AdMIRable Review Spring 2024

The Tennessee Bureau of Workers’ Compensation (TN BWC) adopted the Official Disability Guidelines (ODG – now “ODG by MCG”) as presumptively correct for Utilization Review decisions, and UR Vendors almost always cite the ODG criteria in certifying, or non-certifying, requested tests or treatments for TN workers’ compensation cases. The exceptions are the uncommon requests for procedures for which there is no ODG section that is applicable. Examples would be a request for a sixth operation for non-union of the same fracture, or a third labrum repair on the same shoulder.

The BWC Office of the Medical Director (OMD) receives appeals of UR denials of procedures for which the indication is chronic pain relief. Examples are spinal fusion for back pain, and spinal cord stimulator trial or permanent implantation for chronic back and leg pain. For these procedures an ODG criterion is a “favorable” psychological assessment, which has proven to be problematic.

The Authorized Treating Physician (ATP) orders a “Psychologic Assessment” with typically no additional information provided to the psychologist or psychiatrist. What the BWC typically sees in these psychologist assessments is an evaluation that states the patient is not psychotic, has depression or anxiety symptoms (and frequently diagnoses) that are being treated, has the legal ability to make decisions about their health care, and understands the unstated “risks and benefits” of the proposed procedure.

What the ATP wants to see is “psych clearance has been obtained, and the patient is ‘OK’ for the planned procedure for pain”.

However, the reason psychological assessment is an ODG criterion is that invasive procedures have risks of significant complications, and at times even death, and there is little reason for an UR MD to certify as “medically necessary” a procedure proposed for pain relief for a patient who has little to no chance of benefitting from the procedure. Many psychological factors are predictive of prolonged pain reports and poor prognosis for pain relief by invasive procedures. Major risk without predicted benefit is illogical.

Thus, the UR MD and the BWC Medical Director look for things in the “psychological assessment” that are rarely, if ever present, which include:

• The presence of catastrophizing, fear avoidance beliefs, anger directed at the employer and/or insurer, or other common emotional reactions that may be contributing to the severity of symptom report and can delay or prevent recovery.
• The presence of a depressive or anxiety disorder is commonly documented, but the SEVERITY of the condition (severity of symptoms) is rarely documented. Outlining diagnostic criteria by which the diagnosis was determined is expected, but rarely present.
• The presence of a personality disorder or substantial personality factors that may be influencing symptom severity and/or prognosis.
• The testing of self-reported symptoms for “validity” (or symptom exaggeration), as recommended by the AMA Guides, 6th Edition, Sections 14.2 and 14.3, and the American Psychiatric Association, DSM-5 Handbook of Differential Diagnosis.
• The presence of central sensitization of pain. The presence of nociplastic pain.
• The presence of somatization as a psychological defense (to what extent are physical symptoms likely a defense against emotional distress).
• A summary listing all the factors present that individually or collectively would predict a suboptimal outcome for invasive treatment with the indication being pain relief.

Each of these has published studies in general medical and orthopaedic journals correlating the presence of these issues with suboptimal or no benefit from procedures whose indication is relief of chronic pain. While one psychosocial factor may not predict a poor surgery outcome, the total number of predictors, each with literature documentation of its effect on outcome, should be carefully considered.

In addition, the psychological assessments frequently say “understands the potential risk and benefit of the procedure”. Psychologists are not expected to know the risk and potential benefit of the specific proposed procedure. However, documenting the patient’s recollection of risk and benefit permits reviewers to verify the accuracy of the patient’s recall. Thus, from the reports submitted to UR and to the BWC a reviewer does not know if the patient’s perception of risk is “no complications” and the benefit is “almost everyone gets dramatic pain relief”, or if the risk is “20-30% complication rate, some of which are serious and permanent” and the benefit is “one out of ten patients describes >50% pain relief, but almost no one stops opioids, or goes back to work”.

The treating physician’s office note requesting certification for the surgery or invasive pain procedure will always say the risks and benefits were discussed, but never states percentages for risks (number needed to harm) or benefits (number needed to treat in published studies). What the patient remembers is not necessarily what the physician said (Sahin 2010, Crepeau 2011, Sherlock 2014, Shlobin 2020).

