This article is a transcription of an episode of the RateFast podcast, which you can listen to by searching “RateFast” in iTunes or the iOS podcast store.
If you’re a workers’ compensation provider, adjuster, or case manager check out RateFast Express: the service that writes your impairment reports for you!
In this episode, Dr. John Alchemy gives a slideshow presentation to an audience. He talks about various subjects and how they relate to money, including classical art and new car technology, as well as running a medical practice.
In the workers’ comp world, money is the reason why many doctors may possibly cut corners and not fill out work comp reports accurately. They may not make enough of a profit to think it is worth doing the paperwork. However, if the reports are not filled out properly, then they get sent back and even more time must be spent on them.
Using a program like Dr. John Alchemy’s RateFast, work comp paperwork is digitized and therefore much faster and more profitable for doctors to do.
Disability (noun) – [in workers’ comp] when a patient is unable to meet their social or occupational needs.
Impairment (noun) – [in workers’ comp] measurable loss of an organ or a body part.
QME (noun) – a qualified medical evaluator.
Restriction (noun) – [in workers’ comp] something that’s dangerous to the self or to others.
Narrator: Welcome to the California Work Comp Report, a podcast hosted by Arun Croll and Claire Williams, featuring Dr. John Alchemy.
The following podcast is an audio recording of Dr. John Alchemy presenting “Thriving as a Work Comp Medical Provider.” For the full presentation, including a slideshow, please visit workcompcentral.com, and click the Education tab. Enjoy.
Dr. John Alchemy: …This first one here is a piece of advertising material that we put out with my company. I’m a family practice doctor, by the way. I’ve been doing work comp about 20 years. I’ve done both large corporate work comp, I’ve done private work comp, and I currently direct two clinics. I’ve done just general family practice before, and so I kind of found my way into the work comp arena doing that. One of the things I wanted to bring up with practices and business, is that doctors in general are not good at running businesses, and that’s no secret.
One of the things that I came across was Michelangelo’s David. Has anyone here ever been to see it before? There are some interesting things about David in particular that I wanted to bring up for you to think about. First of all, when you go see this statue, it’s arguably one of the most famous pieces of art in the world. What I didn’t know is that Michelangelo’s David brings in about 10 million dollars a day to Italy. That’s what it brings in. It’s uninsurable, because no one knows its true value, which is interesting. In the billions of dollars, obviously. But, you know, why is it so valuable? And what’s the history of it? What happened? Well, it happens, back in the Renaissance, that not a lot of people read. And so the way that things were communicated was with statues and pictures, and they told stories. Well, there was something really unique about when Michelangelo got commissioned for the David. It was a time when the ruling party, called the Medici family, were thrown out, and the people wanted to celebrate, they wanted to commission a statue. So they wanted Michelangelo to do a classic David statue. It had been done about 150 times before, and everyone was expecting the same David. So he spent about a month just staring at this piece of stone, and he went to work. Two years later, he unveils it and brings it out. Absolutely not what people were thinking about. And in fact, people were so upset when he rolled this thing out, they threw stones at it and a finger got broken off. People nowadays don’t understand that. Why was it so vehemently opposed? It was because the perspective that he presented in this piece of work was radical. Every one and every piece of David that had been done, was after he had killed the giant. He had a sword in his hand, head at his feet, and that’s what people wanted. But Michelangelo, what he really did to upset the apple cart, was he changed the perspective, just a few minutes from where everyone was looking. And so he, he built the statue to show what happened just before the giant was killed, and that was what was so radical about this statue. And now it’s become one of the most famous pieces of art in the world. So it wasn’t that he was technically just an excellent sculptor, it was the fact that he actually redesigned the way that we thought about that story and about power and about conquering things, and that’s really what I wanted to show with this particular picture. Fascinating history behind that piece of art.
This next thing here is about business. This is the dashboard of a Model S Tesla. And right over here at the bottom, you’re going to see that little arm, in orange, and this little monitor over here, that’s energy consumption. And you’re either burning energy or you’re saving energy in a Tesla. And one of the things that I wanted to convey about this is that practices are either making or losing money, at any time of the day. You’ve either got spending going on or you have some profit coming in. And just because the doors closed at 5 doesn’t mean that you’re not losing money or paying for items and goods. So here’s the Tesla with regenerative braking, now you can see that it’s green, okay? And now you’re actually adding mileage to your battery as you’re out driving around. And so this is very analogous to making a profit. You’re going down hills, charging, et cetera.
