Research Article of International Journal of Pain Research and Treatment
How Surgery Saves Money: A Paradox Explained
Tom Emerick1, Nelson Hendler, MD, MS2
1President, Emerick Consulting, former benefits executive for Burger King, British Petroleum and Walmart; 2CEO, Mensana Clinic Diagnostics, former assistant professor of neurosurgery, Johns Hopkins University School of Medicine, and past president -American Academy of Pain Management
“A new analysis from U.S. federal government actuaries say that Americans spent $3.65 trillion on healthcare in 2018, according to a report from Axios. “1 This impacts on companies, where health insurance benefits are the second largest cost in a service business, and 3rd largest in manufacturing business2. Back pain alone accounted for $86 billion a year in 2008 3. The top 5 expenses for a commercial line of insurance were for back pain, osteoarthritis, childbirth, injuries, and non-hip/non- spine fractures4. Work related injuries cost an estimated $1.2 trillion annually, which includes lost wage payment, medical care, and short and long term disability5.
Of all health care expenses paid by a company, workers’ compensation becomes the most expensive, since the company pays not only for medical care, but also the lost wage of the employee. This is usually 66% of the employee’s salary, which come to the employee tax free. This provides the employee with essentially the same income received when at work. These generous benefits lead insurance adjusters to suspect potential for abuse. Estimates of fraudulent claims range from 1% to 80% depending on unsubstantiated reports in the insurance literature6,7,8,9.
However, methods to identify fraudulent cases are not always productive. The State Auditor of the State of California reported that the $30,000,000 a year spent by the State of California to detect workers’ compensation fraud was not cost effective10. Detection methods used include Functional Capacity Evaluations (FCEs). However, Feeler and Schapmire in a review of 180,000 patients found that FCEs were subjective and had no predictive nor diagnostic value11. Attempts to blame prolonged recovery on psychological issues, using the Minnesota Multiphasic Personality Inventory MMPI are consistently thrown out of court often 12.
The most reliable method of fraud detection is the Pain Validity Test, which can predict with 95% accuracy who will have abnormal medical tests, and predicts with 85%-100% accuracy who will not have medical test abnormalities, i.e. who is faking or malingering 13,14,15. In a head to head comparison with the MMPI, in the same group of patients, the MMPI had no predictive ability 13,14,15. The Pain Validity Test has always been admitted as evidence in 30 cases in 9 states, which are listed on SlideShare.net 16.
Once an injured worker has been identified has having a valid complaint of pain, the next step is to o identify the cause of the pain, and properly treat the worker. Research from several sources at Johns Hopkins Hospital report that 40%-80% of chronic pain patients are misdiagnosed 17,18,19. When accurately diagnosed, 50%-63% of patients required surgery to improve 18,19. While the “common wisdom” is that surgery is expensive, a more granular case by case examination documents that this is fallacious thinking. The following case examples show the benefit of accurate diagnosis and the application of the correct surgery resulting in significant cost savings.
Keywords: Surgery Saves Money, Paradox Explained
How to cite this article:
Tom Emerick, Nelson Hendler. How Surgery Saves Money: A Paradox Explained. International Journal of Pain Research and Treatment, 2020, 3:17. DOI: 10.28933/ijprt-2020-07-2205
1. Sherman, E, U.S. Health Care Costs Skyrocket-ed to $3.65 Trillion in 2018, Fortune, February 21, 2019
2. Emerick. T and Lewis, A., Cracking Health Costs p. ix, Wiley, Hoboken, NJ , 2013
3. Dagenais, S, Caro, J. Haldeman, S., A systematic review of low back pain cost of illness studies in the United States and internationally, Spine J., Jan.-Feb., 8(1)8-20, 2008.
4. Paquale, MK, Dufour, R. Schaaf, D., Reiners, AT, Mardekian, J, Joshi, AV, Patel, NC,, Pain conditions ranked by healthcare costs for members of a national health plan, Pain Practice, Feb. 14 (2) 117-31, 2014.
