By Judge Frank R. McKay and Judge Elizabeth D. Gobeil
A man fell 18 feet off a roof, crushing both ankles and suffering a fractured lumbar vertebrae and a dislocated left shoulder. While tragic, the silver lining for this individual was that his employer had workers’ compensation insurance, and the prompt medical treatment provided to this worker facilitated a nearly full recovery. The roofer returned to a non-roofing job after several surgeries and a period of physical therapy and rehabilitation.
When work injuries happen, the State Board of Worker’s Compensation (“the Board”) wants to get workers feeling better and back to work as soon as they are able. Georgia’s medical professionals play the central, and often pivotal, role in determining workers’ health outcomes and, accordingly, also have a huge impact on the disposition of contested claims.
The Board is considering several pressing policy issues that may have a bearing on your practice, and we appreciate the opportunity to share a few of them with you and enlist your help.
Opioid Overutilization and Response
The Problem and National Response. While recognizing that opioids have a place in medicine, we see far too many instances in Georgia’s workers’ compensation system where prolonged use has ended in tragedy for injured workers and their families. More commonly, it has unnecessarily delayed getting injured workers better and back on the job to the detriment of both the workers and their employers.
We participated in the recent National Prescription Drug Abuse and Heroin Summit, which explored the breadth and depth of the opioid problem. According to CDC data from 2007, unintentional drug overdose deaths in the United States occurred once every 19 minutes. Fueled by the growing use of prescription opioid analgesics, the problem has tripled in the 15 years leading up to 2014, culminating in 28,000 opioid-related overdose deaths in that year.
The Summit unveiled several initiatives aimed to curb the opioid problem, including the CDC’s guideline for prescribing opioids for chronic pain released in March. (See www.cdc.gov/drugoverdose/prescribing/guideline.html) Both the American Academy of Orthopaedic Surgeons and the American Academy of Neurology have also issued position statements on the risks of prescribing opioids.
Among other recommendations, the CDC guideline states that opioids should not be used as first-line or routine therapy for chronic pain. The guideline advises clinicians to consider opioid therapy only if clinically meaningful benefits for both pain and function are expected to outweigh risks to the patient.
Further, the guideline emphasizes the importance of counseling patients on the risks of opioid therapy to help facilitate an informed risk/benefit assessment. When opioid therapy is considered, the guideline specifies opioid selection, duration, followup and discontinuation.
What is the Board doing? Georgia participated in a recent study by the Workers’ Compensation Research Institute (WCRI) examining longer-term opioid use over a two-year time period ending March 2012. According to that study, Georgia showed a slight decrease in longer-term use of opioids (0.2 percentage point change over the study period). That decrease, however, was not statistically significant, and we remain concerned about the level of opioid use in Georgia, especially in non-surgical and longer-term situations.
On the judicial side, the Board is mindful of cases in which opioids appear to be used inappropriately, particularly for long-term use. The Board has the authority to order a change in treatment or change in physician when situations warrant.
While the Board prefers those decisions be made between the parties, often these issues are litigated. When these matters come before us, one of many factors we consider is the impact and propriety of the drug regimen in place under the current treating physician. While the Board lacks treatment guidelines, we do consider prescribing practices (and their effectiveness toward better worker health outcomes) when exercising Board discretion over medical authorization and change in physician decisions.
On the policy side, we are working with stakeholders (including several doctors) on the Chairman’s medical advisory committee to vet potential solutions to target inappropriate and overuse of opioids. Options discussed have ranged from physician education to a drug formulary. We rely upon the advisory committee to help us assess the advantages and disadvantages of various approaches and welcome your input into that process.
Aging Workforce Issues
The Challenges. Like the rest of the country, Georgia’s workers’ compensation system is challenged by aspects of an aging workforce. According to the U.S. Bureau of Labor Statistics, between 1977 and 2007, there was a 101 percent increase in employment of workers 65 and over — a trend that is expected to continue. This trend is associated with an increase in medical and indemnity costs due to the increased risk for injury and larger incidence of comorbidities that can deter recovery.
In addition, an aged worker who is injured often presents practical challenges in claim management. For instance, given the greater incidence of comorbidities in the aging population, it is more difficult to distinguish where the work injury starts and ends as compared to the underlying comorbid condition.
Unlike other states, there is no apportionment of liability. The condition is either compensable or it is not. Georgia’s definition of a workers’ compensation injury includes the aggravation of a preexisting condition by accident arising out of and in the course of employment, but only for so long as the aggravation of the preexisting condition continues to be the cause of the disability; the preexisting condition shall no longer meet this criteria when the aggravation ceases to be the cause of the disability. O.C.G.A. Sec. 34-9-1(4).
Accordingly, this issue is hotly debated and turns on the opinion of the medical professionals involved. If you are attuned at the outset to the significance of the work-related contribution, you can provide more precise medical causation opinions. In turn, having more precise opinions can help facilitate quicker authorization and payment of diagnostics and treatment as well as better assist us in compensability assessments.
What’s New in Physician Panel Requirements?
The Board recently updated its rules in response to marketplace realities that were making it difficult for employers to field a panel of physicians. For background, there are specific rules concerning what constitutes a valid physician panel in Georgia and the consequences for failing to maintain a valid panel. (See O.C.G.A. §34-9-201 and Board Rule 201 for specifics).
Historically, one of those requirements was that no two physicians on the panel be associated with one another. This requirement posed problems both in rural areas where there are fewer physicians and statewide with the growth of medical practice consolidation.
Effective July 1, 2015, there is no longer a requirement that physician panels consist only of non-associated physicians. As a result, you and your associates are eligible to appear on the same employer physician panel.
Coming Soon: Physician Registry
The Board is working on creating a physician registry linked to the Board’s website that will allow any physician interested in workers’ compensation to register by name and specialty and provide contact information. This will allow users of the website to search for physicians by specialty who accept workers’ compensation patients and allow the Board to send notices of items of interest and changes in rules and statutes germane to physicians. The site will also have a section of frequently asked questions that will be of interest to physicians.
Thank you for the opportunity to comment. We appreciate your service and welcome the chance to work with each of you as we seek continued system improvement.