Medical Decision Making and the Cost of Care

Every employer wants to find the best source of medical care to treat his or her employees. Every insurance company wants the best treatment for injured employees at the most reasonable price.

So let’s talk about the actual determinants of the cost of care and strategies for getting the most out of your workers’ compensation premium.

The diagnosis is the single strongest determinant of cost.
There is little surprise that a broken neck is much more expensive than a broken toe. Any effect on cost by the provider at this point is limited. Certain diagnoses simply need some intense and expensive treatment. If you can get your occupational clinic doctor to make a trip to your company, you might avoid some of the more serious injuries altogether – and that would be a savings.

Medical provider selection is another large determinant of cost.
Occupational injuries are treated by occupational medical specialists, family practitioners, emergency rooms, urgent care clinics and a few dozen others. The industrial fee schedule is set by the state, but the care ordered and performed by different providers for similar injuries can dramatically affect the cost of care. The first difference is how rapidly a correct diagnosis is made. Someone with true expertise in repetitive motion injuries will be able to quickly sort out the case of carpel tunnel from nerve injury in the neck (which may not even be work related).

Doctors with patient, 1999photo © 2009 Seattle Municipal Archives | more info (via: Wylio)

Different medical providers utilize different amounts of resources to get at the truth. I have had the unfortunate experience of reviewing charts of doctors who needed an MRI on virtually any joint injury in order to make a diagnosis. Medical testing should not take the place of a thorough and thoughtful examination of the injury. Costly decisions can also be made by taking the other path and not ordering enough testing. An inexpensive X-ray of the neck will often save needless treatment of mysterious arm symptoms.

Proper utilization of specialists can also be a multiplier on the cost of care. Identifying the patient with a surgical knee should be made early in the case, not delayed until a month or more of expensive therapy has occurred.

Length of care is another major factor in cost.
This depends somewhat on the specific diagnosis. Even within a particular diagnosis there are wide variances in length of care. The expertise of the treating physician has a great influence on this, so logically, arriving at the correct diagnosis early speeds up care considerably. Putting together the best plan of evidence-based treatment also keeps things moving. Sometimes simply knowing the system will eliminate some needless delay. Knowing workers’ compensation regulations or knowing who to call to get special testing lessens both expense and frustration for company and employee alike.

Specific treatments need to be picked with care. They can be useful, wasteful or cause backward progress. Sometimes money spent on expensive testing doesn’t improve or speed care. The classic example is doing an MRI on someone with a low back injury without leg pain in the first week of treatment. This MRI is usually either normal (and adds nothing to the treatment plan) or a bulging disc is seen, which is actually a normal variant, but will considerably slow care once it is discovered. Nerve testing also has a window of time that produces the most useful information.

Physical therapy is everybody’s favorite to debate, and this is a major expense.
The early start of a physical therapy program in the proper patient is absolutely essential to rapid recovery. But who is the proper patient? Many tomes have been written on selecting this patient. Most doctors believe that functional impairment of a body area suggests some physical medicine rehabilitation is necessary. The patient who has palpable spasm in the low back and can’t move is an ideal candidate. If things work fine, and just hurt, therapy may not be needed. The people between these two extremes are the more difficult cases. Sometimes it comes down to instinct (based on years of practice), and someone just looks like they will never recover unless we make them move. Others obviously have a hard time slowing down, even with a serious injury.

Doctor Handphoto © 2009 | more info (via: Wylio)

It probably goes without saying that care must be good to be cost effective. Having the wrong diagnosis, doing the wrong test or wrong operation is sure to add cost quickly. Particularly abhorrent to insurers is doing two months of physical therapy, then doing the test and operating, only to start therapy all over again post op. Marginal care also results in impairment or disability ratings, which are another significant expense.

We could continue this discussion for awhile longer, but you get the idea.

Take your injured employee to the clinic or the hospital – whichever is more appropriate. Find a thoughtful provider who makes reasoned decisions and to whom you can talk. Seek a relationship with this provider. Pay attention to the care – is it working? Is it necessary and appropriate? Be willing to get involved and ask questions. Your employees will get better care because of that, and you will know your workers’ compensation dollars are well spent.

Stay well,

Dr. B


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