Reprinted with Permission
While worker's compensation systems vary widely from state to state, most systems have tended to dismiss the value of psychological testing in evaluating patients injured on the job. This article highlights practitioners who are educating decision makers in the worker's compensation arena on the benefits of evaluating underlying psychological and social factors that may affect the patient’s response to treatment.
For the past several years, Patrick Waring, MD, has been speaking with case managers, adjustor trade groups, independent insurance companies, and large national insurance companies who carry workers compensation insurance in the state of Louisiana to explain the benefits of psychological evaluation in diagnosing injured workers. Waring specializes in interventional pain management at The Pain Intervention Center in greater New Orleans. The clinic, which specializes in interventional pain management techniques, serves all segments of the population, including worker's compensation patients.
“My experience is that adjustors and payors often don’t want to delve into issues other than the specific work injury reported by the patient,” says Waring. “They feel that doing so might prolong the claim beyond the physical injury reported. They’re concerned about increased costs, and they tend to believe that the whole area of psychological evaluation is a very subjective one. Yet in denying such evaluations, they often are denying the course of care that would actually help the patient return to work soonerand that would in fact be the most cost-effective approach.”
“A person with severe depression, for example, is not likely to respond well to major back surgery,” says Waring. “If you haven’t take the time to identify this psychological factor up front, you might be embarking on an expensive surgery or course of treatment that won’t help the patient and that may lead to the added expense of treatment for a failed back surgery.”
In his practice, Waring administers the BBHI 2 (Brief Battery of Health Improvement 2) test to all worker's compensation patients. This brief psychological assessment, which is normed on a population of pain patients, is designed for use with medical patients to help identify bio/psycho/social factors that may be contributing to the patient’s pain experience.
When speaking with decision-makers, Waring discusses some of the primary benefits the test offers. “The BBHI 2 test helps provide objective information on a number of issues that are particularly relevant in the diagnosis and treatment of worker's compensation patients, such as perceived disability, pain fixation, satisfaction with the treating physician, and compensation focus,” says Waring. “All of these factors tend to come into play more with worker's compensation patients than the average indemnity or HMO patient, and may stand in the way of a positive therapeutic response.” In addition to the test’s usefulness as a screening tool prior to interventional treatment, Waring points out its value as an outcomes measure to assess the patient’s progress.
Since he began talking with key players in the Louisiana worker's compensation system, Waring has seen some change in attitude. “They are beginning to understand that you can’t separate mind and body issues; that psychological factors such as the patient’s motivation play a role in treatment effectiveness,” says Waring. “They are recognizing that these issues need to be taken into account, especially when you are considering a highly invasive therapeutic procedure such as spine surgery.” After meeting with Waring, some adjustors have become strong advocates for psychological testing as a necessary aspect of evaluation. He also notes that some adjustors and case managers are now asking for the results of the BBHI 2 test because of the objective information it provides.
“Often, physicians feel they shouldn’t need to explain themselves,” Waring comments, “but clearly there are benefits in doing so, as a means of educating others so that we can work together more effectively to care for patients.”
In Florida, Albert Ray, MD, is taking steps to influence change in the worker's compensation system as well. Ray serves as medical director at Pain Medicine Solutions in Miami. About 80% of the clinic’s patients are worker's compensation cases.
Ray presents seminars on pain medicine to case managers, adjustors, and nurses who deal with worker's compensation patients through managed care companies that contract with the clinic. He has increased the incentive for participation by arranging for the course to carry one hour of state-approved continuing education credit.
Ray suggests an irony in the worker's compensation system: While guidelines and regulations place an emphasis on making fact-based case recommendations, many decision-makers are operating on false premises about injured workers in general.
“One of the misconceptions I address in the class is the belief that many worker's compensation patients don’t want to improve,” says Ray. “Decision-makers often feel that the worker’s complaint may not be legitimate, that the patient may be exaggerating symptoms for secondary gains. While this is true in some cases, statistics show that the majority of injured workers do want to get better. If the patient hasn’t responded to treatment, it may be because non-structural factors haven’t been addressed.”