5. Fisher, TF, Perception difference between groups of employees identifying the factors that influence a return to work and a work-related musculoskeletal injury Work, 21(3) 211-20, 2003.
6. Ted R and Larrubia E. “Anti-Fraud Drive Proves Costly for Employees.” Los Angeles Times. Aug. 7, 2000. Accessed on May 2013 http://www.harp.org/wc2.htm [Access Online]
7. Paul LJ, Markovitz S, Fahs M, Landrigan P. Costs of Occupational Injuries and Illnesses. Ann Arbor: University of Michigan Press, 2000. pp. 195-197.Accessed in May,2013. http://www.press.umich.edu/ 16885/costs_of_occupational_injuries_and_illnesses [Access Online]
8. Workers’ Compensation Notes, AFL-CIO Department of Occupational Safety and Health, Is-sue 3-00, May/June 2000. Page 1.
9. Kerr Peter. The Price of Health: Employee Fraud – A special report; Vast Amount of Fraud Dis-covered In Workers’ Compensation System. The New York Times. December 29, 1991. Accessed in June 2013 http://www.nytimes.com/1991/12/29/us/price-health-employee-fraud-special-report-vast-amount-fraud-discovered-workers.html?pagewanted= all&src=pm
10. Howle E. Workers’ Compensation Report. 15(11): p 206, May 17, 2004.
11. Feeler L, St James JD, Schapmire DW. Isometric strength assessment, Part I: Static testing does not accurately predict dynamic lifting capacity. Work. 2010;37(3):301-8. [PubMed]
12. Sims DC. The myth of malingering: Is it the truth or a lie? The Plaintiff Magazine, pp. 1-4, Dec. 2007.
13. Hendler N, Mollett A, Viernstein M, Schroeder D, Rybock J, Campbell J, et al. A comparison between the MMPI and the ‘Mensana Clinic Back Pain Test’ for validating the complaint of chronic back pain in women. Pain 1985;23(3):243-51 [PubMed]
14. Hendler, N., Mollett, A., Viernstein, M., Schroeder, D., Rybock, J., Campbell, J., Levin, S., Long, D.: “A Comparison Between the MMPI and the ‘Hendler Back Pain Test’ for Validating the Com-plaint of Chronic Back Pain in Men.” The Journal of Neurological & Orthopaedic Medicine & Surgery. Vol. 6, Issue 4:333-337, December, 1985.
15. Hendler N, Mollett A, Talo S, Levin S. A comparison between the Minnesota Multiphasic Personality Inventory and the ‘Mensana Clinic Back Pain Test’ for validating the complaint of chronic back pain. J Occup Med. 1988 Feb;30(2):98-102.
17. Dellon AL, Andronian E, Rosson GD. CRPS of the upper or lower extremity: surgical treatment outcomes, J. Brachial Plex Peripher Nerve Inj. 2009 Feb;4(1):1.
18. Long D, Davis R, Speed W, Hendler N. Fusion for occult post-traumatic cervical facet injury. Neurosurg. Q. 2006;16(3):129-135.
19. Hendler N., Bergson, C., Morrison, C.: Overlooked physical diagnosis in chronic pain patients in litigation, Part 2. Psychosomatics. 1996;37(6):509-517.
20. Rhoades DR, McFarland KF, Finch WH, Johnson AO. 2001 “Speaking and interruptions during primary care office visits.” Fam Med. Jul-Aug;33(7):528-32.
21. Gottschalk, A, and Flocke,,S, 2005 “Time Spent in Face-to-Face Patient Care and Work Outside the Examination Room” Ann Fam Med November 1, vol. 3 no. 6 488-493.
22. Braithwaite I, White J, Saifuddin A, Renton P, Taylor BA. 1998 “Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography.” Eur Spine J., 7(5):363-8.
