Work injuries in Washington State

 

back-neck

 

 

Washington State Law dictates that an injured worker has a right to choose the doctor of their choice to treat his/her occupational illness or injury (including licensed practitioners of medicine, osteopathic medicine and surgery, chiropractic, dentistry, podiatry, optometry and naturopathy) and further, that a worker may change to a new doctor of his/her choice during the course of treatment.

In Washington State employees and their employers are protected with one of two different variations of industrial insurance:  The Department of Labor & Industries or for some large employers, “Self-Insurance.”  Both systems are subject to and must follow the same rules.

With laws dating back to 1911, worker’s compensation as administered in Washington State is a “no-fault” system, meaning that it forces neither the employee nor the employer to accept “blame” for the accident.

As the first State to make workers’ compensation mandatory for the most hazardous jobs, Washington expanded the system to cover all types of employment in 1971.

Washington Department of Labor and Industries is one of the oldest providers of workers’ compensation in the United States, and also one of the largest, covering over 151,000 employers and 1.7 million workers.

Additionally about 400 large employers “self-insure”, covering the balance (about one third) of Washington employees.

Yearly, about 180,000 Washington State Labor & Industrial work injury or occupational disease claims are filed and of those filed, about 85% are accepted as valid.

Employers and employees both pay for the administration of this system (Labor & Industries State Fund), with employers paying 70% of the cost and employees paying (deducted from their paychecks) the remainder.

This cost (experience rating) increases, for both employees and employers, with each additional claim filed for a given company.  This ‘cost of doing business’ is ultimately incorporated into the price consumers pay for products and services.

High risk occupations, such as logging and roofing, as expected, involve higher workers compensation premium costs for both employees and employers. Striving to reduce risk and accidents in high profile occupations such as these, Labor and Industries regularly inspects and may even levy fines and/or shut down an employer who is allowing dangerous work conditions.

These important occupational preventative measures not only reduce occupational expenses, but also deaths.

Benefits available to injured workers include:

  1. Payment for medically necessary treatment,
  2. Modifications of home, vehicle and workplace (if necessary),
  3. Replacement of a percentage of wage loss,  and
  4. Pensions to unable-to-work employees and families of workers who die due to a work injury or disease.

Wage replacement (time-loss) eligibility is unprecedented on the worker being unable to return to work within three days of their occupational injury.

As a network health care provider caring for injured workers, one of my responsibilities is to educate injured workers about the benefits they should and should not expect to receive from their workers compensation system.

It’s also my responsibility to report unsafe work situations which I identify while treating patients injured on the job.

Although most work injury claims efficiently resolve, resolution of 5 percent of claims is protracted, accounting for 84 percent of the approximately $1 billion which is spent annually in Washington State for injured worker medical and time-loss expenses.

Again, these expenses are passed onto patients and employers alike in the form of increased premiums and onto the consumers of the goods and services produced by these employees and employers.

Premiums depend upon the safety record of a given employer but also on the classification of the industry. For example, with logging and roofing, which are are relatively dangerous occupations, hourly premium (paid to L&I or the self-insured company) exceed $8 per hour.

Safety can really pay, with a small company (20 employees) with a poor safety record paying in excess of an additional $60,000 per year in premiums.

Surprisingly, the most expensive work injury claims are usually neither falls from high buildings nor lost arms or legs, but back injuries that without proper treatment and management linger and deter otherwise able-bodied people from returning to the work force.

This is where chiropractic and massage therapy shine because relative to alternative approaches (injections, medications, extended time-loss), healing and return-to-work-and-full-function are accelerated by the utilization of hands on manual therapy (and sometimes retarded by high tech interventions.  (Source:  L&I research).

A difficult situation may present for the patient presenting with chronic musculoskeletal (back) pain in that once measurable healing progress plateaus, industrial medical care benefits cease.  Thus it behooves an injured worker to choose their clinic / attending doctor wisely.

How the System Works

Claims are initiated when I (as a provider) send an Accident Report to Labor and Industries or the self-insured employer.

