Healthcare Expert Warns of Patient Barriers to Effective Treatment and Recovery

Keep improving the efficiency and effectiveness of our healthcare delivery system and lower costs and better patient outcomes will automatically follow, right? That sentiment may echo conventional wisdom, but it may not be the case at all, says healthcare consultant Tim Kilpatrick. In a recent blog post, “14 Patient Barriers That May Delay or Prevent Recovery,” he argues that an efficient and effective healthcare system may only have minimal or no impact, if persistent patient barriers—patient needs that if left unaddressed, could delay or prevent recovery—are left unaddressed.

Kilpatrick posits that because of traditional reimbursement models, hospitals and physicians are not paid to address 80 percent of the factors that affect a patient’s outcome. If we are serious about reducing the cost of healthcare, we need to identify and address the barriers to real recovery. Among the 14 barriers identified by Kilpatrick that seem most relevant to injured workers in the workers’ compensation system are:

> Access – All too many patients have difficulty getting and keeping timely follow-up appointments or coverage after regular office hours.

> Financial – Patients need to cope with debt and figure out eligibility for other types of medical assistance

> Condition monitoring – Frequent monitoring of a patient’s vitals in the hospital setting produces little good if the patient, following discharge, fails to monitor—and communicate to appropriate medical personnel—his or her blood pressure, weight, pain, and other health-related information.

> Medication – Care needs to be taken to ensure that the list of patient’s medications is optimal and safe, that the patient understands how to take them, and that the patient is adhering to physicians’ instructions.

> Mental health – One’s long-range prognosis is greatly affected by ancillary conditions such depression, anxiety, stress, grief, dementia and other cognitive impairments.

> Caregiver needs – Attention needs to be given not only to the patient, but to the person or persons providing emotional, physical and administrative support, lest that support structure decay and harm the patient.

> Psychosocial – Patients are often ill-equipped to deal with being unemployed, getting motivated, avoiding drug addiction, and interacting with family members and others.

Additional Barriers for Injured Workers

We’ve asked some workers’ compensation experts what other patient barriers they would add to this list. Charles R. Davoli, managing partner of Davoli, Krumholt & Price, Baton Rouge, LA, and President of Workers’ Injury Law & Advocacy Group (WILG) said:

The four Kilpatrick barriers most analogous to injured workers are access, financial, medication and psychosocial. My experience and observations of national "deform" trends in workers’ compensation are affecting access to medical providers; thus, delaying treatment, recovery and return to work. Those trends include imposition of medical treatment guidelines (a/k/a Evidenced Based Medicine or EBM) that impose increased regulatory standards or medical protocols of treatment requiring medical pre-authorization peer reviews, utilization oversight and performance outcomes before treatment is authorized or continued; usually, resulting in further delays required for regulatory appeals of denials of treatment.

Is the System Itself a Barrier?

Other treatment/recovery barriers relate to the workers’ compensation system itself. For example, as pointed out by Vernon Sumwalt, The Sumwalt Law Firm, Charlotte, NC:

When we go to the doctor’s office for “ordinary” medical care, the physician’s staff takes your insurance information (or already has it recorded within the computer system), presses a few buttons on the medical office computer, and knows immediately what services are authorized and the extent to which they are covered. In workers’ comp, on the other hand, insurance companies approve treatment in a piecemeal fashion, often delegating approval decisions to utilization review and third-party intermediaries. The patient may have the medical care or procedure approved, but often only after a lag in time caused by the approval process.

Sumwalt added that many physicians see the approval process for treatment in workers’ compensation cases as unnecessarily duplicative. He said, “They often have to have one or more staff members specially trained to process workers’ compensation claims information. Some doctors feel the increased expense is too burdensome; they just refuse to treat injured workers. Some of the best physicians are self-excluded.”

Davoli agrees. He noted, “Evidence Based Medicine requirements, when combined with reduced medical fee schedules for workers’ compensation patient treatment discourages and frustrates medical providers from treating injured workers; thus, in many jurisdictions, medical providers are abandoning their less profitable and more onerous WC patients.”

Deborah G. Kohl, Law Offices of Deborah G. Kohl, Fall River, MA (co-author of LexisNexis Practice Guide Massachusetts Workers’ Compensation agreed with Kilpatrick’s list, but added:

One of the most significant barriers to recovery for workers’ compensation patients is the time delay inherent in the workers’ compensation system between a recommendation for medical care and the approval for that care by the insurer. In Massachusetts, the greatest barrier is the medical reimbursement rate for office visits and procedures set by the state preventing injured workers from access to quality medical treatment.

Choice of Physician Issues

Sumwalt pointed to another contentious issue in some states that can serve as a barrier to treatment of injured workers—physician choice. He said:

North Carolina, like many states, generally gives employers and insurance companies the right to direct medical treatment. But pretend for a moment that you developed a serious medical condition. Who would you trust to treat you? The doc-in-a-box down the street? Or a qualified expert for that condition that you found through research? Would this trust go up or down if the results of treatment were not as good as you would have hoped? A lot of workers’ frustrations with the system—and, indeed, several of Mr. Kilpatrick’s fourteen factors—are consequences of state rules on choice of physician.

