The treatment of patients with chronic pain can be difficult and challenging. Recent advances in our understanding of the condition have led to viewing chronic pain as a multi-factorial problem with interrelated structural, functional and psycho-physiological factors. Treatment usually requires the integration of a multidisciplinary team of specialists with a bio-psychosocial (BPS) treatment philosophy. The complexities in the medical management usually flow into the claims management process and often become a major hurdle for the claims assessor. A lack of visibility into the treatment regime often leads to poor claims experience.
There is an abundance of evidence clearly demonstrating that being at work is generally beneficial to people’s physical and mental health and well-being, although this is dependent on the nature and quality of the work being undertaken. A best practice philosophy for claims management is to achieve the best outcome for both insurer and customer in the most efficient way. Generally, this means a return to work for the customer.
Due to the complexity of chronic pain, establishing a solid strategy from the very beginning of the claim is imperative. A highly collaborative, multidisciplinary approach engaging all stakeholders from the beginning is important. In conjunction with this, understanding the customer’s return-to-work expectations and vocational options will assist in formulating the most appropriate and effective recovery pathway for the customer.
What is chronic pain?
In acute, recent pain, the unpleasant sensation is nature’s way of alerting one to potential or real tissue damage. The pain is usually proportional to the degree and imminence of that bodily danger, a threat to which one should react promptly so as to mitigate the danger. The experience is both physical and emotional. Once pain has lingered a long time, the pain is not commonly associated with a threat of further physical damage, yet the brain still interprets it that way and reacts as if still under threat, causing emotional distress and enthusiastic avoidance of anything associated with the sense of tissue damage. In such instances, there is no reason to avoid such actions except that one dislikes pain. Of course, while reacting thus, the consequent passivity and inactivity compound the myriad of related issues.
Claims focus when assessing chronic pain conditions
For the majority of disability income claims, ongoing liability depends on the customer’s functional capacity to perform one or more of the major duties of his or her occupation. Claims for chronic pain can be challenging to manage due to the subjective nature of the experience of pain and individually variable responses. However, despite how complex the actual medical management may be, focusing on the customer’s functional capacity and how this relates to his/her ability to perform their previous role is the objective of the claim assessment. It is also the focal point of sound evidence-based treatment.
If a person’s pain is ‘curable,’ someone is likely to have facilitated that within a reasonable time frame, assuming the person is receiving optimal treatment. If not cured, why, then, do patients and their practitioners continue pursuing a cure, when acceptance of chronicity and functional restoration is a more productive and far less destructive route? With this in mind, it’s important to understand the current treatment regime and the initial onset of the condition.
Pain is said to be chronic if it persists for 3-6 months beyond the normal healing time of a particular diagnosis or injury and is considered a condition in its own right, with BPS and vocational factors to be considered. It’s important to identify whether the customer is continuously being treated for perceived complications stemming from the original injury or whether he or she is receiving treatment to manage the chronic pain condition or co-morbid condition, while considering the appropriateness of those interventions. Once determined, this enables a better understanding of the expected claim duration and the identification of medical milestones and potential barriers. It may be beneficial to engage the company Chief Medical Officer (CMO) and/or arrange a specialist Independent Medical Examination (IME) to comment on the treatment regime and expected outcome.
Once the diagnosis of ‘chronic pain’ is made, it is important to obtain as much information as possible in regards to the customer’s current level of function, stage of treatment, return-to-work expectations and illness beliefs. Identifying function can be challenging due to the lack of objective evidence and the psychological overlays of the chronic pain condition.
The scientific literature is unequivocal in the fact that return-to-work potential is greater when incorporating psychosocial assessment and management strategies1,2. An initial needs assessment can be highly beneficial in this regard and can assist in establishing a solid claims strategy. This assessment is completed by an allied health professional experienced in occupational rehabilitation and is usually conducted in the customer’s home, or any other suitable location, and involves such things as:
- Current functional capacity and barriers
- Activities of daily living
- Employment status and return-to-work goals
- Establishing the functional demands of previous duties of employment
- Attitudes and beliefs about recovery and return to work
- Current medical management and treatment goals
- Identification of BPS factors that may impact the overall recovery and return to work
- Discussions with treating professionals (if required)
In conjunction with the above-mentioned key considerations, having a complete understanding of the customer’s employment status, the employer’s willingness to accommodate suitable duties and/or reduced hours, and the functional demands of the pre-disability duties will assist in managing the claim. Any improvement in the customer’s functional capacity can be measured against the functional demands of his or her pre-disability role to determine readiness for work. Depending on the customer’s employment status, this information can then be used to initiate return-to-work discussions. A worksite assessment is a useful method for obtaining an overview of the workplace and determine the availability of suitable duties.
The key factor
Educating the customer about managing the ongoing symptoms of chronic pain is the key factor for successful management of vocational recovery. An inability to make sense of the often worrying and persisting uncertainties of pain may force the customer to avoid undertaking some of the normal activities of daily living, including work. When talking to the customer, it’s important for the claims assessor to understand what the person hopes to achieve and their level of expectations post-treatment. Are they
hoping to be 100% symptom-free? Or are they seeking some pain relief and enough functional improvement to be able to return to their normal daily routine, and perhaps to some form of work? What will happen if the customer can’t ever be 100% pain-free; what will this mean to them? This is an important consideration when managing the claim, as the assessor needs to consider the customer’s readiness to undertake some of the activities the assessor suggests, such as rehabilitation provider assistance or pain management programs.
Having the customer talk to their physicians can help them take an active role in managing the pain and regain control of their life despite ongoing symptoms, which may assist in regaining enough functional capacity to return to some form of work. The overarching strategy is to accept that the pain is not readily curable, but that the secondary losses can be mitigated through conscientious and careful integration of those normal activities that should be considered harmless, or non-damaging.
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