WCIRB Studies Support Concentra’s Early Intervention Model of Care

The findings of two California workers’ compensation studies in 2020 may have surprised some individuals but not Concentra® customers. Both studies offered additional evidence supporting the early intervention model of care that Concentra pioneered, refined for nearly 30 years, and continues to advocate as a cornerstone of our approach to treating work-related injuries.

The studies by the Workers’ Compensation Insurance Rating Bureau (WCIRB) of California concluded:

1. Delaying medical care and physical therapy for soft-tissue musculoskeletal injuries results in significantly higher indemnity and medical costs and longer case duration than similar claims with no undue delay; similarly, delayed cases are more likely to result in higher rates of employee disability.
2. When physical therapy is received early, soft tissue musculoskeletal injuries/workers’ compensation claims are less likely to involve opioid use and lost work time, compared to similar cases when physical therapy is delayed. Also, case costs and duration are significantly less when physical therapy is applied earlier.

The first finding was reported in the WCIRB analysis, Cost Impacts of Medical Care Delays in the California Workers’ Compensation System in October 2020.¹

The second finding was reported in the January 2020 analysis, Physical Medicine Treatments and Their Impacts on Opioid Use and Lost Time in California Workers’ Compensation.²

Concentra working ahead of the curve

In January 2000 – 20 years before the WCIRB studies – a team of Concentra physical therapy leaders and analysts published research in the Journal of Occupational and Environmental Medicine on low back injuries, which today represent 38.5 percent of musculoskeletal injuries that require time away from work.^3,4 The study, “Effectiveness of Early Physical Therapy in the Treatment of Acute Low Back Musculoskeletal Disorders,” was authored by lead researcher Gary Zigenfus, MS, PT, who founded the physical therapy program at Concentra in 1992 and served as national therapy director.

“As time elapses, although both medical and non-medical costs rise significantly, non-medical costs accelerate at a more rapid pace than medical costs. Reducing disability duration as well as shortening the treatment process will lead to tremendous savings in both medical and non-medical costs,” Concentra researchers stated in 2000. “Employers, insurers, and health care providers have been searching for cost effective ways to treat injured workers. The sports medicine model, with its emphasis on early intervention and functional restoration, is one such approach.

“Our results showed that initiating therapy early in the course of treatment was associated with fewer physician visits, earlier discharge from care, fewer restricted workdays, and fewer days away from work. The shorter the delay, the fewer medical treatments patients require and the more quickly patients return to work at full capacity.” They added, “The effectiveness of early therapy intervention in reducing primary care utilization, shortening restricted workdays, and reducing absences from work has important economic implications.”

Now, compare those Concentra statements in 2000 to key findings stated in the WCIRB’s October 2020 research into the consequences of delayed care⁵:

• Claims with soft tissue injuries that had a month delay before receiving the first medical service had, on average, significantly higher indemnity and medical costs than similar claims without medical care delays. The cost differential persists for years after the injury.
• Soft tissue claims with delayed care were more likely to stay open longer, have a longer duration of temporary disability, and involve permanent disability.
• The long-term cost implications of delayed medical care were similar for claims with other leading medical diagnoses in the workers’ compensation system, such as low back pain, dislocation, sprain, and fracture.
• Soft tissue claims with delays in the first physical therapy treatment also had significantly higher medical and indemnity costs years after the injury compared to similar claims with no delays in physical therapy.

The WCIRB study supports Concentra’s model of care and joins the burgeoning research since 2000 supporting a sports medicine approach of early intervention and focused functional restoration as leading to better outcomes, reduced use of pain medication, injections, and imaging, and less need for surgery.^{6,7,8,9,10,11}

Concentra’s model of care explained

“Concentra's treatment model is an early intervention, function-based, active hands-on approach. Research shows very clearly that early intervention improves recovery time for musculoskeletal injuries. In addition, the early intervention model has been shown to decrease total health care costs, opioid use, numbers of injections, and diagnostic imaging. We focus on ability or function versus disability or pain and limitations. Active treatment and therapy keep injured employees focused on function, and that's our whole purpose,” Concentra Vice President of Therapy and Specialist Services Mark Glover, DPT, explained in a recent Concentra webinar, “The Role Manual Therapy Plays in Early Injury Recovery.”