As a patient it is entirely your decision whether or not to file a claim.  Even if a given doctor doesn’t think a claim is appropriate, he or she (if they are an L&I network provider) are required to file the claim for you, if that is your request, so that the final determination can be made by L&I or the self-insurance.

Sometimes patients do not wish to file even when an occupational injury is clear cut in this scenario as a provider I am required to inform him or her of their rights and to offer to lend assistance in making application for compensation.

Sometimes employers think it would be a good idea for them to pay directly for an injured worker’s care in order to avoid a mark on their work injury experience rating (and the premiums they pay), but Washington State law (RCW title 51) forbids this.

If a patient does elect to not file a claim for a clear cut occupational injury, the law further dictates that they or their providers should no then seek payment from their other health insurance, in other words, they must pay for tests and care out-of-pocket.  Along with this, when providers submit insurance claims to regular health insurance, the claim almost always requires the provider to check a box indicating if the patient suffered either an occupational or auto injury.

Workers need to be aware that the law dictates that claims should be filed even for minor injuries, for example only those requiring first aid.  And again, if workers fear being fired or facing employer retaliation, the law protects workers against such discrimination.

Note:  Ask our front desk for the brochure, “Workers’ Guide to Industrial Insurance Benefits,” in English and Spanish, available to help guide injured patients toward realistic industrial insurance expectations.

Re-training expectations, for example, are a frequent point of contention between injured workers and the system and the reality is that re-training options are both a last resort and limited at best.

For a patient who has been on time-loss for three months, there is a 50 percent probability that he / she will still be on time-loss at one year (source:  Department of Labor & Industries).

Treatment should be aimed at recover and return-to-work.  Nearly all injured or ill employees have jobs and when off work they should keep in touch with their employer.

As soon as it is safe, Early Return-to-Work can usually be achieved under medical supervision when jobs are modified or limited while injured workers continue to recover, with the goal of optimizing return to a productive life. With proper injured worker accommodation and job modification, early return to work can actually play a crucial role in maintaining activity and enhancing treatment.  Truly pro-active employers will do everything they can to accommodate a recovering injured worker along these lines.

Some of the most difficult cases often involve:

  1. Catastrophic injuries requiring hospitalization,
  2. Injuries requiring 90 days or more of time loss,
  3. Older (45 years old plus) patients with carpal tunnel syndrome,
  4. Secondary medical conditions, such as diabetes or depression,
  5. Unorganized doctors with unorganized treatment plans,
  6. Misuse of medications,
  7. Physicians fostering illness beliefs,
  8. A lot of prior surgeries,
  9. Stalled recovery progress,
  10. Alcohol or drug abuse,
  11. Depression or avoidance anxiety, post-traumatic disorder,
  12. Anger at one’s employer or employer anger anger at employee,
  13. History of abuse or family instability,
  14. Problematic personality traits, disorders, or interpersonal relationships,
  15. Low educational level,
  16. English not primary language,
  17. Employment in heavy industry by an over 50 year old worker,
  18. Back, hip, thigh, knee, leg, ankle, or foot injury with medium or heavy labor employment, and
  19. When the injured worker is nearing retirement age

Note:  Ask for the brochures at our front desk titled, “Getting Back to Work:  It’s Your Job and Your Future.”

Getting back to work as soon as possible has been shown to enhance injured worker recovery, reduce their impairment, and help them feel more self-confident and valued.  Furthermore, if you can perform some type of transitional work during your recovery, you may qualify for loss of earning power (LEP) benefits.  LEP usually allows you to earn more than if you were receiving time-loss compensation alone.

Transitional work during your recovery gives you an opportunity to perform:

  1. Light duty work,
  2. Graduated work,
  3. Part-time work, and/or
  4. Modified-work.

One does not need to be medically stable to benefit from these early return-to-work strategies and again, they usually result in a better medical outcome.  All that is usually needed is a little flexibility on everyone’s part–including the attending doctor and employer, to help the recovering worker.  Labor & Industries even offers to reimburse employers for tool or equipment modification (up to $5000), if it will help the injured worker make a more successful transition back to work.  Special vocational counselors are also available to help employers consider additional helpful options for transitioning back to work employees.

