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An ideal system serves the two primary stakeholders (the employer and the employee).

An ideal system allows and encourages clear, concise, timely and accurate communication (in-person, phone, fax, text, app, semaphore, morse code, smoke signals) between all parties. 

An ideal system provides a prompt provision of fixed and “fair” benefits to the legitimately injured worker within a no-fault system.

An ideal system ensures that all workers are covered by the system. 

An ideal system gives appropriate civil legal immunities to the employer. 

An ideal system utilizes the same criteria for compensability for all participants.

An ideal system encourages and mandates prompt reporting of all claims, a prompt determination of compensability and a prompt provision of appropriate benefits. 

An ideal system encourages and mandates that all claims to be finalized within a reasonable timeline. 

An ideal system provides the “same” benefits regardless of representation. .

The ideal system has few exceptions to the exclusive remedy doctrine. 

An ideal system engages, encourages, and mandates the participation and involvement of the worker in their treatment, benefit provision, recovery and return to work. 

An ideal system incentivizes, mandates, and encourages a high attention to safety in the workplace by both the employer and employee. 

An ideal system is designed so its financial incentives are focused to maximize injury prevention, prompt benefit provision, injury recovery and return to work. (incentives are not always penalties)

An ideal system uses “evidence-based criteria” to determine compensability of the claim as well as the appropriateness of medical care. 

The ideal system provides the appropriate and necessary medical care for the injured worker to achieve maximum medical improvement, and a return to maximum functionality. 

The ideal system provides an appropriate economic safety net for injured employees to meet their primary financial obligations while they are temporarily disabled. 

The ideal system economically reimburses the injured worker for permanent loss of a body part or the loss of its function. (To create consistency of this benefit throughout the United States. ideally every State and the Federal Workers Compensation systems would use the same criteria to make this determination) 

An ideal system facilitates and encourages prompt return to work for the injured workers. (Light duties, modified duties, transitional return to work programs, alternative work duties, and even permanent accommodations of the work sites)

An ideal system determines compensability and provides benefits consistent with the other states and social welfare benefit systems.

An ideal system recognizes, encourages, and builds a systematic coordination of benefits between workers compensation benefits and group health, LTD, STD, and with other employer obligations such as FEHA, ADA, Subsequent Benefits Injury Trust Funds or any other State or Federal benefits or disability programs. Coordination of the benefits should result in an improved economic safety net for the injured worker with minimal cost shifting and minimal overlap between benefit systems. 

The ideal system has specific measurable goals and expectations for all participants. These goals should include compensability decision and benefit provision by the claim’s administrators, timeliness of reporting by the injured workers and employers, quality medical care by the medical community, prompt accurate provision of reports by medical legal physicians, timely decisions by the Judges and prompt case resolution. To do this, the ideal system captures the necessary data and information from the participants, to determine cost trends, as well as the necessary information to measure the goals and expectations. 

An ideal system should result in the employers of the State being economically competitive in the world market. 

An ideal system has appropriate oversight (administrative and Judicial) to ensure that all parts of the system function in accordance with the intent, laws, rules and regulations. Oversight also ensures there is a safety net to continue benefits in case of bankruptcy by the insurance carrier or self-insured employer.  An ideal system does not tolerate any fraud or abuse by any participant in the system.