Active, hands-on treatment and patient engagement depart from the largely more antiquated approach of passive treatments, such as sedentary relaxation and application of heat or cold. Instead, Concentra’s active, hands-on treatment approach utilizes therapeutic exercise and therapeutic activities to build strength, improve coordination and flexibility, boost the cardiovascular system, and relieve muscle stiffness and fatigue in the injured employee.

Therapeutic exercise involves targeted exercises to address limitations in movement that are found during a physical therapy evaluation. They are developed for each individual’s treatment program and always include a home exercise program. Therapeutic activities are functional activities that simulate job functions. Examples are lifting, carrying, pushing, and pulling.

Concentra focuses on restoration of function – assessed at each visit based on a set of objective measures – to empower employees to take ownership of their recovery so they can return to work and life faster. Again, this is a departure from an approach based on continually asking employees to rate pain severity on a scale, which can increase the experience of pain and delay recovery.

“We don’t want to cause injured employees to entrench pain pathways by asking them to think about pain at every visit. Even when there is no longer tissue damage in the body, the brain’s learned pathways can create feelings of real pain,” Maja Jurisic, MD, vice president and medical director of strategic accounts, said in an article on Concentra’s alternative to the pain scale: Functional Restoration/Status of Healing scale, or FReSH scale.

Concentra’s model of care incorporates the FReSH approach to help employers and injured employees think about injuries with an “ability mindset” focused on gains in functional ability and what the employee can do – instead of dwelling on pain and limitations, a disability mindset that delays recovery.

This “reframing” of injury recovery provides early and effective motivation for the injured employee to actively participate in the treatment plan. Concentra has learned that after an injury, an employee may experience uncertainty, frustration, depression, and even anger, which may lead to fear avoidance behaviors: lethargy, avoiding movement, and feeling anxious about the possibility of re-injury.¹²

Again, Concentra has forged a new path, one that has been largely unavailable or even understood outside of occupational medicine and workers’ compensation. Concentra’s Chief Medical Officer John Anderson, DO, explains, “We use a biopsychosocial approach that addresses psychological and social factors to motivate an employee to actively participate in their treatment plan and frequently return to work in some capacity to prevent issues that can adversely affect healing. Those issues can include feelings of social isolation, fear of job loss, loss of income, and even anger or hostility. Eliminating these barriers can promote recovery and avoidance of unnecessary disability, as well as reduce lost time, lost productivity, and total case costs.”

Dr. Anderson and Giovanni Gallara, MPT, PT, senior vice president of national therapy and ancillary services, led creation of Concentra’s Occupational Health University (OHU) to provide ongoing instruction to Concentra clinicians in Concentra’s model. OHU curriculum has evolved under the expert guidance of Barry Magnus, MD, Lisa Figueroa, MD, and Mark Glover, DPT, PT, aided by Concentra’s Learning and Development team, under the direction of Amy Barbour. Dr. Anderson and OHU were featured by Risk&Insurance, as well as profiled in an article on Concentra.com.

Reducing use of opioids, injections, and diagnostic imaging

Concentra follows a best practice of avoiding the use of opioid medications, exhausting all alternative therapies first and, if use is necessary, prescribing the lowest effective dose. Long-acting opioids are never prescribed for acute pain. This best practice is well-supported by Concentra’s treatment model (early intervention, active hands-on therapy, function focus, and early motivation) and our FReSH alternative to the pain scale.

This is a good time to consider how the WCIRB’s January 2020 study on early intervention care reducing the use of opioids supports Concentra’s model of care.

WCIRB findings in the January 2020 report included:

• When soft-tissue injury claims received early physical therapy (within 30 days), they were less likely to involve opioid use within one year of the injury than similar claims without early physical therapy.
• When opioids were used, dosages were significantly lower when physical therapy was provided early.
• Early physical therapy also was less likely to result in lost time compared to claims without early physical therapy.¹³

In 2016, an article by a group of Concentra therapy directors in Illinois, Arizona, South Carolina, Texas, and Florida was published by the Occupational Health Special Interest Group (OHSIG) of the Academy of Orthopedic Physical Therapy. Entitled, “Physical Therapy Early Intervention in the Work Place,” the article was authored by Daniel Dudek, PT, DPT, CMT, MS, ATC, with Michael Morgan, PT, DPT, Chris Studebaker, PT, DPT, OCS, Sarah Stultz, PT, OCS, FAAOMPT, and Shelby Warner, PT, FAAOMPT, CSCS.¹⁴