Additionally, returning to work with another employer is also a possibility.

Finally, “job retraining” is one of the last strategies for injured workers, but the financial allowance for this is limited to $4000 per calendar year.

Another benefit to injured workers is that State law requires the attending doctor to review your job description prior to your return to work–this would include a review of the functions, schedule, and physical demands of your particular work duty(s).

Along with this, a work injury attending doctor should be willing to speak with your employer over the telephone regarding what can be done to enhance your successful transition back to work.  If your doctor feels that your job duty is too strenuous for you to perform, he or she can suggest possible modifications.

Washington State law actually dictates the following specific return-to-work progression of priorities:

  1. Your same employer and your previous job.
  2. Your same employer and your previous job, with modifications &/or transitional return.
  3. Your same employer with a new job, keeping with limitations & restrictions.
  4. Your same employer with a new job, with modifications &/or transitional return.
  5. A new employer and your previous job, with necessary modifications.
  6. A new employer and a new job, based upon transferable skills you may possess.
  7. A new employer and a new job, with necessary modifications.
  8. A new employer and a new job, requiring on-the-job training, and finally,
  9. Only after documenting that option #1 through #8 are not feasible, return-to-work goals may involve short-term retraining and job placement.

Usually offered only as a last resort, job re-training may be considered.  However, even if an injured worker can no longer perform a lucrative paying vocation, L&I is under no obligation to return the injured worker to an equally lucrative paying job.

In other words if you get hurt at a job which pays very well, you may end up with a job which pays far less and although this may not seem fair, this is precisely what Washington State law provides dictates for workers-compensation.

In addition to occupational injuries, claims for “Occupational Diseases” such as carpal tunnel syndrome, hearing loss, infections, dermatitis, and asthma, if they result from your job, are appropriate.  Conditions such as these which would not of occurred, but for the conditions of your employment, fall within the domain of worker’s compensation.

Time limits for filing an occupational injury or illness claim are as follows:  One and two years, after the date of the  injury/exposure, respectively.

And again, if an employee should fear employer retaliation or discrimination in the event that they file a claim, they should know that Washington State law protects employees in these circumstances, if they file a claim reporting such discrimination within 90 days.  Likewise, employees who report an unsafe work environment are also protected, but they must file such a discrimination claim within 30 days.

Worker’s compensation will pay for psychiatric treatment, if for example a bank teller was traumatized by a bank robber, or, if depression is preventing recovery of a work related condition, but such treatment must be pre-authorized.  For such treatment to be deemed medically necessary, it would be expected to improve the recovering worker’s level of physical activity, participation in work hardening or counseling, normalization of sleeping or eating, and/or medication use.

Obesity treatment, pain management, biofeedback, rehabilitation, head trauma treatment, work hardening, and spinal, shoulder, and knee surgery also require pre-authorization.

Industrial Insurance in Washington State may also pay for the temporary treatment of conditions unrelated to your industrial injury, if such condition impedes your recovery:  Examples would be obesity or substance abuse treatment.

Work injury claims are closed when the injured worker’s condition reaches maximum medical improvement (MMI) and with L&I, this is also known as being “Fixed and Stable.”

To reach MMI an injured worker must also be able to work, but not necessarily at the same job–just that the recovering worker can work in ANY occupation.

This means that if a well paid skilled worker performing heavy manual labor is injured and unable to ever return to their particular job of injury, that the workers compensation system is satisfied if the return to a lesser paying (and physically less demanding) job or position.  This again underscores the tremendous value of safety and prevention.

With workers compensation in Washington State, “Fixed & Stable” is when an injured worker has reached a point in their recovery that further recovery is not expected.  With the passage of time further improvement is often likely, but pain and symptoms may still be present and continue to fluctuate.  Within this context fixed does not mean “healed” or “static.”