So first of all, what is a primary treating physician? It’s a doctor with certain administrative responsibilities, who has to generate a story on these patients. You have to write a doctor’s first report, you have to write a PR-2, then you have to write a PR-4, alright? And there’s problems along the way with every step of those reports. The level of detail, the quality, how they’re written, et cetera. Doctor’s first reports, probably one of the bigger problems I see — Remember, the first report sets the tone for the client. And often, what I’ve seen happen is a lot of claims start in the ER. So they come in, they wanna make sure that their neck’s not broken, do a CT scan, send them out and then they show up in a work comp clinic somewhere. One of the big challenges is taking a correct inventory of the client. What we don’t want to happen is that three body parts are injured but only one was reported. Because of the way that the work comp moves, if you didn’t have it down, it didn’t happen, in many respects. And so taking just a brief inventory, not getting all the body parts in the claim, is doing a great disservice to everyone in the system. So for a doctor’s first, it’s very important to get all those body parts in there. If I’m gonna say one thing: Get the body parts down, get the history.
Number two, what are the benefits? Well the benefits are very important, because if we don’t have the correct body parts laid out, we can’t roadmap the case. One of the things I talk to newer docs about in work comp that are learning the system, is that from that very first day of injury, you should understand all the way through the end of the claim what’s gonna happen. You should have an idea and a roadmap in your head that we’re gonna start here, these things are gonna come in to play, this case will not be done until A, B or C is met. So I try to put into the doctor’s head a framework for how to manage and think about these cases, knowing that things can come up and change. And why is this important? Because in your practice and in your business, if you’re not able to lay out and deliver the goods to the employer, to the injured worker, and to the insurance carrier, you’re not gonna be in business very long. That’s a very interesting triangle to balance. You’re there for the patient, but you’re also there to make sure that every one of the stakeholders in the system gets a fair shake and that the benefits are done correctly and accurately.
So here’s some of the basic underpinnings of what I consider very important in claim management and helping patients along. Number one: Setting their goals. Are they at work, or are they not at work? One of the most common issues that you’ll run into is a patient will come in and they’ll say ‘Well, my employer doesn’t have modified duty, and you’ve given me a restriction for no lifting over 10 pounds. And so you have to send me home.’ And I think that’s one of the biggest challenges for providers, is to understand that well, someone may have an inability to do an activity, but their employer might still have accommodations that they can do at work. Or they may be disqualified from work because it’s an essential part of their job.
One of the great shortcomings is we never have job descriptions in the clinic. And if there’s one thing that you can probably do in any aspect of what you play when interacting with doctors, is to try to get them a job description. And so when you ask for that, often what happens is I get an administrative job description that says “This person needs to have a high school degree, play well with others, and no criminal record.” That’s not what we’re talking about. I like the RU-91 (description of employee’s job duties form). It’s pretty simple, it’s listed, it’s filled out. And I often won’t really make an opinion on that until I have both signatures on it. So I don’t send it home with the patient and say “Fill this out and bring it back.” I say “Go talk to your Human Resources, your supervisor, agree on what’s done and then bring it to me and I can make a determination.” So having that job description is probably one of the bigger challenges. And working with some of the bigger employers, it’s always nice because they’ll have their job descriptions laid out on the website. “This person is a package handler.” Click, boom. And that can really save them a lot of time of missed time in the workplace, et cetera. So having that available is key.
Functional limitations are really interesting. I quit calling them “restrictions” a long time ago, but they still get called restrictions. Has anyone ever thought about the way that work limitations are created? I never even really had a good working definition until I found one of these AMA Guides side-published books about work and return to work. But it’s really interesting, because in the book, they define, someone’s actually thought about this, restriction’s something that’s dangerous to the self or to others. So if I restrict you from driving because you have a seizure disorder, that’s a restriction because if that disorder causes a seizure, you’re gonna kill yourself or possibly someone else on the road or in the car. That is, by AMA definitions, a restriction.
