such as chronic tendinitis and shoulder problems, leg pain, arm numbness, or TMJ, will eventually follow as research showing chiropractic effectiveness is more widely broadcast."

As for referrals to medical doctors, both within and outside the scope of workers' compensation, Dr. Fletcher's philosophy is a time-honored one: Two heads are often better than one. "Getting a second opinion can be a good thing, especially if you do not see the expected improvement, or patients cannot return to their previous jobs," she adds.

In addition to treating work-related injuries, chiropractors need to take an active role in the return-to-work process. From the first day of the injury to the first day back and beyond, good communication among doctor, employee, and employer can mean the difference between a safe return and permanent disability. Physical rehabilitation is essential, especially if the job is physically demanding, because a patient off the job for as little as two weeks will experience deconditioning. After injured employees have recovered suf ficiently, employers can play an active role in their recovery by providing transitional, light-duty work so that employees can return to work sooner-and safer.

"There is something very socially and emotionally therapeutic about returning injured employees to the routine of their work, even though they may not be ready to assume the full demands," Dr. Fletcher says.

"Unfortunately, a lot of employers assume that if employees are injured and cannot function fully, they don't want to see them until they are ready to work without any restrictions. That takes longer and makes the return to work harder. As a doctor of chiropractic, I think it is important that I get on the phone with employers to explain the treatments and let them know that I'd like to get the patient back to work four hours a day with light duty. I ask them to provide me with more information about the job and what we can do to get the employee back to work safely." Working with employers in this manner has an added advantage-it provides a natural way to market chiropractic. As Dr. Munsterman puts it, "They get to know you, and through that relationship, you build a reputation." In addition to giving information, Sherman recommends listening, citing the Steven Covey adage to seek first to understand before you are understood" as the best way of approaching employers and promoting chiropractic.

"Before you can dispel any biases, you've got to find out what's on the employers' minds. To do that, you have to ask questions," Sherman explains. "If out of 100 employers only three will talk to you, talk to those three. After you talk to those three, ask them to introduce you to three more. It's a common sales technique. Develop employer advocates who will pick up the phone and call a buddy and say, `You've got to talk to this chiropractor. Look what he's doing for us here.' It's so simple, and yet so hard. Unfortunately, only a small number of doctors will ask."

Dr. Munsterman recommends developing relationships with industry people in the community even before treating their injured workers. "Call the human resource managers, safety personnel, and anyone else who's in charge of the workers. Tell them you'd like to see their process, learn about their return-to-work policy, find out about their light-duty jobs. As a doctor, first and foremost, you want to take care of your patients and get them functional as quickly as possible. When industry people understand that your goals with your patients are the same as theirs-productivity, reduced absenteeism, healthy workers-then the walls start to break down. Of course, their philosophy about chiropractic can range from totally antagonistic to having had chiropractic care ever since they were kids, so you never know what you're going to encounter. And it can take two, three, even four years for the relationship to develop. Whatever the case, be open, ready to educate, and show them you are ready to be of service."

Education is the key, whether teaching employers about the effectiveness of chiropractic, instructing workers on return-to-health guidelines, or learning more about occupational health yourself. Dr. Munsterman, as former president of the South Dakota Chiropractors Association, and John Carr, DC, current president of the South Dakota Board of Chiropractic Examiners, have been instrumental in developing educational opportunities for employers, safety personnel, managed care/case managers, and state officials. Ten years ago, inspired by Dr. Joseph Sweere, they inaugurated a conference with consultants who addressed many aspects of health and safety. The South Dakota Safety Council declined to join them, so the South Dakota Chiropractors Association proceeded on its own. Within three years, the conference was so successful the Minnesota Safety Council (which had taken over the South Dakota Safety Council) asked to be involved.

"It's been a great partnership ever since," Dr. Munsterman adds. "Over the last several years, between 300 and 400 people have attended. Because the primary sponsor is a chiropractic association, our profession is earning broader respect-and that has increased the number of workers' compensation injuries we treat."

Educational opportunities for doctors of chiropractic interested in developing their workers' compensation practice include a diplomate program in occupational health, which Dr. Munsterman recommends. Even if time constraints do not allow for the completion of the diplomate work, he suggests taking a portion of the classes or going for the one year certification.

"There is a plethora of information that pertains to occupational health and how you can build relationships," he explains. "You can then get into doing ergonomic consultations using the biomechanics that we use every day in treating patients, extending that into the workplace and helping in terms of prevention."

Dr. Munsterman says he would like to see greater movement toward prevention of injury by managed care organizations, insurance carriers, and employers. In his state, for example, managed care organizations are taking an aggressive stance by identifying high-risk areas within companies and encouraging employers to develop plans to fix them.

Dr. Fletcher recommends that doctors of chiropractic get involved with local employers to address workplace ergonomics and other work-related health issues, such as schedules and food service. "The reality is that we mostly see people who are having a health crisis, and you cannot talk about prevention at that time," she says. "But when you are getting out of the acute crisis and doing follow-up, you can sit down with a patient and discuss what must be done so that this injury does not happen again. It's the same thing with the employer-after an employee is improving, it's time to call the human resource or safety manager to suggest changes to avoid injury to more employees. Of course, we find a wide spectrum of people-some patients and employers are open to prevention, while some are not. But I believe there is always something we can offer."