Again, the evaluating psychologist would not be expected to know the specifics about incidence rates for specific complications, or the published “number needed to treat” rates for “minimal clinically important difference” and for “substantial clinical benefit”, and the “number needed to harm” for specific complications. These statistics would be available in published literature to the UR MD and the BWC Medical Director. Absent the psychologist independently documenting specifically what the prospective surgical patient remembers about risk and benefit, the UR MD and the BWC Medical Director cannot know, or comment on, whether the patient’s perception of risk versus benefit aligns with published literature on the chronic pain related surgical procedure in question in populations with similar demographics, or if the patient’s perception is unrealistic.

Thus, the psychological assessments seen by the BWC OMD may “check off a box” on the ODG criteria list, but these are rarely helpful, and they typically miss the purpose for which they have been requested.

Now that we have stated the issue, we can examine the published evidence behind these statements.

Surgeons’ ability to recognize psychic distress is suboptimal, and hence the need for independent psychological assessment:

The American Academy of Orthopaedic Surgeons (AAOS) officially recommends Early Screening for Psychological Risk for patients with traumatic injuries of the extremities, spine, or pelvis (Keizer 2022, Piuzzi 2021). They suggest a number of validated patient questionnaires to screen for psychosocial issues that hinder recovery for musculoskeletal injuries. Questionnaires for screening for these issues are readily retrievable using internet search engines. Screening by questionnaires indicates which patients most likely have a significant mental health issue, and is meant to guide referrals for evaluation and potentially for mental health care. Screening positive for a mental health issue by questionnaire is not the same as a formal mental disorder diagnosis by a fully trained mental health professional (MD/DO Psychiatrist or PhD Psychologist).

Why does AAOS recommend screening injured patients for psychological risk? Surgeons frequently assume all pain is due to the biomedical model, and surgeons frequently fail to recognize major mental disorders or psychosocial stressors that will hinder or prevent improvement of symptoms (like pain) or function (like return to work). (Grevitt 1998, Daubs MD, 2010, Daubs 2014, Moon 2023). Personality Style tests document that the same personality traits that make good surgeons (attention to detail, ability to stay calm in crisis, intellectual and not emotional decision making, etc. – “Compulsive style” – Doherty 2011) mean surgeons live in their intellectual brain and suppress their emotions, so they are less prone to recognize emotional stress in their patients.

The correlation of Pre-Operative psychological factors and suboptimal surgical outcomes has been shown for lumbar surgery (Halicka 2022, Serrano-Garcia 2020, Suri P 2017, Dorow 2017, Menendez 2014), lumbar surgery and spinal cord stimulation (Celestin 2009), musculoskeletal pain (Vranceanu 2009, Vargas-Prada 2015), total joint arthroplasty, ACL reconstruction, and spine surgery (Flanigan 2015), foot & ankle surgery (Henry 2021), musculoskeletal trauma (Kang 2021, Vranceanu 2014), total hip replacement (O’Connor 2022), total knee replacement (Khatib 2015, Lewis 2015), shoulder surgery (Baker 2022, Vajapey 2020, Gil 2018) and total joint replacement (Hecht 2023).

The study by Moon, et al (2023) evaluated 296 initial evaluation spine patients by use of the Distress and Risk Assessment Method (DRAM). This questionnaire has been validated in multiple languages and cultures and assesses depression symptoms by the Zung Depression Questionnaire (Psychology Tools 2023, Jokelainen 2019) and assesses somatization and somatic anxiety by the Modified Somatic Perception Questionnaire – Georgoudis 2023, Bianchini 2014).

