Monthly Archives: September 2016

September 26, 2016

Two faulty beliefs about IMEs & impartial physicians

Patients and their advocates tend to be skeptical about independent medical opinions.   There are legitimate reasons to be concerned.  However, I want to point out two common but faulty beliefs that create UNNECESSARY distrust in this aspect of disability benefits and workers’ compensation claim management systems.  First, despite patients’ faith in their own doctors, treating physicians as a group are NOT a reliable source of accurate and unbiased information.  Second, although justice IS even-handed, impartial physicians should not find for both sides equally.

Based on my experience leading teams on three consulting projects that audited the quality of more than 1400 reports of independent medical evaluations and file reviews I definitely share MANY other concerns about the quality of the reports, the process by which they are procured, and the physicians and other healthcare professionals who provide them.  But these two particular issues are not among them. Read on to find out why.

FACT:  As a group, treating physicians are NOT a reliable source of accurate and unbiased information

First is the incorrect belief that the treating physician is the BEST place to turn for an “independent” opinion because they are highly trained professionals who are familiar with the patient’s case.   There are two main reasons why this is incorrect:

(a) There is considerable variability in the appropriateness and effectiveness of the care delivered by practicing physicians, and patients are not in a good position to assess it.  Evaluating appropriateness and effectiveness is admittedly a difficult and imperfect process, but the best way we know to do it is through the eyes of another physician who is equally or more expert in the matter at hand — and has no axe to grind and no financial stake in the outcome:  neither a friendly colleague nor a competitor.

(b) In medical school and residency, physicians are often told they should be “patient advocates” — but that instruction may not include a definition of advocating. (True for me and many others in physician audiences when I have asked about it.)  Patient advocacy sometimes turns into doing or saying exactly what the patient wants, not what is actually in the best interest of the patients’ long term health and well-being.  (I call this being a McDoctor.)  Particularly in today’s world with fierce competition between medical groups for patients and the use of “patient satisfaction scores” in calculating physician bonuses, that is true.  The data is clear:  treating physicians provide unnecessary antibiotics, pain medications, inappropriate treatments and are even willing to even shade the truth on reports in order to keep their patients happy.

The reason why arms-length or “third party” physicians are preferred as the source of opinions is to protect patients from harm from EITHER the “first party” (treating physician) OR the “second party” (the payer — which has an OBVIOUS business interest in controlling cost).  Judges, public policy people, and I get uncomfortable when the WAY the arms length physician is SELECTED is distorted by the interests of either the first party or second party.

FACT:   Impartial physicians’ opinions should not find for both sides equally

Second is the belief that “truly” impartial physicians should come down on the side of the patient vs. insurer half the time.  Or call it 50:50 for plaintiff vs. defense.  This belief is WRONG because cases selected for review or IME have been pre-selected by claims managers and case managers.   These professionals may not be healthcare professionals but because they see thousands of cases and become very familiar with the medical landscape, they ARE often more experienced OBSERVERS of the process of care than many physicians. They learn to recognize patterns of care that fit normal patterns, and care that is unusual.  These days, they are often expected to use evidence-based guidelines to identify outlier cases.  Those who focus on specific geographical areas come to see which doctors get patients better and which ones don’t.

The VAST MAJORITY of the time, there is no need / no reason to refer a case for independent review.  The treating physician IS doing the right thing;  the diagnoses, prescribed treatment, and causation determination (if work-related) DO appear reasonable and appropriate.   If the claims managers/ case managers see no problems or have no questions, they don’t refer the case for outside review.  If it aint busted, why fix it?

So as a rule of thumb, you can assume that some feature or another in ALMOST EVERY case being sent to review has RAISED QUESTIONS in the mind of an experienced observer of the care process.  The reason WHY the case is REFERRED is because that observer has only a very superficial knowledge of medicine.  They need an adviser — an impartial and expert physician who can evaluate the clinical facts and context and then either CONFIRM that the treating physician is doing the right thing or VALIDATE the claims/case manager’s concerns.

