Kevin Walsh M.D.

1. Kevin Walsh M.D. Partner: Industrial Medical Associates Staff Anesthesiologist University Hospital Member of Medical Advisory Committee to Chairperson of WCB

2. Background Family Practice Emergency Medicine Occupational Health (IMA) Anesthesiology Interventional Pain Management

3. Today's Objective Review WC in context of 2006 Illustrate how the system is dysfunctional Identify three pivotal cost drivers How they may be better managed Case management illustration

4. Are Workers Compensation Costs Important? Business council of NYS Major obstacles for recruitment & retention of jobs in New York State Tax Structure WC Costs Energy Costs

5. History of New York�s WC System Created by the Legislature around time of WWI Legal framework to protect injured workers and employers. Orderly litigation, predictable outcome Medical sciences were in their infancy, medical costs were irrelevant. NEEDS WORK< NOT COMPLETENEEDS WORK< NOT COMPLETE

6. 1980�s Conditions Relationship between worker, family, and employers Health benefits were comprehensive and improving. Providers preferred to care for injuries under BC/BS - employees didn�t object. Fewer MD�s Fewer paramedical professionals PT - OT - Chiropractic - Massage Therapy Few diagnostic tools Cat scans new to scene Sparse legal interest locally Pharmacy costs irrelevant Biomedical engineering costs were non existent.

7. WC - The Players The Legislature Lawyers WCB Injured worker Employer Physicians & Paraprofessional Providers Insurance Carriers

8. 2006 Conditions Workers feel disenfranchised. No loyalty between worker/employer. Erosion or absence of benefits. Private health insurers actively push cases to WC. Patients and physicians see WC as default insurance. Full force of best pharmaceutical marketing machine in the world with no constraints. Biomedical engineering research funding. Proliferation of medical providers and advanced technologies. Lifetime medical care. Inability to close cases.

9. Problem Modern medical practice & Antiquated WC system Square peg / Round hole Trying to treat medical problems in a political versus market driven environment

10. The (Paradox/Dilemma) in WC Care Medical technology abundant Diagnostic capabilities much improved Supply of medical and paramedical specialties abundant Why is the severity of WC cases escalating rapidly and outcomes of care are so poor?

11. Three Pivotal Cost Drivers Nature & Severity of the injury. Interface between the worker and employer. Dynamic between the injured worker and medical providers.

12. Employer / Injured Worker Interface Visceral response Negative Adversarial

13. Injured Worker / Medical Care Dynamic Review in detail what happens through the course of long term workers comp case. The Human condition + behavior and their implications

14. Workers Comp: Low back injury case review Day 1 - �I really hurt my back� Day 7 - �Feeling a little better thank you� 4 Weeks Later� Feeling Worse �The Pain Is Awful!�

15. Pain Pain Nociceptive Pain Suffering

16. WC Care Walk-through cont�d 6 weeks In physical therapy Request CT or MRI scan 10 - 12 weeks The pain is worse Abnormal MRI scan Request Pain Blocks / EMG study 4 - 6 months The pain is worse Failure of conservative therapy Request authorization for surgery

17. Request for Surgery Based on abnormal MRI & report of persistent of pain. The most common cause of poor surgical outcomes is not bad surgeons. It is operating for the wrong reason.

18. Pain Pain Nociceptive Pain Suffering

19. Case Continued 6 months plus Post operative visit Still have pain Repeat pain blocks & rehab Chronic medication requirement Including narcotics

20. Workers Compensation Cost Cascade In house health resource $ Off site health resource $$ Hospital based care - Emergency dept. $$$ Specialist consultation - Orthopedic $$$$ Imaging studies - CT, MRI, Pet Scans, EMG $$$$$ OT, PT, Chiro Massage therapy $$$$$$ Surgical Intervention Surgical fee $$$$$$$ Facility fee More rehab - Pain Management Nerve blocks $$$$$$$$ Pharmaceuticals

21. Managing the Cost Drivers-Nature & Severity- Safety training Safety culture Ergonomics Engineering

22. Managing the Cost Drivers-Employer / Injured Worker Interface- Be positive and supportive. Treat like a valuable athlete. How can I help you recover? You are important to the success of our business. Maintain regular personal contact. Facilitate timely medical care. Make sure compensation checks arrive on time. Make return to work pathway easy.

23. Managing the Cost Drivers-Dynamic between Injured Worker & Medical Provider- This is really a triad: Worker Employer Medical Provider More Complex Requires persistent effort When I do right nobody remembers, when I do wrong nobody forgets.

24. Managing the Cost Drivers-Dynamic between Injured Worker & Medical Provider- Keep it simple. Engage with �problem solver� medical providers / systems. Attentive patient management. Mechanisms to resolve disputes quickly. Utilization review. Encourage early return to work.

25. Workers Compensation Cost Cascade In house health resource $ Off site health resource $$ Hospital based care - Emergency dept. $$$ Specialist consultation - Orthopedic $$$$ Imaging studies - CT, MRI, Pet Scans, EMG $$$$$ OT, PT, Chiro Massage therapy $$$$$$ Surgical Intervention Surgical fee $$$$$$$ Facility fee More rehab - Pain Management Nerve blocks $$$$$$$$ Pharmaceuticals

26. Workers Compensation Reform Changes in law will never keep up with changing business environment. Employers who manage the process and human behavior can effectively reduce losses regardless of reforms. Reform efforts should address: Direction of care. Appropriate utilization of medical services. Timely resolution of all disputes.

27. Employer Influence Employers can influence the length of the disability more than they realize. Manage the process. Develop relationships/programs with medical community.

28. Wrap Up Preemptive efforts: Invest in the Recruitment Process Invest in Safety & Training Make it important part of culture Patient Care management: When accident or injury occurs don�t pass it off. Be involved in care management from day 1. Medical management: Have a �Friend In The Business� Safety person Occupational health nurse Contracted service offsite Physicians Positive ongoing relationship with Employee: Treat like valuable asset Frequent in person relationship Facilitate medical care Make sure compensation checks arrive on time Make return to work pathway easy

29. Contact Information Kevin Walsh M.D. Industrial Medical Associates wcpainreview@aol.com IMA: (315) 478-1977 Digital Pager: (315) 441-1324