I spent two very productive days last week at the Workers Comp Research Institute (WCRI) conference in Boston. WCRI plays a unique role in the comp system. Their annual conference, devoid of the usual hucksterism, focuses on the fundamental paradigms of insurance and poses the toughest questions. Some of the answers provided by conference speakers (most of whom are not from WCRI) are both radical and surprising. I find myself relentlessly jotting down notes from topic to topic.
Here are ten paradigm-shifting propositions that I have extracted from my time at the conference. A number of these propositions address the issue of opiate use, perhaps, along with back surgery, the most important cost drivers in the treatment of workplace injuries.
[VERY IMPORTANT DISCLAIMER: These are my interpretations and should not be attributed in any way to WCRI]:
1. Pain is hard to objectify, expensive to treat, and absolutely the wrong focus for treating workplace injuries. Treatment should focus instead on behavioural approaches to pain and the relentless encouraging of maximum feasible physical activity.
2. The comp system, a wonderful success story celebrating its 100th anniversary, is poorly designed to confront the problems in today’s fractured and highly unstable economy.
3. Monopolistic systems for comp (only 4 remain) have unique leverage to solve intractible problems such the cost of drugs in the comp system. Washington state has solved the pharma problem through the aggressive use of generic drugs, the limiting of opiate prescriptions and the imposition of a favorable fee schedule. Alas, these solutions are unlikely to work in states with competitive systems.
4. Most prescriptions for opiates in the comp system are unnecessary, ill-advised and poorly managed. [See below.]
5. Virtually all injured workers prescribed opiates should be evaluated for dependency issues prior to beginning an opiate regimen, drug tested prior to receiving opiates and throughout the course of treatment. Without these pre-conditions, opiate use is full of uncertainty and fraught with danger. (Dr. Janet Pearl has a compelling and well-structured approach to the use of opioids in treatment.)
6. Opiates should come with a written contract and a User’s Manual. Workers should be tested on their knowledge of the benefits and the risks.
7. Most doctors who prescribe opiates have no idea what they are doing, no idea how to manage opiate-based treatment and no clue about the potential for harm. Medical schools simply do not address these issues.
8. Back pain is virtually universal, the inevitable result of aging, and generally is unrelated to workplace trauma. (You might want to read that again for full effect.) To be sure, this is a controversial assertion and involves a complete paradigm shift. Nonetheless, the idea is well worth scrutiny by all parties involved: doctors, payers, injured workers and their families. Conference speaker Dr. James Rainville asserts, among other things, that exercise is the best treatment for back pain.
9. Medical fee schedules lower costs, except when they don’t (e.g.Connecticut, where the schedule appears to be set too high).
10. There is an enormous disconnect between the workers losing their jobs in this recession and the severely limited number of jobs projected for creation over the coming decade. This bodes poorly for the 25 million injured or unemployed workers with obsolete skills who are struggling to return to productive employment.
I recognize that these ideas require much more in the way of detail and documentation. I offer them as a Monday morning stimulant. Consider this posting as a micro-conference on some of the major issues facing the time-worn workers compensation system. I hope it’s a list worth a few moments of your time, as you sip your coffee and prepare for the holiday-shortened week ahead.
Special thanks to Andrew Kenneally, WCRI’s able communications director, for recognizing that bloggers have a role to play in disseminating information about workers comp research and who invited me to attend the conference. I would also acknowledge Dr. Richard Victor, whose penetrating insights animate the entire WCRI world and whose conference-concluding talk (“The Elephant in the Room”) made it well worth the time to stay to the end (see # 10 above).