When claims/case managers are doing a good job selecting cases for referral, we SHOULD expect that MOST of the decisions will favor the insurer / defense. The more expert the claim/case managers are, the MORE LIKELY the independent physicians will agree — because the claims/case managers are accurately detecting real problems and concerns.

(By the way, a similar ratio seems to apply in the court system.   A judge once told me that MOST defendants ARE guilty – because the prosecutors don’t want to waste their time and public funds bringing cases to trial if they think the defendant is innocent – or if they simply think they will lose.    A perfect example  of this pragmatism is the FBI’s recent decision not to prosecute Hillary Clinton.  The Director made it clear that they didn’t want to waste the taxpayers’ money on a case in which they wouldn’t be able to convince a jury “beyond a reasonable doubt.”)

Consider this:  If you are a treating physician who FREQUENTLY ends up with your care plans rejected by claims managers and utilization review, consider the possibility that YOU stick out.  Your care patterns may be more unusual than you realize.  Your outcomes may be worse than your colleagues’.

Sadly, some physicians discredit input from independent experts in front of patients.  They THINK they are advocating for their patient — on a social justice crusade, but end up harming their patient instead — by teaching them they have been wronged, are a victim of “the system,” and a helpless pawn.  This message:

  • increases distrust, resentment and anger (which in turn worsens symptoms);
  • encourages passivity rather than problem-solving (which in turn increases the likelihood of job loss, permanent withdrawal from the workforce, and a future of poverty on disability benefits).

A former president of the Oregon Medical Association said he counsels patients this way:  “Your two most important treasures are your health and your job. And  I am here to help you protect both of them.”  Healthcare practitioners really ought to do everything they can help their patients find a successful way out of these predicaments, instead of allowing them to believe they are trapped.  The “system” is not designed to solve their life predicament for them — they may have to do it themselves.  The physicians’ care plans should consist of those treatments known to restore function and work ability most rapidly.  Physicians should encourage their patients to tell their employer they want find a way to stay productive and keep their jobs.  And if the employer won’t support them, physicians should counsel their patients to try to find a new job quickly — even if it’s temporary or they have to make a change to the kind of work they do.

Adapting to loss is a key part of recovery.   When I was treating patients, I could tell they were going to be OK when they said with pride “I’ve figured out how to work around it, and life is getting back on track.”


September 9, 2016

Pithy 4-min Video & 1-page Manifesto for you to use

Mathematica just released a 4-minute video of me pointing out why the work disability prevention model is important — in plain language.  The video was made at the request of the US Department of Labor’s Office of Disability Employment Policy (ODEP).  The main messages in the video are:

  1. MILLIONS of Americans lose their jobs every year due to injury and illness;
  2. Worklessness and job loss have been shown to harm physical and mental health as well as personal, family, social, and economic well-being;
  3. Worklessness and job loss should therefore be considered poor healthcare outcomes;
  4. Unexpectedly poor outcomes can often be prevented and there is good research evidence about how to do that;
  5. Changes need to be made so that vulnerable people get what they need at the time when they need it — and as a result are able to have the best possible life outcome, stay in the workforce, and keep earning their own living.

In addition, the video also explains WHY and HOW some people have unexpectedly poor outcomes of conditions that do not normally cause significant work disruption and job loss.  Unless you’re in my line of work, it is hard to understand why things turn out badly in some cases and not in others — especially if they looked exactly the same at the beginning.

The video is loosely based on a one-page Work Disability Prevention Manifesto I wrote.  I put a draft of it on this blog last spring and got many useful comments.  After many revision cycles, it is now as succinct and compelling as I know how to make it.  ODEP had no hand in the Manifesto; it’s my independent work.

I’m glad I can now share these two items with you because the WORLD needs to know more about these issues—and most PEOPLE in the world have a very short attention span and no interest in the topic to begin with.   I hope you will pass this stuff along to the people whose thinking you want to change or whose buy in you need. Then maybe THEY will pass it along to others as well.  Social norms ONLY SHIFT when people share powerful mind-opening ideas with one another.

Lastly, let’s all stop speaking ABOUT these problems.  It is time for us all to start speaking FOR action and FOR changes.

