By Karen O’Hara
Cardio-pulmonary resuscitation (CPR) is used on cardiac arrest victims until normal heart function can be restored. A similar principle applies to the CPR program at Caritas Good Samaritan Occupational Health Services (OHS), Avon, Mass., but in this case, the acronym stands for Chronic Patient Resolution. The CPR program represents a radical departure from traditional approaches to the management of chronic workers’ compensation “casualties,” explains OHS Medical Director Robert Naparstek, M.D.
“Candidates for the CPR program have been out of work for at least three months and as long as two to three years,” he said. “While chronic pain is seldom cured, we believe there is hope for participants in our program because they are given the opportunity to understand and manage their pain.
“This program leapfrogs managed care by bundling services and getting patients to maximum medical improvement (MMI).”
The foundation of the program is mutual agreement among the patient, the workers’ compensation insurer, and the provider for the patient to reach MMI within a six-month period. Memoranda of understanding signed by each party stipulate that:
- The provider will follow established standards of care.
- The insurer will not interfere with the recommended course of treatment during the agreed-upon timeframe.
- The patient will keep appointments and adhere to clinical recommendations.
The primary goals are to eliminate or reduce patients’ symptoms and degrees of impairment, help patients obtain maximum functional ability, and prepare them for meaningful work. If return to full duty is not achievable after six months have elapsed, the patient is evaluated for permanent partial disability.
If the case becomes eligible for settlement, the patient is “liberated” from the workers’ compensation system, and insurance reserves are released. Upon settlement, the patient may receive vocational rehabilitation services and a lump-sum payment.
“I don’t promise patients they will be pain-free, but if we can wean them off narcotics and get them to MMI and working again, they will be a whole lot better off than they were,” said Dr. Naparstek, an occupational medicine physician with a long-standing interest in alternative and complementary approaches to medical care.
Program Components:
The CPR program incorporates occupational medicine, acupuncture, work hardening, chiropractic, psychosocial intervention, and aquatic therapy. Because each care plan is designed specifically for the individual undergoing treatment, it may include only one or any combination of these components.
The psychosocial component, billed as cognitive behavioral therapy, is one of the more innovative aspects of the program. It is provided by a psychiatric social worker with expertise in hypnotherapy and is intended to help patients become aware of and obtain control over emotional pain triggers. Therapy is used to help patients recognize and change patterns of behavior that perpetuate and reinforce pain.
The work-hardening aspect of treatment involves progressive, supervised work simulation. Proper body mechanics, strength training, coordination, and flexibility are emphasized. The work-hardening component is applicable in cases involving behavioral health and vocational issues, as well as physical limitations.
Prior to introducing the CPR program, Caritas OHS already had a history of successfully treating work-related injuries with acupuncture. Outcome studies show that acupuncture helps decrease inflammation and can break the pain-spasm cycle so healing can occur at a faster rate.
At any given time, there are about five CPR patients in various stages of treatment. To date, approximately 100 patients, about 70 percent of them male, have completed the program. While the number of patients is relatively small, the program has achieved 100 percent success in terms of patients reaching MMI.
“It’s a case-by-case slog,” Dr. Naparstek said. While he has not yet been able to convince any major insurance carriers “to open up their floodgates and give me all of their worst cases,” the offer remains on the table.
CPR Genesis
The concept for the CPR program was borne out of Dr. Naparstek’s frustration with a system he believes is poorly equipped to resolve the suffering of some patients. Workers’ compensation reimbursement rates are relatively low in Massachusetts, and many physicians don’t have the time or inclination to argue with insurance adjusters to get approval for what they consider to be an appropriate treatment plan. Meanwhile, a small percentage of chronic workers’ compensation patients remain off work, depressed and in pain, while costs mount.
Having tried and failed to get adjuster approval for specific treatments in these difficult cases, Dr. Naparstek decided to try packaging services, including limited psychological intervention, which typically is not reimbursed by insurers in Massachusetts.
“I am often sent the patients other doctors don’t want to see,” Dr. Naparstek said. “I like seeing chronic patients. I am interested in the psychosocial context of their situation and how it relates to their pain.”
Patients who are candidates for the CPR program tend to have similar profiles. For example, many have childhood histories of sexual and/or emotional abuse and continue to experience confounding problems in their daily lives. Most are not well educated, and their injuries are often associated with labor-intensive jobs. Some are reluctant to become more physically active or attempt to return to work because they are afraid of re-injury or being accused of fraud by watchful authorities.
“Patients can get to the point where they can’t do much of anything. In those cases, the repercussions on their family are gigantic,” Dr. Naparstek said.
Despite his good intentions, Dr. Naparstek’s plan to bundle services for this particular patient population was initially greeted with skepticism by insurers.
“An adjuster at one major carrier said, ‘I don’t care how good your program is. I will never give up control of this case,’” Dr. Naparstek recalled. “I told him, ‘You want to have an illusion of control while this person is suffering. You are paying our bills, you are not getting your bonus for freeing up reserves and the person is not getting better.’ It’s a power equation.
“Eventually I got an adjuster to listen and the proposal went all the way up to the president of the company for approval.”
Replicable Model
To ensure that the program is legally sound, Dr. Naparstek worked with the health system’s legal staff to devise suitable contractual language. He said the provisions spelled out in memoranda of understanding signed by the patient, the provider, and the insurer can be replicated in other jurisdictions – as long as incentives are appropriately aligned and all parties are moving forward on the same page.
“One of our secrets of success is that we only take motivated patients,” Dr. Naparstek noted. “I also see patients who don’t want to sign the contract, so there is a self-selection process. The contract becomes a therapeutic tool for those who are willing to take that risk, even though they don’t know what is going to happen. During that six-month treatment period, they have to start thinking about what they are going to do next. And, because there are teeth in the contract, the adjuster can cut the patient off for non-compliance.”
Since its inception, the CPR program has been able to cover its costs and achieve a modest profit. Caritas Good Samaritan OHS, a wholly-owned subsidiary of Caritas Good Samaritan Medical Center, Inc., provides facilities, supplies, and staff support for affiliated caregivers. Dr. Naparstek gives credit to the well-credentialed group of professionals who support the program.
“We have to make some money; otherwise, I can’t justify the program to our hospital,” Dr. Naparstek said. “Although it’s not megabucks, acupuncture, hypnosis, and chiropractic produce revenue,” even with low state reimbursement rates. The median case cost is $5,000 to $6,000.
Ultimately, a patient who really wants to get better has the most to gain. The CPR credo is: “Our goal is to return you to work. We want to take good care of you. We want to advocate for you. We will tell you the truth. We expect you to share in the goal of returning to work, and we want you to work hard to get there,” Dr. Naparstek said.