• The right medical care at the right time is always in the best interest of the injured worker and almost always will result in the lowest claims costs.
• The right medical care at the right time will (almost always) result in an earlier return to work with less permanent residual disability.
• Evidence-based medicine is the right care for the legitimately injured workers. (There is a hierarchy on how to apply evidence-based medicine).
• One of the best medicines for most injured workers is returning to work. Those who return to work (light or modified duties) usually recover faster with less disability.
• To control worker’s compensation medical costs requires both a fee schedule and an ability to control the frequency and the appropriateness of treatment. One without the others usually results in massive increase in medical costs for the system.
• The medical treatment fee schedule should be clear, easy to use, accurate and reflect the latest technology.
• A fee-for-service system may result in incentives for physicians to inappropriately over-treat.
• In many jurisdictions Worker’s Compensation is generally the last fee-for-service system.
• As long as workers compensation uses a fee-for-service system, medical utilization review is needed to make sure that the physicians will adhere to evidence-based medicine.
• Pharmacy utilization is problematic because of the “Medicalization” of the general population. (Medicalization is the direct advertising of symptoms and diagnoses to the general population by drug manufacturers, resulting in an overuse and/or misuse of some types of drugs and therapies).
• There is a significant problem with “off label use” of drugs in the worker’s compensation system. (Off Label is the use of a drug for treatment that was not the reason for its approval from the FDA).
• Medical decisions should be made by medical professionals. Most Workers’ Compensation judges, attorneys, and claims adjusters have little to no formal medical training and are not medical professionals.
• Poorly (inappropriate) placed incentives will result in poor medical outcomes. (There are several studies that demonstrate that allowing physicians to do self-referrals or to dispense pharmacy goods from their offices will usually result in a utilization of unnecessary services or inappropriate usage of drugs).
• Even if the doctor is not dispensing the drugs, opiates require regular visits to the doctor for renewal of the prescription and also may involve expensive drug testing; so there is an unintended financial interest on the part of some doctors to prescribe opiates.
• Some physicians who prescribe opiates do not fully appreciate the addictive power of the drugs that they are using or the difficulty in detoxing the patients.
• There are currently enough treating physicians and specialty physicians in most urban areas; however there are not enough physicians (treating, orthopedic or neurosurgery, etc.) in the rural areas to meet the demand. This problem will only get worse as the population ages and more doctors retire. It will also get worse if physicians leave workers’ compensation due to the demand for their services due to the implementation of the federal universal health care programs.
• Many surgeons and other physicians want to perform their craft (do surgery, provide injections, etc.). They truly believe that their surgery or injections will work even if the prior treatments have not been successful or if current evidence-based medicine says surgery is not appropriate.
• Every patient looks like a good candidate for an MRI when there is an MRI machine in the doctor’s office.
• Not every person with a surgical or potentially surgical condition is a good surgical candidate. Though pre-surgical psychiatric evaluations are required for spinal cord stimulators (post spine surgery), the same is not true for many other surgeries.
• It is difficult for a patient who is in intractable pain to believe that strong medications (including opiates) are not appropriate or are not good.
• It is difficult for a patient who is in intractable pain to believe that not having back surgery will have the same ultimate result as having surgery when the surgeon is saying (with confidence) that the surgery will cure all. Even though current evidence-based medicine says differently.
• Because “doing something is better than doing nothing” when the patient is in intractable pain, if the surgeon says surgery will not be successful, the injured worker will attempt to find someone who will say that the surgery “will be more successful than not having surgery,” and will then attempt to have the surgery.
• Patient advocacy is the application of appropriate treatment and patient encouragement that allows the patient to remain as functional and productive as possible.
• Patient advocacy does not always mean the pursuit of treatment a patient desires.
• Patient advocacy may require the physician to decline to do the treatment sought by the patient when that treatment is inappropriate.
• In Workers Compensation, there are many (known and unknown) underlying non-industrial, psyche/social issues that may hinder or completely stop optimum medical recovery.
• Outcomes are better for the injured workers when the treating physician instills expectation of recovery and involves the patient in the recovery process.
• Physical job descriptions are a valuable tool for the treating physician and physical therapist to help understand the mechanism of injury and set goals for recovery and return to work.
• The injured workers’ support group (family, friends, work environment) have a significant impact on positive recovery and return to work.
• An unintended consequence of tying attorney fees into maximizing disability is that it significantly hinders quality medical treatment, recovery, and return to work.

For thousands of years deer had two primary methods of survival.  The first was to run very fast when they were in an open field.  The second was to stand very still when they were in a forest.

If they could not outrun the mountain lion, they knew that if they stood still while in the forest that their camouflage would make it harder for them to be seen.

For thousands of years these methods worked very well to insure their survival.

With the advent of automobiles, the fundamentals of survival for deer changed. However, their basic instinct has not changed.  When a car is coming at them at 60 miles an hour many times, they freeze believing that they will not be seen.  The results are usually very hard on both the car and the deer.

This is called DITMR (Deer in the middle of the road) syndrome.

Every person can experience DITMR.

Most supervisors do not recognize when their employees are experiencing DITMR.  If the worker is dealing with a new task, when the volume of work is overwhelming or if there are large dollars at stake some people freeze.  The unconscious thought of the employee is “If I do nothing, I at least will not make a mistake or show how little I know about the job.” 

Unfortunately, for most jobs, doing nothing usually is worse than doing something.  In workers’ compensation, doing nothing usually results in slowing down the compensability decision, failure to provide benefits and significantly increases claims costs. 

When doing something, sometimes mistakes are made.  However, for claims examiners minor mistakes are actually one of most effective learning tools.  Doing nothing, usually results in a worse outcome than doing something.

It is good for supervisors and front line managers to recognize symptoms of DITMR and directly deal with the person to help overcome the problem.

The top three issues which create the most DIRMR are:

1.  The first time an employee had to perform a specific function

2.  Large or extremely complex claims files with high dollar exposure

3.  An excessive volume and variety of work which was thrown at the examiners in a short time frame.

DITMR is usually more acute with new employees than with highly experienced employees.

There are system analytics which may be employed to help identify employees who are experiencing DITMR.  These are a backlog on managing the claims diary, an unusually high number of claims which are delayed vs accepted or denied, stair-stepping reserves, or chronically not returning phone calls. Another symptom is when all claims settled are at the examiner’s settlement authority and none are above the settlement authority.

There are wonderful programs to help avoid or overcome DITMR.

• Recognize when the examiner is doing something for the first time and carefully walk them through the process. When completed, debrief.
• Do group staffing for larger files.
• Trade complex files between examiners to get the right case in front of the right examiner.
• Look for outside stressors which may be causing
• Look for relief if the caseload if overwhelming

One successful method to deal with the DITMR, is to talk about the phenomena with all of the employees.  I encouraged them to say “I don’t know what to do on this file” “This is my first time doing this and I would appreciate some help to get me through it.” Or I am completely overwhelmed!   DITMR is one of the roadblocks to productivity and success for the employee and for the office.  Identifying who may be impacted by DITMR is the first step to solving the problem.  Implementing analytics to identify DITMR is the second step.  Creating an environment where the issue was recognized and resolved in an appropriate way is the third step to success for the employee and the company.