WORK DISABILITY PREVENTION MANIFESTO
©Jennifer Christian, MD, MPH August 2016

Preventable job loss demands our attention

  • Millions of American workers lose their jobs each year due to injury, illness or a change in a chronic condition.
  • Preserving people’s ability to function and participate fully in everyday human affairs, including work, is a valuable health care outcome, second only to preserving life, limb, and essential bodily functions.
  • A new medical problem that simultaneously threatens one’s ability to earn a living creates a life crisis that must be addressed rapidly and wisely. Most people are unprepared for this double-headed predicament. It can overwhelm their coping abilities.
  • When medical conditions occur or worsen, especially common ones, most people are able to stay at or return to work without difficulty. However, many prolonged work disability cases covered by private- and public-sector benefits programs began as very common health problems (for example, musculoskeletal pain, depression, and anxiety) but had unexpectedly poor outcomes including job loss.
  • Loss of livelihood due to medical problems is a poor health outcome. Worklessness is harmful to people’s health, as well as to their family, social, and economic well-being.

Why do such poor outcomes occur?

  • Medical conditions by themselves rarely require prolonged work absence, but it can look that way. Both treatment and time off work are sometimes considered benefits to be maximized, rather than tools to be used judiciously.
  • Professionals typically involved in these situations (health care providers, employers, and benefits administrators) do not feel responsible for avoiding job loss.
  • Unexpectedly poor outcomes are frequently due to a mix of medical and nonmedical factors. Diagnosed conditions are inappropriately treated; others (especially psychiatric conditions) are unacknowledged and untreated. The employer, medical office, and insurance company (if there is one) operate in isolation, with little incentive to collaborate.
  • Without the support of a team focused on helping them get their lives back on track, people can get lost in the health care and benefits systems. With every passing day away from work, the odds worsen that they will ever return. After a while, they start to redefine themselves as too sick or disabled to work.
  • When people lose their jobs and do not find new ones, they barely get by on disability benefits and are vulnerable to other detrimental effects.

How can we fix this problem?

  • Good scientific evidence exists about how unexpectedly poor outcomes are created, how to avoid them, and how health care and other services can protect jobs.
  • Health-related work disruption should be viewed as a life emergency. Productive activity should be a part of treatment regimens.
  • When work disruption begins, it can be both effective and cost-beneficial to have a coordinator help the individual, treating physician, and employer communicate and focus everyone’s attention on maximizing recovery, restoring function, accommodating irreversible losses, and making plans for how the individual can keep working, return to work, or quickly find a more appropriate job.
  • We must urgently establish accountability for work disability and job loss in our workforce, health care, and disability benefits systems and build nationwide capacity to consistently deliver services—just in time, when needed—that help people stay at work or return to work.

September 7, 2016

Is this disability porn? Lovely duet by disabled dancers

A physician colleague sent me a link to the video entitled “Hand in Hand Dance.”  It features two Chinese dancers, each with a different impairment.  The woman has lost one arm; the man has lost one leg.

As a former dancer myself who has never seen obviously disabled dancers, I was curious.  So I watched the video — and am embarrassed to admit I was surprised at how aesthetically pleasing it is.  Their duet is beautiful and very professional.  The emotional story is clear and compelling:  loss, grief, encounter, relationship, attraction, love, joy.  But for me, the thrilling part was seeing their mastery and pure enjoyment of dance itself.  They use their bodies both gracefully and athletically — exulting in their youth, capabilities, talent, strength, life, and love,

Some people in the disability community are offended by what they call “disability porn”.   You can read about it here  and here.   Is that what this dance video is?  I don’t think so.  These two deserve admiration because they have done the work and have the talent to create an artistically satisfying dance.   But on the other hand, insensitivity is in the eye of the receiver, not the sender.  If I’ve got it wrong, please let me know — and tell me why.

See what you think:  http://biggeekdad.com/2013/09/hand-hand-dance/


September 4, 2016

“Upstreamist” reduces healthcare utilization by providing a lawyer!