Furthermore, within the Washington Worker’s compensation systems (L&I and self-insured), continued care to temporarily alleviate symptoms, even though those symptoms may have originated with an occupational injury, is not a covered benefit.

Once an injured worker’s condition does reach its peak of improvement, if permanent impairment continues, then that injured worker may receive a “monetary reward.”

Then once a claim is closed, L&I or the self-insurer no longer pay for unauthorized medical care and only services related to filing a “reopening application” will be paid.

Often claimants wonder if in the future they can reopen a claim.  Reopening a claim is possible only when the industrial injury or illness worsens from the time of the last claim closure or reopening denial.  Denial for reopening an old claim frequently occur for new injuries, unrelated conditions, or simply because worsening can be attributed to the natural progression of the prior injury.  But even if the reopening application is denied, L&I or the particular self-insurer will at least pay the provider for the work they do to attempt to reopen the claim on behalf of the injured worker.

Treatment Guidelines

Sometimes with work injuries, the application of medicine and surgery create additional problems and because of this, specific treatment guidelines have been created, for example for treatments such as prescription of certain classes of medications, the application of MRI for lumbar spine conditions, and the assessment and treatment of acute low back pain.

For example, the long-term use of controlled substances for chronic nonmalignant pain may be a factor in the development of long-term disability.  With this a guideline has been created dictating that schedule II drugs (see the following) are not be prescribed for no longer than 2 weeks and schedule III & IV drugs for no longer than 6 weeks. Beyond these guidelines consultation or referral to a chronic pain specialist would be considered.  This guideline in particular was developed in reaction to considerable addiction and disability which seemed to result from physicians prior prescribing habits.

Medical prescribers are now expected to document within their treatment plan:

  1. A finite plan which does not exceed 6 weeks,
  2. Clear measurable treatment goals,
  3. List of all medications used and their dosage,
  4. Description of reported pain relief from each medication,
  5. Justification of the continued use of controlled substances,
  6. Documentation of attempts at weaning off pain medication,
  7. Explanation of why weaning attempts failed,
  8. Detailed history of alcohol and drug use,
  9. How the patient’s response to medication will be measured,
  10. Further planned diagnostic tests, and
  11. Alternative treatments to medication considered (such as chiropractic and massage).

Relative contraindications for the use of controlled substances include:

  1. History of alcohol or other substance abuse, or a history of chronic, high dose benzodiazepine use,
  2. Active alcohol or other substance abuse,
  3. Borderline personality disorders,
  4. Mood or psychotic disorders,
  5. Other disorders that are primarily of a depressive nature,
  6. Off work for more than 6 months.

Special circumstances to these guidelines do exist, but from these lists one can see how the Washington State workers compensation system is attempting to prevent treatment related problems, including deaths, from the mis-use of certain medications.

In fact, a disclaimer has been created by L&I and the Washington State Medical Association (WSMA), which states:.

“The WSMA and L&I believe that it may do you more harm than good to take addicting drugs for a long time.”

Examples of the controlled substances noted above include:

Schedule II Opiods

  1. codeine
  2. fentanyl (Sublimaze, Innovar)
  3. hydromorphone (Dilaudid)
  4. meperidine (Demerol)
  5. meperidine w Promethazine (Mepergan)
  6. methadone (Dolophine)
  7. morphine (MS Contin, MSIR, OMS, RMS, Roxanol)
  8. oxycodone
  9. oxycodone w/ acetaminophen/aspirin (Percoset, Percodan, Roxicet, Roxiprin, Tylox)

Schedule III Opiods

  1. acetaminophen with codeine (Codaan, Phenaphen 2, 3, 4, Tylenol 2, 3, 4)
  2. aspirin with codeine (Empirin 2, 3, 4)
  3. hydrocodone
  4. hydrocodone w/ acetaminophen / aspirin (Anexsia, Azdone, Bancap, Cogesic, Damason-P, Dolacet Duocet, Endal-HD, Hyco-Pap, Hydrocet, Hyphen, Lorcet Plus, Lorcet HD, Lortab, Vicodin, Zydone)
  5. nalorphine
  6. paregoric