The next category is medical capacity. And so that means that there’s clearly an underlying medical condition that would prevent the activity from taking place. So for instance, if my arm is amputated at the shoulder, my medical capacity comment is “Unable to use right arm.” Because I have no arm, okay? And there are some different variations of that, but that’s a capacity, a medical capacity.
The third and most common one we run into is tolerance. And I would say that’s 99 percent of the time. And that’s where the patient says “I can’t do something because it hurts.” And then what happens is that the doctor and the employer and the insurance company start to play a guessing game. “Well, we don’t think you’re in that much pain. You should be able to do this, you should not be able to do that.” But now they’re talking medical capacity, they’re not talking tolerance. And in a lot of injury, there is no definable underlying smoking gun saying that “This is the problem and this is why you can’t do that.” More times than not, “It hurts too much, I can’t do it as much as I used to.” So that’s tolerance. I write most of my restrictions based on tolerance. And I simply tell the patient and I tell the employer, “Look, I’m going to give you something based on what the patient is saying.” And then you have to make a determination if you can make an accommodation or not. If you can’t, that’s just fine. And I explain the same way to the patient. “We’re not here to hurt you, we’re gonna write down what you say. You’re the one that has to do this.” Because if I write something else down, all I have is that patient in my office the next day saying “I couldn’t finish my shift.” That gets everyone nowhere. So putting that down and letting the parties take a look at it, make a determination, great. Now about half the time, the patient might come back and say “Hey, you know, maybe I could lift a little bit more. I do want to go back to work, it’s important, et cetera, et cetera.” And I say “Great, so let’s go ahead and adjust the functional limitations, and away we go.” So after my 20 years of doing this, that seems to be the most efficient and amenable way to addressing the functional limitations.
Setting the structure for recovery – I always like to tell patients that “Look, we’re here to get you better, okay?” And there’s two ways that I’m gonna make a determination on that: One is your physical exam. “Are you moving better? Are you able to do more than you could before? Can you lift more, and all those things. And secondly, am I able to advance your work limitations?” If I can show that I’m advancing your work limitations, I am showing the stakeholders that what we’re doing is working, and there’s a return on the investment here. The investment is you, and the resources are physical therapy, medications, et cetera. So if I order a chiropractic adjustment and you feel 50 percent better, but it only lasts for two hours, is that really a great investment long-term for your recovery? So I try to table that to the patient so when they come back, I try to train them as to what am I looking for as a provider. So if you can get your patients and your doctors in that type of mindset, it becomes very quickly apparent if treatment is gonna be successful or not.
Disability versus impairment: one of the businesses and companies I own is RateFast, and we do and create software that helps providers and stakeholders in the system figure out what is going on with an injury with regards to impairment. One of the greatest pieces of confusion I see is using these two terms interchangeably – disability and impairment. If you’re going to read the AMA Guides, which is a daunting task to do, the AMA Guides is all focused on impairment. And the AMA Guides also talks about the difference between disability and impairment. And in its purest form, in my opinion — the judge might have some different stuff to put on this from a legal standpoint — these are two independent concepts, although we use one sometimes to help create a definition or a value for the other. Let me give you an example: an impairment is a measurable loss of an organ or a body part. And it is measurable. What’s interesting about the AMA Guides that I’ve learned over the years is that measurable just doesn’t mean that I’ve lost a couple of degrees of motion in my shoulder; measurable also means that I can’t do some things in my activities in my daily living, okay? If you’re familiar with the AMA Guides, there’s 34 activities of daily living. And if you can’t do some of those, they’re not called out in the book as disability. They’re called out as limitations, okay? They’re reflective of impairment, and that’s a big difference. Impairment is a measurable loss.
Now disability means that you’re unable to meet your social or occupational needs, okay? “I can’t lift 25 pounds, I’m disabled as a package handler.” “I can’t sit for more than 20 minutes, I’m disabled as a secretary, my job description says.” So that’s the difference between wanting to do something and not being able to do something, disability, okay? An impairment is that measurable loss, and impairment is what drives this system, from the medical standpoint, as coming up with that number between 0 and 100, that WPI, whole person impairment. We’ll talk a little bit about that later.