In an effort to reduce demand for healthcare services among high utilizing homeless vets,  Rishi Manchanda, MD did NOT ask to hire more health care professionals.  Instead, he successfully persuaded the West LA Veterans Administration Medical Center to bring in a public interest lawyer once a week.

The purpose was to identify vets with unmet legal needs that were in turn creating / driving demand for health care services.   That bet paid off.  Healthcare utilization decreased by 24% among the 139 homeless vets who participated.   The pilot program cost an average of $525 per person, and the vets gained access to more than a half million dollars in increased disability and other cash benefits.    Helping the vets resolve stressful legal, administrative, or financial barriers to housing, for example, made a big difference.

Manchanda is an advocate for moving “upstream” in order to achieve the so-called “quadruple aim” of healthcare:   better care, lower total medical costs, as well as increased patient and physician satisfaction.   [The Institute for Healthcare Improvement uses the term “triple aim” which ignores the issue of professional satisfaction.]  In Manchanda’s view, the KEY to achieving the quadruple aim is the integration of “social determinants” in health care.

Manchanda asserts that physicians are forced to work  with one hand behind their backs unless social determinants are addressed.  “Unlike all of our peer nations, we have more spending on health care than social services.  That actually creates a scenario where you have DOCTORS talking about moving upstream.”  In fact, he now calls himself an “upstreamist.”    You can read more about his remarks which were made at an AMA conference on radical redesign in health education.

Public health researchers have been intently studying what is called health inequalities or health inequities.  The country of Ireland has a particularly straight-forward definition:  “Health inequalities are preventable and unjust differences in health status experienced by certain population groups. People in lower socio-economic groups are more likely to experience chronic ill-health and die earlier than those who are more advantaged.”  In the U.S., health status varies with race and culture as well as with socio-economic status.

In the US, the phrase “social determinants of health” refers to the EXTERNAL CONTEXT in which a person lives such as safe housing, local food markets, access to educational, economic and job opportunities, access to healthcare services, public safety, cultural and social norms and attitudes, exposure to crime and violence; housing and community design, natural environment, etc.. All of these things have been shown to have an impact on health status.  (See more below).

Social determinants do not include INTERNAL PERSONAL FACTORS like a person’s life philosophy, the things they or don’t know, their past life experiences, preferences, attitudes, motivations, intentions, values, beliefs, emotions, or other psychological dynamics.  Obviously, both internal personal and external factors influence people’s behavior and what happens (outcomes).  Thus, our more comprehensive BPSE model of sickness and disability includes the ENTIRE context:  BOTH external AND internal personal factors.  (BPSE = bio-psycho-socio-economic)

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From the U. S. Government’s Healthy People 20/20 website:

Understanding Social Determinants of Health

Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Conditions (e.g., social, economic, and physical) in these various environments and settings (e.g., school, church, workplace, and neighborhood) have been referred to as “place.”5   In addition to the more material attributes of “place,” the patterns of social engagement and sense of security and well-being are also affected by where people live. Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.

Understanding the relationship between how population groups experience “place” and the impact of “place” on health is fundamental to the social determinants of health—including both social and physical determinants.

Examples of social determinants include:
•    Availability of resources to meet daily needs (e.g., safe housing and local food markets)
•    Access to educational, economic, and job opportunities
•    Access to health care services
•    Quality of education and job training
•    Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities
•    Transportation options
•    Public safety
•    Social support
•    Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
•    Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community)
•    Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)
•    Residential segregation
•    Language/Literacy
•    Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)
•    Culture

Examples of physical determinants include:
•    Natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)
•    Built environment, such as buildings, sidewalks, bike lanes, and roads
•    Worksites, schools, and recreational settings
•    Housing and community design
•    Exposure to toxic substances and other physical hazards
•    Physical barriers, especially for people with disabilities
•    Aesthetic elements (e.g., good lighting, trees, and benches)

By working to establish policies that positively influence social and economic conditions and those that support changes in individual behavior, we can improve health for large numbers of people in ways that can be sustained over time. Improving the conditions in which we live, learn, work, and play and the quality of our relationships will create a healthier population, society, and workforce.