Schedule IV opiods

  1. propoxyphene (Darvon)
  2. propoxyphene w / acetaminophen / aspirin (Darvocet, Dolene, Wygesic)
  3. pentazocine (Talwin)

Schedule I Sedatives

  1. amobarbital (Amytal)
  2. secobarbital (Seconal)
  3. pentobarbital (Membutal)

Schedule II Sedatives

Any compound containing an unscheduled drug and:

  1. amobarbital
  2. secobarbital
  3. pentobarbital
  4. glutethimide (Doriden)

Schedule III Sedatives

  1. chloral hydrate
  2. chlorazepate (Tranxene)
  3. chlordiazepoxide (Librium)
  4. clonazepam (Klonopin)
  5. diazepam (Valium)
  6. ethchlorvynol (Placidyl)
  7. flurazepam (Dalmane)
  8. meprobamate (Eqainil, Miltown)
  9. oxazepam (Serax)
  10. paraldehyde (Paral)
  11. phenobarbital
  12. prazepam (Centrax)

Tips to Avoid Undue Back Irritation

  1. Most patients do not require bed rest, with prolonged bed rest (more than 4 days) having potentially debilitating effects.  At best, the efficacy of bed rest in the treatment of acute low back problems is unproven, with two to four days of bed rest reserved for those with the most severe limitations (due primarily to leg pain).
  2. Activities and postures which increase stress on the back also tend to aggravate back symptoms.
  3. Patients limited by back symptoms can minimize the stress of lifting by keeping any lifted object close to the body at the level of the navel.
  4. Twisting, bending, and reaching while lifting also increase stress on the back.
  5. Sitting, although safe, may aggravate symptoms for some patients, so its usually best to avoid prolonged sitting, changing position often.
  6. A soft support placed at the small of the back, armrests to support some body weight, and a slight recline of the chair back may make required sitting more comfortable.
  7. Until one returns to normal activity, aerobic (endurance) conditioning exercise such as walking, stationary biking, swimming, and even light jogging may be recommended to help avoid debilitation from inactivity.
  8. An incremental, gradually increasing regimen of aerobic exercise (up to 20 to 30 minutes daily) can usually be started within the first 2 weeks of symptoms. Such conditioning activities have been found to stress the back no more than sitting for an equal time period on the side of a bed.
  9. Exercise might increase symptoms slightly at first and if intolerable, exercise alteration is usually helpful.
  10. Conditioning exercises for trunk muscles are more mechanically stressful to the back than aerobic exercise. Such exercises are not recommended during the first few weeks of symptoms, although they may later help patients regain and maintain activity tolerance.
  11. There is no evidence to indicate that back-specific exercise machines are effective for treating acute low back problems. Neither is there evidence that stretching of the back helps patients with acute symptoms. These modalities are best reserved for chronic back problems
  12. Specific instructions about activity at work for patients with acute limitations due to low back symptoms may be helpful, with the patient’s age, general health, and perceptions of safe limits of sitting, standing, walking or lifting (noted on initial history) providing reasonable starting points for activity recommendations.
  13. Moderately heavy unassisted lifting may aggravate back symptoms.  Restrictions are intended to allow for spontaneous recovery or time to build activity tolerance through exercise.
  14. Usually activity restrictions are prescribed for short time periods, depending upon work requirements and it is thought that no additional benefits are apparent beyond 3 months.
  15. With back pain, sitting should not exceed 20 minutes (without getting up and moving around).
  16. Even without back pain, sitting should not exceed 50 minutes.
  17. With moderate-to-severe back pain, unassisted lifting should not exceed 20 lbs.
  18. With mild back pain, unassisted lifting should not exceed 60 lbs for men or 35 lbs for women.
  19. Even without back pain, lifting not exceed 80 lbs for men or 40 lbs for women.