This is most nearest and dearest to my heart, the PR-4 report. And the PR-4 report is obviously just a report that the primary treater uses to create the impairment rating. And it’s in more general sense an impairment report, and that can be in anyone’s report, an AME, a QME, et cetera. And it’s just this process of coming up with the value of the injury. And after doing this for years, to me, the best analogy is “This is the tax return of the insured worker,” okay? It takes into account all kinds of things for the case: When they got hurt, what they were treated with, how they responded, what their pain levels are, what their frequencies are, et cetera. One of the most difficult things in doing an impairment report is putting in the piece of the patient’s report, “how did the injury affect me,” “it’s 8 out of 10,” “it’s frequent,” “it affects me four days out of the week” – taking that piece and including it into the numeric result of the report – that is the true art form of impairment rating.
The other art form is the ability to not put on blinders and say “Oh, because this is a back pain, I have to use the DRE method (Diagnosis-Related Estimates) in this particular regard, I’m only gonna collect these pieces of data.” Because the AMA Guides’ pretty clear on the data that it needs, and the more data that you have, the more comprehensive value you have for that report, and the more accurate it is. One of the most frustrating things is to look at QME or AME reports or PR-4 reports, and you see wide variances on the medical opinions, okay? And that’s something that really ate at me. It’s like, how can two people look at the same person, collect the same data, and get two very different results, when the recipe book is very standard?
So, the way that the report is organized, the way that the information is collected and analyzed, is critical on getting a consistent impairment report. And that’s really why we signed up for the AMA Guides, so we could stop guessing. The problem with the AMA book is that, for the most part, it’s unusable for doctors. It’s not really a medical textbook, it’s not really a legal textbook, it’s kind of this weird anomaly of partial definitions and terms that were created by committee, basically. And so it’s very, very frustrating. But I always tell new doctors starting out, “Look, your job is to get that number as the book says. And then you can talk about why it’s right or why it’s wrong, or create analogies. But step 1 is getting the correct impairment rating.” And so the PR-4 report is really important, because it now changes the flavor of the case.
Why do they get delayed? Well, doctors don’t want to do them. Period, okay? And when we were checking and surveying practices, probably about one in four primary treating practices now, aren’t even doing PR-4’s. They refer them out, they send them to QME, they just don’t want to deal with them. Why? Because you can’t keep the lights on writing PR-4 reports. A single body part PR-4 report, the doctor’s office is probably going to make somewhere — $300, $320 on that report. And if the doctor is truly doing the report, doing the math, and if you’re doing it manually, you’re probably looking at about 90 minutes of calculation time and dictation, okay? And you put that on top of 20, 30 minutes with the patient interview, and pretty soon, this isn’t looking like a very profitable endeavor, okay? So it is cheaper to send them out. Also what happens, if you don’t do a lot of these reports or they’re incorrect, you get letters. Doctors don’t get paid to answer those letters, okay? And it gets put on the bottom of the pile, because I can do a refill in 5 minutes and feel like I got something done, or I can sit down and have to remember this PR-4 and go through this lengthy letter.
So from a medical provider standpoint, they’re becoming much less and less popular to use and to create. It’s like “Why do I want to write a report where I don’t get paid, and I get abused afterwards?” And that’s really the sentiment with a lot of medical providers in doing the PR-4’s. And they’re often wrong, because they’re just missing a lot of information, the doctors don’t understand it, there’s validations and rules, and they’ll come up with a number. And here’s the other political issue that I found: The PR-4 reports, there really is no motivation for a doctor to do them accurately. Why? Because no one can really check their work. So why am I gonna put down all this time and effort to do something and not get paid well, and if I do it poorly, I seem to get paid just the same? What’s in it for me? And that’s really been really one of our most challenging barriers in working in impairment rating, and the business, is why does someone want to adopt a system that gives them a more accurate product when they’re not penalized for being inaccurate? Okay? Now I don’t necessarily subscribe to that, but that is the reality out there. And that will be changing for a variety of reasons, I believe.
Narrator: Thank you for joining us for this episode of the California Work Comp Report. We look forward to next week in continuing our discussion of work comp claims in California. Questions or comments? Got a great workers’ compensation story to share? Find us on Twitter at @ratefast or at rate-fast.com.