Ray also points out to attendees that making fact-based decisions about patients depends on gathering all of the relevant data by conducting a comprehensive pain evaluation. Such an assessment looks not only at structural issues but also at psychological, emotional, and cognitive issues, including the role of cellular memory of pain. He explains the benefit of identifying underlying factors that may present obstacles to the patient’s progress before reaching a diagnostic conclusion.
Ray provides three criteria for determining when a comprehensive pain evaluation is recommended: 1. if the patient is not responding to treatment in the expected time frame; 2. if the patient is declared a non-surgical candidate; and 3. if pain is the patient’s major complaint.
In addition, Ray emphasizes the value of using an interdisciplinary treatment program such as the one employed at his clinic. “The facts show that this approach is frequently more effective than having the patient see various practitioners, each of whom is focused only on one area of specialty. When practitioners are operating independently of one another, communication among them may be limitedor it may fall on the case manager to review all of the practitioner’s notes and try to reach a conclusion about the best course of action for the patient.”
“In an interdisciplinary treatment program such as ours, the physician, physiatrist, psychologist, and other practitioners work together as a team to treat the patient,” Ray says. “Because we all are officed in the same building, we can communicate readily about the patient, including meeting weekly to discuss the case.”
Ray’s presentation also includes a discussion of the psychometric tools used at the clinic with all patients. The battery includes the TOMM (Test of Memory Malingering), a brief visual recognition test designed to help discriminate between individuals with true memory impairment and malingerers; the MMPI-2 (Minnesota Multiphasic Personality Inventory-2) test, which helps identify underlying psychopathology that may predate the injury; and the BBHI 2 test.
“The focus on objective evidence that governs the worker's compensation system has traditionally meant that if the problem doesn’t show up on a medical test such as an MRI or an X-ray, it doesn’t exist,” says Ray. “But pain perception is a very complex issue. The difficulties facing most chronic pain patients don’t show up on such tests. The value of the BBHI 2 test is that it provides a useful tool for gathering objective information on underlying pain-related issues.”
Ray points out that the BBHI 2 assessment is particularly useful because it is normed on pain patients. Another benefit he emphasizes is that the test helps pinpoint specific information such as pain level in different areas of the body, which is likely to prove far more valuable to the clinician than a general daily pain measurement. In addition, the use of the BBHI 2 instrument, along with the TOMM and the MMPI-2 tests, allows comparison of results to determine if there is any indication of malingering or magnification.
Ray has found that attendees of the training gain a better appreciation of how powerful underlying influences can be. “Once people learn that patients are much more likely to improve when the correct factors are identified, they tend to have a different attitude about patients in general, to refer them to appropriate treatment earlier, and consequently to help the patient return to work sooner,” says Ray.
In addition to providing education for decision-makers within the worker's compensation system, Waring also points out the value of educating patients. “Patients often have the misconception that until they are ‘100% fixed’ they will not be ready to go back to work,” says Waring. “The concept of a ‘fix’ is a dangerous one. Most patients will not experience a complete return to their previous state of health. The focus should be on improvement. We need to help patients take charge of their physical and psychological problems and move in a positive direction.”
Waring notes that the BBHI 2 test can be useful in this regard. “The test provides objective information that can help physicians and other providers as well as case workers open the conversation with the patient about their choices. Through dialogue, we may help the patient overcome their resistance to change, which is often a significant issue. We may also identify that with job modification or retraining, the patient can continue working during the course of treatment.”
“There are issues on both sides of the equation,” says Waring, “with patients as well as with those of us who play various roles in the worker's compensation system. Both sides need to come together or we won’t succeed in improving the situation.”
Albert Ray, MD, is board-certified in both pain medicine and psychiatry. In addition to operating an interdisciplinary private practice, he serves as medical director at Pain Medicine Solutions in Miami, Florida. Ray also is a clinical associate professor at the University of Miami School of Medicine.
Patrick Waring, MD, is board-certified in both pain management and anesthesiology. Waring has served as medical director of Pain Management Services at Memorial Medical Center-Baptist Campus and Doctor’s Hospital of Jefferson in New Orleans. He presently practices interventional pain management at The Pain Intervention Center, which is located in the greater New Orleans area.
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