 

Guidelines for acute work injury back pain treatment

  1. Attending doctor reviews the basic history.
  2. Attending doctor screens for history of cancer/infection.
  3. Attending doctor screens for signs/symptoms of cauda equina syndrome (CES)
  4. Attending doctor screens psychosocial history.
  5. Attending doctor performs of straight leg raising test.
  6. Attending doctor performs a focused neurological exam.
  7. Patient education about low back symptoms.
  8. Back school in the occupational setting.
  9. Prescription of Acetominophen
  10. Prescription of NSAIDs
  11. Application of spinal manipulation
  12. Temporary avoidance of activities that increase mechanical stress on the spine.
  13. Gradual return to normal activities.
  14. Low-stress aerobic exercise.
  15. Conditioning exercises for trunk muscles after 2 weeks.
  16. Exercise quotas.
  17. Attending doctor considers ordering bone scan, needle EMG and H-reflex tests to clarify nerve root dysfunction, SEP to assess spinal stenosis, if no improvement at 1 month.
  18. Attending doctor considers ordering x-rays, if red flags for fracture, cancer or infection are present.  Attending doctor considers ordering CT or MRI when CES, tumor, infection, or fracture is strongly suspected.
  19. Attending doctor considers ordering MRI for patients with prior back surgery.
  20. With persistent and severe sciatica, clinical evidence of nerve root compromise, and 1 month of conservative therapy, attending doctor discusses surgical options such as discectomy, microdiscectomy, and chymopapain.
  21. Attending doctor reviews social, economic, and psychological factors, which can alter one’s response to symptoms and treatment.

Guidelines for acute back problems in adults generally do NOT advise

  1. Opioids use > 2 weeks.
  2. Phenylbutazone.
  3. Oral steroids.
  4. Colchicine.
  5. Antidepressants.
  6. Manipulation performed by non-experts.
  7. Traction.
  8. TENS.
  9. Shoe lifts.
  10. Corset bracing.
  11. Epidural injections for back pain without radiculopathy, trigger point injections, ligamentous injections, facet joint injections, or needle acupuncture.
  12. Bed rest beyond 4 days.
  13. Back specific exercise machines.
  14. EMG testing for clinically obvious radiculopathy.
  15. Surface EMG and F-wave tests.
  16. Thermography.
  17. Routine x-rays or MRI imaging within the first month (in the absence of red flags).
  18. Disc surgery in patients with back pain alone, no red flags, and no nerve root compression.
  19. Surgery for spinal stenosis within the first 3 months of symptoms.
  20. Surgery for spinal stenosis based solely on imaging.
  21. Spinal fusion in the first 3 months in the absence of fracture, dislocation, or complications of tumor or infection.
  22. Referral for extensive evaluation / treatment prior to exploring patient expectations or psychosocial factors.

Some Work Injury Definitions

Injury:  A sudden and tangible “happening” of a traumatic nature producing an immediate or prompt result and occurring from without, and such physical conditions as a result therefrom.

Occupational Disease:  A disease or infection that arises naturally and proximately out of employment.

Objective Findings:  That which can be seen, felt, or consistently measured by physicians.

Transitional-Return-To-Work:  Any return-to-work strategy that assists a gradual resumption of work tasks, e.g., modified work, allowing the worker to return to the workforce during medical instability.

Curative Care:  Medical care that is likely to improve the patient’s medical condition.  Within the Washington worker’s compensation system, curative and rehabilitative care are the only types of care injured workers are eligible to receive and for which the program will reimburse attending physicians.

Claim:  A written request and an assertion of the right to compensation.  A patient’s claim is initiated by a doctor with the submission of the Report of Industrial Injury or Occupational Disease or the Physician’s Initial Report form.

This information is not to be considered or used as a substitute for medical advice, diagnosis, or treatment. Please talk to your health care provider for anything related to your health including but not limited to diagnosis, treatment advice and/or care. Always seek the advice of a health care professional. If you have or suspect that you have a medical problem or condition, please contact a qualified health care professional immediately. If you are in the United States and are experiencing a medical emergency, please call 911 or call for emergency medical help on the nearest telephone.