How Medical Over-Diagnosis Drives Claims Costs

At the 2015 SIIA Annual Conference, a panel presented a session entitled “How Medical Red Herrings and Over-Diagnosis Drive Poor Outcomes and Big Losses”. The panel was:

• Dr. David Ross, Chief Medical Officer from NeuroPas Global LLC
• Keith Rosenbloom, Senior Strategist Workers Comp and Risk Control from Lockton Companies LLC
• Dr Jennifer Christian, President of Webility Corporation

Over the last 20 years there has been a significant increase in treatment for back pain. This includes:

• 600% increase in MRIs.
• 400% increase in spine injections.
• 300% increase in back surgeries.
• 500% increase in opioid prescriptions.
• 300% increase in people disabled due to back pain.
• $150 billion per year in medical treatment costs for chronic pain.
• US is #1 in the world in dollars spent per person in the healthcare system.
• US is #37 in quality of care, so more money does not equal better care.

In spite of this significant increase in treatment, outcomes have not improved as evidenced by the corresponding increase in people disabled due to chronic pain in this country.

There are a number of issues that can cause back pain that are not related to the back. Even if the pain is due to a condition originating in the spine, diagnostic testing often identifies benign issues that are not causing the symptoms and the treatment shifts to those benign conditions (such as a disc bulge).

Spinal MRI findings are more often than not common adnormalities that are due to aging and the normal degenerative process vs injury. Most common injuries do not cause spinal changes or major joint changes. The National Institute of Health says that low back pain cannot be classified using MRI findings or nerve testing alone. Relying on an MRI as a diagnostic tool has resulted in significant overdiagnosis which is in turn leading to significant overtreatment which fails to resolve the injured worker’s complaints.

According to many studies, the best predictors of chronic pain are poor coping behaviors, psychiatric comorbidities and other psych-social issues instead of objective phycial injury. The most powerful healing tool is the mind. Most physicians are not trained to understand pain and what is causing it. The focus is on treating the symptoms, not the cause, which only precipitates the cycle of overtreatment and overdiagnosis.

There are two main groups of high-cost claims. The true catastrophic injury claims including spinal cord injury, major burns, major amputation, or brain injury. The other category is creeping catastrophic claims whereby a relatively minor injury continues to develop over time. A large excess carrier indicated half their claims over $1 million incurred involve creeping catastrophic claims.

There are both positive and negative BPSE (Bio Psycho Social Economic) factors that can impact a claim. Among the negative ones are things like delayed access to medical care, adverse childhood experiences, a toxic workplace, overreacting to adversity, fear of pain or reinjury, weak coping skills, financial worries, perceived injustice, and learned helplessness.

To reduce the costs of back pain, we need to take action to make the right things happen more often, and make the wrong things happen less often. It is important to be prepared and set up a program ahead of time so your plan is carried out consistently every time.

To make the right things happen more often, it is important to assure that BPSE factors are identified and addressed BEFORE a MRI or other invasive intervation has taken place. You should arrange for BPSE services  designed to increase coping skills and help injured workers better understand their health condition and disability.

Back surgeries should only be done after an adequate trial of conservative treatment. Back surgery has not been proven to be a good remedy for low back pain alone. The failure rate of surgery to treat back pain is very high because the condition being treated with surgery (disc bulge) is not actually the source of the pain.