Davoli and Kohl agreed that balancing the interests of the employer/carrier, who pays the bill, with the medical needs of the injured worker is not easy. It seems the comp system’s gears often grind together, resulting in delays and dissatisfaction.

Inadequate Systems at Employer Level

Rebecca A. Shafer, JD, President of Amaxx Risk Solutions and author of Your Ultimate Guide to Mastering Workers’ Comp Costs points out that many delays could be avoided if the employer had an effective procedure for the initial handling of injuries. She said:

Problems usually start very early on, soon after the injury with lack of a post-injury response procedure. The initial documentation that the employer provides to the injured employee often does not provide adequate information, such as the policy number or full name of the insurance company. The result can be that the employee either delays treatment or pays out of pocket from his or her savings and tries to get reimbursed later on. In some cases, the employer does not provide transportation to a medical facility, leaving the worker to determine where and how to obtain the proper level of care.

Simple errors in paperwork can produce significant delays. Shafer pointed to numerous examples of an employer providing an injured worker with a medical provider list containing incorrect contact information—old phone numbers or physicians who no longer accept workers’ compensation patients. She added that sometimes the lists include specialists who are booking appointments three or more months in the future, yet the primary treating physician is reluctant to refer the patient to another qualified specialist.

Transportation Issues/Excessive Utilization Review

Transportation issues can be particularly problematic, said Shafer.

Providers can be located hours away, providing a severe limitation for employees with limited transportation resources (families with only 1 car, or no cars) or physical barriers such as TBI (traumatic brain injury), which leaves a patient unable to drive long distances due to confusion and vision problems.

Shafer was also critical of how some employers, third-party administrators, and carriers have implemented Utilization Review (UR). She cited instances in which carriers were sending medical requests for Pepto-Bismol® ($5.00) or walking canes ($20.00) UR, whereas the employer and the employee would both be better off if the employer simply told the carrier in advance not to deny such requests.

Both Shafer and Davoli identified problems with patients who do not want a "pill-based" solution. They are often left to pay for alternative (or more natural) treatments such as acupuncture, chiropractic and neuro-feedback out of pocket.

Competition Among the Many Stakeholders

According to Stuart D. Colburn, Esq., Shareholder at Downs Stanford, Austin, TX, the number of competing interests involved in a claim can be a substantial burden to recovery and return to work. According to Colburn:

As more and varied stakeholders “touch” the patient, the more risk each stakeholder knowingly, or otherwise, push for action that favors their bottom line rather than the patient’s recovery.

Secondary Incentives Not to Recover

Colburn also identified a number of secondary considerations that delay or limit recovery. He cautions that a patient’s motivations for recovery can be influenced by a great number of factors. The injured worker may also have motivations not to recover in an optimal fashion. Colburn said, “A patient may have secondary gain issues on her mind or less nefarious, but still recovery-delaying issues, such as bad supervisors, possible termination, FMLA, or unemployment. These concerns can be heightened in a bad economy or if the employer is seeking to replace older, well-paid workers with younger, cheaper workers.”

Leslie J. Hutchinson, MD, MPH, FACOEM, of HLM Consultants agrees. He added, “Being off work while receiving a substantial portion of one’s base pay becomes appealing to some people over time.”

Hutchinson indicates that another potential problem or barrier is physical and psychological “softening” on the part of the injured worker, over time. According to Dr. Hutchinson, “Once one has been away from the day-to-day activity associated with his or her job, it becomes more difficult to return to the pre-injury level of work activity.” He added, “After six weeks off work following an injury, the probability of a worker ever returning to a workplace is small. This is probably the combined result of many of the other factors identified by Kilpatrick and others.”

Careful Balancing of Interests

Tim Kilpatrick has identified a number of important barriers to recovery within our health care system. Most, if not all, equally apply to the recovery of an employee following a work-related injury. And yet, unfortunately, the competing interests at play within the workers’ compensation system add even more to the list. If optimal outcomes for injured employees are to be the rule, rather than the exception, the workers’ compensation system must increase its efforts at vigilance. Injured employees need not be given a blank check—claimants’ advocates aren’t proposing that, by the way—but employers, TPAs, and carriers must also recognize that unnecessarily sending a medical matter to UR helps no one. It only increases worker cynicism and supports the contentions by some that the system is always stacked against them. Employees and employers alike must come to the understanding that patient recovery and return to work serves everyone’s interests.

As Kilpatrick argues, if society wants to manage its overall healthcare costs, it can’t just look at the efficiency and effectiveness of the various medical procedures. It must examine all the factors that stand in the way of patient recovery. The same applies to the workers’ compensation system. It’s just that with workers’ compensation, there are even more barriers that need to be overcome.

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