Each patient completed the DRAM questionnaires, and then one of 3 spine surgeons assessed each patient’s spine problem, made a treatment plan, and then also guessed how the patient would score on the DRAM. 129 of the 296 patients had a normal DRAM, and 51.8% of them were labelled correctly as “normal” by the surgeons. 120 patients were in the DRAM “at risk” group, and 44% of them were correctly labelled by the surgeons, but 35.8% of them were classified as “normal” by the surgeons. The most critical group to recognize are the “distressed” group by the DRAM, and of the 47 patients in this category 47% were correctly recognized by the surgeons, but they classified 9.2% normal. This occurred while the surgeons knew they were in a study of surgeons’ ability to recognize mentally stressed patients, so this should represent better accuracy than surgeons not being studied. These results were similar to those in 5 other published studies with 22% to 33% of spinal pain patients being in the most severe “distressed” category, and surgeon accuracy of assessment varying from 29% to 69%. The surgeons’ overall reliability in this study comparing their assessment to the patients’ DRAM was a kappa of 0.13 indicating minimal agreement with a strong bias toward under-recognition of patients’ mental stress burden. The surgeons were statistically less likely to recommend surgery for those patients they did recognize as distressed. The patients with DRAM scores indicating “at risk” or “distressed” had more disability (by Oswestry Disability Index for the low back pain patients or the Neck Disability Index for the neck pain patients). Based on the other studies (Daubs 2010), the surgeons’ years of experience in practice did not improve their accuracy in assessing patients’ stress levels. Multiple studies have documented the ability of the DRAM classification to predict the outcome of spine surgery (Pollock 2012, Jackson 2020, Serrano-Garcia 2020).

Anger directed toward the employer/insurer

If a patient remains angry at the employer or third party over the circumstances that resulted in his injury, or at the insurer over workers’ compensation claim handling the Injustice Experience Questionnaire (AAP 2023, Scott 2015) can identify this anger, that impairs or prevents recovery. Ongoing residual anger, whether “justified” or not, is one of the strongest predictors of poor post-surgical outcomes and failed pain procedures (Reme 2022, Ikemoto 2019, Sullivan 2008). Psychiatrists and psychologists work with patients to diffuse residual anger, as they quote the saying variously attributed to Alcoholic Anonymous, Nelson Mandela, etc. “Holding on to anger is like drinking poison and expecting the other person to die”. Although anger directed at a perceived transgressor is not a diagnoseable condition, it may nevertheless respond to cognitive behavioral therapy or other mental health intervention.

In preparation for a 2023 BWC sponsored conference a search of the web sites for 4 “orthopaedic journals” using the word “anger” yielded 223 article citations in Journal of Bone and Joint Surgery, 23 citations in Journal of the American Academy of Orthopaedic Surgeons, 38 citations in Spine, and 243 citations in The Spine Journal. Not all of these cited articles are related to persistent anger in patients (some are anger in health care providers, and some even are “anger” in musculoskeletal tissues).

Catastrophizing

Catastrophizing is conceptualized as having an exaggerated negative orientation toward noxious stimuli, negative expectations, increased accessibility of previous memories of pain, worry, and inability to cope effectively with pain (Sullivan 1995, Osman 2000, Ranger 2020). This can be oversimplified as Dorothy, the Tin Man, and the Scarecrow who feared that there were “lions, and tigers, and bears, oh my” everywhere they went in the Wizard of Oz movie. Importantly, catastrophizing does not mean that the individual is malingering or is not experiencing pain, but suggests a tendency to overstate negative experiences in a way that is predictive of poor outcomes. The questionnaire is 13 questions scored by the patient from 0 to 4, so the total score possibilities are 0 to 52. A score of ≥ 30 is usually considered very significant. Patient responses vary slightly by country and culture (Hayashi 2022). Surgeons will frequently fail to recognize this issue (Sabo 2019). Symptoms of depression and catastrophizing combine to significantly affect outcomes of spine surgery (Menendez 2014) and joint replacement (Springborg 2023, Hardy 2022, Lewis 2015). Poor mental health and catastrophizing are associated with knee replacement outcomes (Olsen 2023).

A search of the web sites for 4 “orthopaedic journals” (not psychology journals) using the word “catastrophizing” yielded 99 article citations in Journal of Bone and Joint Surgery, 27 citations in Journal of the American Academy of Orthopaedic Surgeons, 153 citations in Spine, and 378 citations in The Spine Journal, so the effect of this concept on musculoskeletal injury and surgery is very well researched. A systematic review of 85 studies is available (Martinez-Calderon 2019).

Fear avoidance beliefs

Kinesiophobia, or fear avoidance beliefs are derived from the concept that injuries produce pain, and the injured person extrapolates to the false concept that “if I feel pain during activity after injury, I must be causing further injury to myself”. Most athletic locker rooms have the exact opposite message posted – a sign stating simply “No pain, no gain”. Rehabilitation after injury or surgery involves activity that is frequently painful, but some patients are so afraid of injury or reinjury that they are unwilling to challenge themselves with activity required to gain strength, endurance, flexibility, etc.

