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Condition does not have to be direct result of injury
An innovative new set of workers’ compensation guidelines developed by the Washington Department of Labor and Industries offers coverage for psychiatric conditions that are either a direct result of an industrial injury or are unrelated, but retarding recovery from an industrial injury. Under the guidelines, if authorization for psychiatric treatment is requested following an initial psychiatric evaluation, the mental health professional must clearly indicate their opinion and the basis for their opinion, whether:
"To me, this seems like a creative way around a longstanding problem," says Jennifer Christian, MD, MPH, of Webility Corp. in Wayland, MA. This creativity enables the state agency to overcome widespread objections from insurers and claims managers that make such coverage unlikely throughout most of the country. "They’re not saying they will accept [the psychiatric condition] as part of the injury, but they will pay for the service," she explains. "That, to me, is where the finesse is happening; they reserve the right to make a second determination."
The other reason insurers have been reluctant to cover such treatment is that "they have poured a lot of money down rat holes on poor care," says Christian. "If the insurer has confidence in the care, the claim will probably be paid."
This, she asserts, is the no-nonsense part of the plan. The psychiatrist or psychologist must specifically identify any barriers to recovery; provide a detailed formulation of the psychiatric treatment plan; and assess the ongoing treatment and recommendations, including goals for recovery. "This increases the willingness of claims payers to pay the money," says Christian. "As long as they see signals the provider is really interested in the patient getting better [they will keep paying]. Since they are doing this voluntarily, as soon they do not see the proper signals, they can stop paying."
In a strong position
In the state of Washington, all of the workers’ comp insurance is sold by the Department of Labor and Industries, except for those employees covered by the federal system. There are some large, self-insured employers that must follow the state rules. "So our state is in a position to set policies that globally affect workers’ comp," explains Lee Glass, MD, JD, the department’s associate medical director and moving force behind the new guidelines. "The state works together with the Washington State Medical Association, among others, to try to work out treatment guidelines in areas that work for everyone involved — doctors, employers, organized labor, the department. That’s our ideal."
It was from that perspective that Glass approached this problem. "In workers’ compensation, there are numerous times someone will suffer occupational injury, and recovery may be delayed by psychiatric factors that may not be related to the injury," he notes. "Whether they are or not, if these conditions delay recovery from an injury that’s a problem for the patient involved, for the employer, and for the Department of Labor and Industries. Our goal is to help people get back to health as effectively and efficiently as possible."
The treatment of psychiatric conditions for which the department may not be financially liable was of concern, Glass recalls, so he worked with state’s medical association to put together a team in 2000 to address the issue.
It is an issue that is of great significance across the country, notes Christian. "In every state, human beings who have injuries have emotional and psychological reactions, and people with underlying psychological conditions develop other illnesses — this is simply true of humans. Historically, the medical system has been slow to realize that physical problems create mental accompaniment, so we’re not sure people are getting all the support they need."
This is doubly true in workers’ comp, she says, because insurers are not interested in creating a second injury. "Historically, they have not been interested in acknowledging it, because they do not want a second claim," she says. "The legal theory in workers’ comp is that everything caused by a problem is part of the claim. If you stubbed your toe, and you were incredibly fragile psychologically and had a nervous breakdown, went into the hospital, had a horrible misadventure, and ended up on life support, the workers’ comp insurer would be on the entire hook. Therefore, their attitude is to keep small things small."
What sets this plan apart, then, is that it was specifically designed to meet such objections. "I know first hand from prior employment that across the United States, from Alaska to Atlanta, the issue of psychiatric conditions retarding recovery from industrial injury is a significant problem," says Glass. "If an insurer starts to pay for the treatment of the psychiatric condition, they will be found responsible for the condition by the board of industrial insurance appeal in many cases. So what insurance companies have learned through bitter experience is not to be too generous. The original problem then becomes problematical; it’s a Catch-22. Insurance companies are damned if they do and if they don’t, and that was what we tried to address."
The foundation for the document, and the key to the solution, is communication with claims managers. "It’s structured in way that enables them to say, OK,’" Glass explains. "Doctors are not typically trained to communicate with claims managers, and commonly, they don’t understand their needs, nor provide them with the information they need, so the claims manager will say no.
"Claims managers have huge caseloads, and they don’t have the luxury of time to put on seminars for doctors to explain all this," Glass continues. "Docs will often say to me, This patient needs X,’ and it may look fine to me, but if that’s where it stops they will not get to yes.’ We tried to structure the communications in way that causes the doctor to provide information the claims manager needs in order to say yes."
Regardless of what the issue is in workers’ comp, Glass says, the case manager needs to know the following:
"If those two questions are answered no,’ there is no way the insurance company pays," Glass explains. "If the answer to the first question is no, but the second is yes, the case manager will continue to read. Then, if the psychological condition is retarding recovery, he will want to know how you propose to treat it. Plus — and this is crucial — how will you know if it’s working?"
There is always somebody looking over the case manager’s shoulder, Glass notes. "In our case, it’s the state auditor. The case manager has to be able to document that what the physician is doing is appropriate. If the doctor says, Here’s how I plan to treat the patient, and we’ll know in a few weeks if we are successful,’ the case manager will say, Fine, we have a few weeks.’"
But psychologists and psychiatrists are not used to thinking in such short-term frames of reference, Glass says. "So, we give them things that they can say."
Can anybody do it?
Since the Washington Department of Labor and Industry is, to use Glass’s term, monolithic, did it have a special advantage in terms of developing these guidelines?
Christian believes their efforts can be replicated in other states as well. "Some people think the structure in Washington made it easier, but I’m not sure," she offers. "It seems to me that any insurer who wanted to [cover such conditions] could do it." She concedes, however, that Washington’s state agency may have a more strongly established communication channel with the medical community than most.
"In addition, I’d have to say this was made possible by committed, talented, and diplomatic physician leadership," she observes. "Dr. Glass was clearly able to speak in a language that created collaboration in the medical community, and willingness in claims care. [Once the plan was presented], he got the whole thing wrapped up in three weeks. He was expert, diplomatic, and creative — and created a win-win situation."
For more information, contact:
Lee Glass, MD, MPH, Associate Medical Director, Washington Department of Labor and Industries. Telephone: (360) 902-5024. E-mail: email@example.com.