Improved relationships with medical doctors, managed care organizations, and employers have resulted, in part, from changes taking place within the profession. In South Dakota, for example, doctors of chiropractic have enjoyed increased credibility due to effective professional guidelines and a peer review system that is the only one of its kind in the state and serves as a model for others.

"Even before workers' compensation and managed care, we started a peer review system that was developed primarily because doctors-chiropractic and medical-were being judged by unqualified personnel who were reviewing their cases. We needed a fair system to review a case record on its merit," Dr. Carr explains. "Our peer review system uses an unbiased party to look at the records and decide whether the frequency and duration of care are warranted and whether the cost is reasonable. As to workers' compensation and managed care specifically, we have set out to select the best guidelines for care. And I state strongly: They are guidelines, and not standards of care.

We don't interfere with the clinical rationale or judgment of a doctor."

The South Dakota Board of Chiropractic Examiners conducted an in-depth study of all the guidelines and then convened state meetings for doctor input. The Board of Examiners chose to oversee the process because, as the licensing body of the state, it could lend "teeth" to the process.

"If somebody has a moderate cervical strain, for example, and a doctor is treating it at a frequency and duration that's excessive, we have the criteria to say that that's above the guidelines and the doctor needs to do a better job of documenting why this case is taking longer. We ask the doctors questions, such as `Can you see the improvement that you think is appropriate? Have you really done the diagnostic workup? Is your treatment effective? Has the outcome assessment been supported?' In other words, is the doctor getting the patient maximum therapeutic benefits so that he can be released from care?"

Later, when managed care and workers' compensation insurers began to impose their own criteria, South Dakota, armed with its own professional guidelines and a strong Board of Examiners, was in a good position to respond to a confusing array of guidelines. "Every one of them was different-and there seemed to be no rhyme or reason," Dr, Carr recalls. "So we sat down with the Department of Labor. We were the only profession that could present recovery and fairreimbursement guidelines. The

Department of Labor liked that; in fact, I can quote the head of the Department of Labor who said that they got more bang for their buck from the chiropractic profession than any other health care profession in our state. We've gotten the reputation with the state that we are leaders. Now, when we do the workers' compensation reviews and give our opinion, that opinion usually stands. In fact, we've been challenged, and it's gone to the Supreme Court in the state of South Dakota and our opinion as far as peer review has stood up as the expert opinion on chiropractic care."

Associations in every state can play a key role in advancing the profession's reputation, but, according to Sherman, the biggest challenge facing associations today is to get beyond reacting and become proactive. "Associations need to look at workers' compensation from two angles. One is the short termwhich is the battle to help your members. You cannot ignore the short term; if you do, you lose your membership. Our biggest problem right now, perhaps of concern only in Ohio, is our own chiropractic consultants who interpret guidelines so restrictively that they essentially refuse to allow treatment for supportive care, ongoing care of chronic conditions for injured workers. If we don't work on that, we will lose our membership. We already have freedom of choice in Ohio, but in states that don't, associations need to work on their immediate access problems. Without that, patients are being steered toward medical providers and occupational medical centers. That's a critical problem for doctors of chiropractic. Occupational medical centers have done an incredible job marketing themselves to employers. Unfortunately, chiropractors have done little. As a result, employers are steering patients to occupational medical centers. Associations must also fight to make sure the patient is informed that they have the freedom of choice to go where they want."

For the long term, Sherman recommends that associations assist with the collection of data and education of membership, especially in areas such as the Degree of Disability Management (DODM), a rating system to track effectiveness at returning patients to work. "This is the new language of workers' compensation and will eventually filter down to the employer. These are benchmarks-reasonable times according to statistical studies-for taking injured workers off the job and returning them to work, based on a specific injury. Those who speak the DODM language will relate best in this new environment. Associations need to give doctors who want to work within this model the opportunity to do so."

Dr. Carr agrees, adding that if associations don't get involved in this, someone else will dictate the standards under which the profession will have to work. "Our main objective is to help the chiropractic consumer get the best possible care. We must have the research to prove our effectiveness; we need that to stand for what we do. If we don't have the documentation to justify what we do, along with research and guidelines like Mercy, for example, we're nowhere. You can brag all you want, but you'd better have it down in writing because that's the way industry is now. We back it up by saying that we will do what it takes to have the consumer of chiropractic care in South Dakota get the best care possible."

References

1. National Safety Council. Workers' Compensation Cases, Injury Facts 1999 dWn, p. 51.

2. How-Ran G, MD, MPH, ScD; Tanaka S, MD, MS; Halperin WE, MD, MPH, Cameron LL, PhD. Back paz prevalence en U.S. industry and estimates of lost workdays, Ameraan Journal of Public Health 1999; 89(7):1032.

3. Kukurin GW DC, DACAN. Chiropractic vs. medical management of work-related back injuries:costcomparison studies of workers' compensation caden. The Digest of Chiropractic Economics, January/February 1995, p.28-34.

4. Jarvis KB, DC; Phillips RB, DC, PhD; Danielson C. Managed care preapproval and its effect on the cost of Utah worker compensation claims, Journal of manipulative and Physiological therapeuties 1997;20(6): 372-376.

5. Redwood D, DC, editor. contemporary Chiropractic, Churchill Livingstone, 1997; pp. 163-187.

6. Mootz RD, DC; Franklin, GM, MD, MPH; Stoner WH, RN, MPA. Strategies for preventing chronic disability in injured workers, topics in Clinical Chiropractic 1999; 6(2): 13-25.

Copyright American Chiropractic Association Jul 2000
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