1. IOM-DHS Occupational Health 6/10/2013 Gary M. Franklin, MD, MPH Research Professor Departments of Environmental Health and Neurology University of Washington Medical Director Washington State Department of Labor and Industries

2. Over the past decade: Claims with disability payments are staying open longer

3. What is the relationship between health care delivery and prevention? Disability Prevention: Changing the Paradigm Primary preventionPrevent workplace injuries and illnesses Secondary preventionPrevent disability among workers with work-related injuries and illnesses Tertiary preventionManage disability to reduce residual deficit and dysfunction

4. What are the main categories of risk? Disability Prediction in Workers’ Compensation Most important risk factor categories Medical Work Administrative Psychosocial Demographic Legal More Modifiability Less

5. 38% Increase since 2001

6.  Use of harmful treatments, which contribute to prolonged disability: opioids, spinal surgery (lumbar fusion)  Multiple diagnosis problem (eg, TOS)  Bad docs

7.  Webster et al, 2007 Spine; 32: 2127-32 ◦ >450 mg MED associated with 69 additional time- loss days  Franklin et al, 2008 Spine 33: 199-204 ◦ >7 days or 2 Rxs opioids associated with doubling of risk of disability at 1 year

8. 3% of prescribers account for 55% of Schedule II opioid Rxs DLI will send letters to all prescribers with any patient on opioid doses at or above 120 mg/day MED  Call their attention to AMDG Guidelines and new WA state regulations  Associate medical director will meet with these docs personally http://www.cwci.org/research.html

9.  Harris et al, JAMA 2005; 293: 1644-1652 ◦ Reviewed 211 studies, 1966-2003 ◦ 175 outcome worse, 35 ND, 1 better ◦ Meta-analysis of 129 studies (N=20498):  Summary odds for unsatisfactory outcome 3.79 (3.28- 4.37)

10. ComponentWashingtonCalifornia Claims process State agency*Private insurance* Initial fusionSingle levelNon limited Repeat surgery Subject to reviewNot limited PrerequisiteImaging of instability No requirement Review Criteria Prospective URBinding second opinion PaymentDiagnosis group (DRG) Diagnosis + implant *

12. WashingtonCaliforniap-value Charges, mean $103,223$160,994<0.001 Costs, mean$40,329$49,435<0.001 Controlling for age, sex, comorbidity & diagnosis

13. Year Number of distinct lumbar fusions billed per year Avg. number of years from claim established to lumbar fusion date Number of SIMPS Number of claims that received a fusion that are currently on pension % On pension 2000 4073.9 15741% 2001 4193.9 16641% 2002 4473.3 19044% 2003 4183.7 16440% 2004 4123.5 15639% 2005 366319011333% 2006 3823.523011231% 2007 3413.12698626% 2008 3453.32778726% 2009 4153.33656617% 2010 4123.75494211% 2011 4033.5632103% 2012 528

14. Prevent Chronic Disability thru Physician Education and Support Cheadle A et al. Factors influencing the duration of work-related disability. Am J Public Health 1994; 84:190–196. 1211109876543210 0 20 40 60 80 100 Months of Lost Work Time % Patients on disability Increase use of occupational health best practices to reduce disability Current Desired

15. Wickizer et al, A communitywide intervention to improve outcomes and reduce disability among injured workers in Washington State, Milbank Q 2004; 82: 547-67 http://www.lni.wa.gov/ClaimsIns/Providers/R esearch/OHS/default.asp

16. Pilot Community COHE Business Labor Advisory Board Community Physicians Dept. of Labor & Industries UW Research Team WCAC/HC COHE Organization and Governance

17. This is a health care system, not an insurance company, intervention Health care institutional support Occupational health leadership Business/labor advisory committees

18. Occupational health best practices Quality Indicators Health Services coordination-function reports to the health care providers Information support system Modest payment incentives for best practices

19. Process, not specific treatment, indicators Prompt submission of ROA (48 hrs) Telephone call Re RTW by physician Activity prescription 4 week assessment of barriers to RTW

20. Eastern WA COHE 935 providers ~16,000 claims (annual) Operations began 2003 Renton COHE 270 providers ~8,500 claims (annual) Operations began 2002 Institution-based COHEs The Everett Clinic 327 providers ~3,000 claims (annual) Operations began 2007 Harborview Medical Center Emergency Department Operations began 2007