A search of the web sites for 4 “orthopaedic journals” using the words “fear avoidance” yielded 100 article citations in Journal of Bone and Joint Surgery, 38 citations in Journal of the American Academy of Orthopaedic Surgeons, 380 citations in Spine, and 265 citations in The Spine Journal, so the effect of this concept on musculoskeletal injury and surgery is very well researched.

The patient questionnaires that assess the degree of this false belief in patients are Gordon Waddell’s Fear Avoidance Beliefs Questionnaire, or the Tampa Kinesiophobia Scale. The Fear Avoidance Belief Questionnaire has 5 questions in the subsection on Physical Activity, each scored 0-6 so the maximal score is 30. The Work subsection has 11 questions with a maximal score of 66. Cut point for low back pain patients in physical therapy are described (George 2008) as >14 for Physical Activity and > 29 for the Work section.

The Tampa Kinesiophobia Scale originally had 17 questions, but a newer 13 question form has been psychometric statistics. Each question is scored 0-4 so the newer form maximal score is 52. Moderate (scores of 33-42) and Severe (scores of 43-52) are particularly concerning (Neblett 2015). A systematic review of the 41 publications on all the versions was recently published (Dupuis 2023).

A systematic review of 31 kinesiophobia treatment studies found this to be treatable with improvement by psychological treatment and by multimodal treatment that includes both psychological treatment and physical therapy (Huang 2022).

While fear of reinjury is common, and most work-related injuries are not life or limb threatening, and thus don’t meet the DSM5-TR criteria for a Category A PTSD exposure, a number of patients with work injuries are diagnosed with Post-Traumatic Stress Disorder (PTSD). PTSD like symptoms after non-life or limb threatening injury are associated with chronic musculoskeletal pain and disability (Jadhakhan 2023). This symptom profile is better captured as either a normal response to a stressful circumstance or, if criteria are met, as an Adjustment Disorder.

Presence and severity of depression symptoms/disorder and the presence and severity of anxiety symptoms/disorder

The best and most recent epidemiologic study of anxiety and depression in the United States used the pre-Covid 2019 National Health Interview Survey of almost 32,000 U.S. adults (De La Rosa 2024), that was then adjusted statistically to mirror the entire population of 244 million U.S. adults. Cut point scores ≥ 10 on the GAD-7 and/or the PHQ-8 questionnaires were used to define a moderate or severe level of chronic anxiety or depression. The prevalence of either anxiety or depression in adults was: without chronic pain 4.9%, and with chronic pain 23.9%. In U.S. adults, 20.5% had chronic pain. In adults with BOTH anxiety and depression 61.3% had chronic pain, and 41% had high impact chronic pain. Compared with those with only chronic pain only, people with anxiety or depression symptoms and chronic pain were approximately 3.0 times more likely to report difficulty doing errands alone, 3.5 times more likely to report difficulty participating in social activities, and 1.6 times more likely to report that work is limited.

Introduction

It is no longer unusual for the news to carry stories about robberies or other traumatic events in our community or our state occurring to workers, such as the shootings at McDonald’s in Antioch, Kroger’s in Germantown, or the Covenant School in Nashville. Whether or not they are physically injured, the effect on individuals in that work environment can be profound and life-altering. As a result, many individuals develop acute stress disorder and/or PTSD that can be directly related to a traumatic event in the course and scope of their employment. Therefore, their treatment is covered by the employer’s workers’ compensation insurance. Finding timely and competent treatment under the limitations of workers’ compensation has been difficult. I cannot change the law but would like to see what we might do to help these persons get the mental health care they need and deserve. The purpose of this article is to try to overcome some of the resistance of Psychiatrists to accept and treat these individuals.

Many, if not most, Psychiatrists do not accept assigned insurance and require payment at the time of service. There should be acceptable ways to get payment in a timely manner when treating these patients that will not burden you or your staff. We have received several complaints and we hope to offer some potential solutions to allay some of the issues.

