The Moving Fulcrum

When I started in the workers' compensation field, medical treatment requests needed only a physician's opinion that it was reasonable and necessary. Virtually anything that a doctor wanted for the injured worker was ...

That led, of course, to abuses, and a long line of injured workers who didn't get better, who didn't return to work, who incurred intractable disability and a few medical providers that benefited from the liberality financially.

Along came guidelines.

Guidelines were first introduced by the general health insurance industry to assist meting out treatment dollars. While efficacy was a paramount concern, the primary consideration for the medical insurance companies was controlling the outflow of dollars - prescriptions, if you will, for what would and wouldn't be paid.

The health carriers provided appeals processes, largely in response to federal mandates, to allow for exceptions where the standard treatment protocol wasn't effective but where a technique or service that hadn't yet been fully vetted could be implemented and investigated. If it worked, super, and if not, on to the next thing.

It took a couple of decades for guidelines to merge into workers' compensation. Now virtually every jurisdiction uses some form of medical guideline to regulate the administration of treatment.

This works most of the time for most people.

Some people fall outside the bell curve of guidelines, though. For those people the usual remedy is to find other evidence either not recognized by the guidelines in place or for which the guidelines had not yet been updated and then convincing someone up the appellate process that the evidence sufficiently supports the treatment attempt.

An interesting debate occurring in Oregon demonstrates the forces at work.

The Oregon Workers’ Compensation Division isn’t impressed with platelet-rich plasma injections despite evidence that professional athletes have used the therapy as a way to heal injuries faster and get back on the job sooner.

At least not yet.

WCD and is moving toward renewing a policy that the treatment is not compensable in workers' compensation claims.

Platelet-rich plasma ("PRP") injections take a sample of the patient’s own blood and process it to produce a concentrate of platelets, cells best known for their role in blood clotting. The platelet-rich plasma also contains growth factors that can help with healing, the theory goes. A doctor injects the PRP into the injury site, repeating the treatment every few weeks as needed.

According to an information page posted by the American Academy of Orthopaedic Surgeons, PRP has been found to be most effective in treatment of chronic tendon injuries, such as tennis elbow. Although more evidence is needed regarding the therapy’s effectiveness for other injuries, AAOS says risks of the procedure are about the same as for cortisone injections.

The Medical Advisory Committee subgroup of the Oregon WCD evaluated PRP treatment and proposed a recommendation that platelet-rich plasma injections should not be compensable, at least yet, because there is inadequate published scientific studies supporting its use.

The committee, however, leaves the door open to reevaluating the policy in the future since research on the injections is continuing.

What this really means is that the financial risk of paying for a relatively innocuous medical treatment service outweighs the probability of medical efficacy. Since workers' compensation is a "first dollar" medical benefit system (i.e. the patient in the vast majority of jurisdictions doesn't have a co-pay, deductible or any other financial participatory obligation) the party that actually pays (i.e. the employer/carrier) has a say as to whether or not it is willing to assume the efficacy risk.

Whether this is right or wrong in the privatized public benefit system of work comp can be debated endlessly. It just is the way it is, and is part of the deal.

While PRP holds "great promise," says AAOS, it also notes, "Few insurance plans, including workers' compensation plans, provide even partial reimbursement."

At some point, all of the studies on professional athletes using PRP will have sufficient correlations to determine whether, in fact, it is a beneficial treatment that should be provided via workers' compensation.

Until then, the fiduciary component of workers' compensation - watching where the money goes - will remain conservatively based. There will be some cases where the therapy is approved on an industrial basis when the physicians provide sufficient evidence and argument in favor of approval, and those cases will be studied too.

It's not a perfect system. And some folks will get denied treatment that could help them move on ... or not. 

Balancing the interests of those who pay, and those who receive, is inherently vague. The fulcrum is always moving.