21.  20% reduction in likelihood of one year disability, 30% reduction for back injuries  Among COHE participating doctors, high adopters of best practices had 57% fewer disability days than low adopters  http://www.ncbi.nlm.nih.gov/pubmed/22015 667

22.  20% reduction in likelihood of one year disability, 30% reduction for back injuries  Among COHE participating doctors, high adopters of best practices had 57% fewer disability days than low adopters

23. Based upon the COHE regression model, the number of reduced disability days per 1,000 injured workers treated was: Renton: 4,800 days (13.2 years) of disability avoided per 1,000 workers treated Spokane: 5,800 days (15.9 years) of disability avoided per 1,000 workers treated

24.  Health care in large communities can be re-organized to provide more highly integrated Occ Health best practices  Reorganization is possible with modest financial and non- financial incentives  Maintained worker choice of provider without a mandate to direct care  Improved satisfaction at all levels in the community  From our standpoint, a small investment for big return from both the human and the $ standpoint Contrast this experience with the 2004 CA reforms mandating medical provider networks-impact short lived, very low satisfaction among providers and workers-Off the shelf PPOs and MCOs have no impact on preventing disability

25. Clinical Efficiency Poor Good Community Physicians Zone 1Zone 2Zone 3Zone 4 Low or Average Medical Costs Reduced Disability Costs Excellent Health/ Disability Outcomes Average Medical Costs Average Disability Costs Questionable Health/ Disability Outcomes Moderate to High Medical Costs Moderate to High Disability Costs Poor Health/ Disability Outcomes High Medical Costs High Disability Costs Very Poor Health/ Disability Outcomes (Costs & Quality) COHE Model: Identify high performers to serves as mentors Incentives for quality indicators known to improve outcomes Resources to help docs apply them (CME, HSCs, reminders) Geared toward improving well-intentioned Zone 2 & 3 Incentives for quality indicators known to improve outcomes Resources to help docs apply them (CME, HSCs, reminders) Geared toward improving well-intentioned Zone 2 & 3 Patterns of poor quality care that presents injured workers a risk of harm typically require other (non-COHE) interventions (minimum standards & risk of harm)

26.  The department may permanently remove a provider …when the provider exhibits a pattern of conduct of low quality care that exposes patients to risk of physical or psychiatric harm or death. Patterns that qualify as risk of harm include, but are not limited to, poor health care outcomes evidenced by increased, chronic, or prolonged pain or decreased function due to treatments that have not been shown to be curative, safe, or effective or for which it has been shown that the risks of harm exceed the benefits that can be reasonably expected based on peer- reviewed opinion

27. Positive Functional Recovery Questionnaire (FRQ) Not worked for pay in past two weeks Pain greater than 5 on VAS Back and leg pain OR pain in multiple body sites Functional Recovery Interventions (FRI) Graded exercise/activity Address low recovery expectations Address any fear of usual activity reinjuring or worsening condition Flag additional HSC focus on RTW

29.  Four weeks after care begins (up to 8 weeks after care begins), unless contra-indicated, AP referral for PT-supervised time-limited graded exercise program if worker not progressing sufficiently in self-managed activity program  AP referral of IW to activity coaching (weekly contacts with a trained activity coach using structured sessions and materials aimed at re- integrating the IW into life activities, including work) if worker still off work 4 weeks after care begins and no contra-indications for activity coaching  IW ratings of pain and function are obtained at each visit, using the 2 question Graded Chronic Pain (Von Korff) instrument

30.  For IWs having surgery, there is a documented pre-op assessment of RTW capacity and specific goals related to RTW post-op  For IWs who have surgery, the HSC assists in transitioning the patient back to primary care after surgery when requested by surgeon  For IWs having surgery, there is an integrated post-operative team (e.g., COHE-delivered care) that will evaluate the patient if RTW goals are not met by 8 weeks post-op (12 weeks for lumbar fusion)

32. For electronic copies of this presentation, please e-mail Laura Black ljl2@uw.edu For questions or feedback, please e-mail Gary Franklin meddir@u.washington.edu THANK YOU!