Treatment

Early and effective treatment provides the best possibility of a good outcome, whether it means returning to the same employer/circumstance or eventually just returning to as close to a normal enjoyment of life as possible. So, the availability of enough physicians to accept these patients is important. Delay in treatment is one of most important reasons for a poor outcome.

Granted, these patients are hard to treat. They feel victimized by both the event and by the “system.” They may not express their reluctance to return to the situation either emotionally or physically and may not be honest about their circumstances. In addition, you are viewed with suspicion as the “company doctor”, not keeping their best interest as the most important aspect of your treatment. It takes extra time and effort to overcome the barriers of victimhood and suspicion.

Communications

This is compounded by poor initial (and subsequent) communications with the patient from their employer, the insurance adjuster, and the case manager. Also, there is often the same problem of poor communication by the adjuster and the case manager with the treating Psychiatrist. Their goals are sometimes at odds with the needs of the patient. The Bureau provides training programs for adjusters and case managers to try to improve their communication skills, empathy, responsiveness, timeliness, and honesty. Unfortunately, the system does not allow the adjusters to have a reasonable workload to be able to efficiently and timely read some of your notes or other materials. This compounds your reluctance to treat these patients.

Training

The Bureau has provided a special educational initiative for physicians that gives training on the best practices for treating injured workers, called the Certified Physician Program (CPP). These sessions include how to communicate with stakeholders and what is required for these patients including causation, return-to-work slips and assessing maximum medical improvement. These sessions are online, can be viewed at your convenience and provide 10 hours of free CME, AMA Category 1 Credit®. Special arrangements can be made for the impairment guides training for your specialty. Once certified through this program, you receive extra reimbursement. More information can be found at Certified Physician Program.

Work Status

Questions about work status may not be appropriate during initial treatment visits but are a legislatively established requirement of the employers/insurers that permits the workers, that are unable to work, to receive wage replacement benefits. Having a form and completing it at each visit so that it can accompany the records (and be given to the injured worker and the case manager) is the best way to solve this dilemma. If it would be helpful, we can work with you to develop an example form specifically for psychiatric treatment and to include the next appointment date and time. You should also be aware that the insurer’s expectation is that you will forward a copy of your treatment notes to the insurer with your bill for each session.

Appointment Processes

Appointment issues can be solved but they do take some forethought and education of your staff. When an appointment is made for a new patient covered under workers’ compensation, being clear about the expectations from the person making the appointment is important.

Intake office staff questions when scheduling an initial appointment for this group of patients, should have a form just like your questions about past history:

1. Is this a visit for causation determination? Ongoing treatment?
2. Is this an Independent Medical Examination? Are you not expected to treat?
3. Has the patient received prior or other mental health treatment? If so when and by whom?
4. Is this visit to take over the mental health care of the patient?
5. Who is responsible for payment?
6. For ongoing treatment, has there been any change in the patient’s adjuster or claim status (ask at each visit)?

Payments

For your satisfaction and protection, a written agreement (contract) with the adjuster may help and might include clarity about such issues as specific payment amounts for your codes (that are not subject to discounts), timeliness and timeframe of payments, timely notification of adjuster changes, timely notification of cancellations, claim status changes, follow-up appointments, extra questions, understanding about case managers, records requests, determining treatment outcomes, opining on maximal medical improvement and permanent impairment-there are statutory rules about these issues that require some extra education.

Focus of Treatment

When treatment notes indicate psychosocial stressors pre-existing and unrelated to the workplace incident become the focus of treatment, insurers are reluctant to continue paying for ongoing treatment. Notes and treatment should focus primarily on work-related events or notes should reflect how the current treatment is related to the covered injury.

Reluctance

The workers’ compensation fee schedule maximums pay a premium over Medicare (180%) but we suspect that payment is not what keeps most Psychiatrists from accepting these patients. You already have enough to do, and the extra hassles of billing, collections, questions, and interference probably rank higher than the level of payment. There is also the evidence of poorer response to treatment and delayed outcomes that make Psychiatrists reluctant to take on these patients.

However, they do need good physicians to undertake their care. We at the Bureau are willing to meet with any of you in groups, or one-on-one, to exchange and provide more information. We hope to encourage you to explore the possibility of helping with these deserving individuals.