The Concentra therapy directors highlighted the link between early intervention physical therapy, reduced opioid use, and cost savings. Citing supporting research, their findings included:

• A positive effect of early physical therapy is seen in the psychosocial impact of employee injury and reduced use of more expensive diagnostic imaging and other interventions such as steroid injections, prescription pain medication (opioids), and surgery.
• Increased costs of care are tied to greater use of diagnostic imaging, spinal injections, surgeries, and opioid medication. While at times necessary, injections and surgery come with a risk for complications caused by the intervention itself.
• Opioid medications and other painkillers can have side effects and pose the risk of addiction.
• The use of opioids, injections, imaging, and surgery have a significant impact on the overall cost of a case – one study found that a 108 percent increase in prescription opioid use in lower back pain cases produced case costs that were 423 percent higher, adjusted for inflation.¹⁵
• The use of opioids, injections, and surgery are associated with moderate to poor to worsening outcomes and persistent high rates of opioid use two years after surgery.

Concentra researchers concluded their article with this statement:

“With escalating health care costs relating to workers’ compensation, it is crucial to effectively manage cases to optimize both employee and employer outcomes. Therapists can optimize employee injury management by educating employers, employees, payors, and referral sources about the benefits and cost-effectiveness of providing therapy as soon as possible after an injury.”

Conclusion

Concentra saw the benefits of early-intervention therapy decades ahead of others in workers’ compensation and transformed research findings into a model of care that has been providing benefits to employers and workforces for 30 years.

Contact Concentra to learn how our early intervention model can enhance your workforce health and safety.

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NOTES 
1 Cost Impacts of Medical Care Delays in the California Workers’ Compensation System. WCIRB California. October 2020.  
2 WCIRB Releases Study on Impact of Physical Medicine Treatments on Opioid Use and Lost Time in California Workers’ Compensation/ WCIRB Wire. January 16, 2020.
3 Zigenfus GC, Yin J, Giang GM, Fogarty WT. Effectiveness of early physical therapy in the treatment of acute low back musculoskeletal disorders. Journal of Occupational and Environmental Medicine. 2000; 42(1): 35-9.
4 Back Injury Statistics. The Good Body. January 30, 2020.
5 Cost Impacts of Medical Care Delays in the California Workers’ Compensation System. WCIRB California. October 2020.
6 Fritz J., et al. Primary care referral of patients with low back pain to physical therapy: impact on future healthcare utilization and costs. Spine May 18, 2012
7 Gellhorn A., et al. Management Patterns in Acute Low Back Pain. Spine. 2012; 37:775-782.
8 Dudek D, Morgan M, Studebaker C, Stultz S, and Warner S, Physical Therapy Early Intervention in the Work Place, Orthopaedic Practice, Vol. 28; 2:16 (2016), 
9 Linz, Douglas H., et al. "Effectiveness of occupational medicine center-based physical therapy." Journal of occupational and environmental medicine 44.1 (2002): 48-53.
10 Arnold, Elizabeth, et al. "The effect of timing of physical therapy for acute low back pain on health services utilization: a systematic review." Archives of Physical Medicine and Rehabilitation 100.7 (2019): 1324-1338.
11 New study on low back pain from the Workers’ Compensation Research Institute. WorkCompAcademy.com. September 9, 2020.  
12 Dudek D, Morgan M, Studebaker C, Stultz S, and Warner S, Physical Therapy Early Intervention in the Work Place, Orthopaedic Practice, Vol. 28; 2:16 (2016),
13 WCIRB Releases Study on Impact of Physical Medicine Treatments on Opioid Use and Lost Time in California Workers’ Compensationhttps://wcirb.com/news/wcirb-releases-study-impact-physical-medicine-treatments-opioid-use-and-lost-time-california. WCIRB Wire. January 16, 2020.
14 Dudek D, Morgan M, Studebaker C, Stultz S, and Warner S, Physical Therapy Early Intervention in the Work Place, Orthopaedic Practice, Vol. 28; 2:16 (2016),  
15 Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? Journal of the American Board of Family Medicine. Jan-Feb 2009; 22(1): 62-8.