23. Sandhu HS, Sanchez-Caso LP, Parvataneni HK, Cammisa FP Jr, Girardi FP, Ghelman B. 2000, “Association between findings of provocative discography and vertebral endplate signal changes as seen on MRI.” J Spinal Disord., Oct;13(5):438-43.
24. Hendler, N. and Baker, 2008 “ An Internet questionnaire to predict the presence or absence of organic pathology in chronic back, neck and limb pain patients.” Pan Arab Journal of Neurosurgery, Vol. 12, April No. 1: 15-24.
25. Hendler, N.: 1988 “Chapter 20 -Validating and Treating the Complaint of Chronic Back Pain: The Mensana Clinic Approach. “ in Clinical Neurosurgery. Vol. 35 Edited by P. Black, E. Alex-ander., D. Barrow, et. al.,385-397, Williams and Wilkins, Baltimore.
26. Hendler N., et al. “Comparison of Clinical Diagnosis Versus Computerized Test Diagnoses Using the Mensana Clinic Diagnostic Paradigm (Expert System) for Diagnosing Chronic Pain in the Neck, Back and Limbs”. Pan Arab Journal of Neurosurgery (2007): 8-17.
27. Landi A., et al. “Diagnoses from an Online Expert System for Chronic Pain Confirmed by Intraoperative Findings”. Journal of Anesthesia and Pain Medicine 1.1 (2016): 1-7.
28. Long DM., et al. “Fusion for occult post-traumatic cervical facet injury”. Neurosurgery Quarterly 16.3 (2006): 129-135.
29. Emerick. T and Lewis, A., Cracking Health Costs p. 11, Wiley, Hoboken, NJ , 2013
30. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, et al. (1994) Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 331:69-73.
31. Zinreich J, Long DM, Davis R, Quinn CB, McAfee PC, Wang H.Three-dimensional CT imag-ing in postsurgical “failed back” syndrome, Comput Assist Tomogr. 1990 Jul-Aug;14(4):574-80.
32. Landro L. The Biggest Mistake Doctors Make, The Wall Street Journal Nov. 17 (2013).
33. Emerick. T and Lewis, A., Cracking Health Costs pp 104-107, Wiley, Hoboken, NJ , 2013
34. Emerick. T and Lewis, A., Cracking Health Costs p 103, Wiley, Hoboken, NJ , 2013
35. Hendler, N, An internet based expert system to control workers compensation costs document-ed by outcome studies, Anaesthesia, Pain & Intensive Care, Vol. 17, No. 2, pp 166-170, May- August 2013.
36. https://pittslaw.com/PittsLaw.10/independent.medical.examinations.html) 262-886-8240 JAPitts@PittsLaw.com.
38. Emerick. T and Lewis, A., Cracking Health Costs p 93, Wiley, Hoboken, NJ , 2013
39. Emerick. T and Lewis, A., Cracking Health Costs p 72, Wiley, Hoboken, NJ , 2013
40. Hendler, N, and Romano, T. Fibromyalgia Overdiagnosed 97% of The Time:Chronic Pain Due To Thoracic Outlet Syndrome, Acromioclavicular Joint Syndrome, Disrupted Disc, Nerve Entrapments, Facet Syndrome and Other Disorders Mistakenly Called Fibromyalgia, Journal of Anesthesia & Pain Medicine, Volume 1: Issue 1, pp: 1-7, 2016.
41. Emerick. T and Lewis, A., Cracking Health Costs p 93, Wiley, Hoboken, NJ , 2013
42. Emerick. T and Lewis, A., Cracking Health Costs p 168, Wiley, Hoboken, NJ , 2013
43. Bernacki EJ, Tsai SP. Ten years’ experience using an integrated workers’ compensation management system to control workers’ compensation costs J Occup Environ Med. 2003 May;45(5):508-16.
44. Hendler, N, and Goff, R, Innovations Including Pain Validity Testing, The Self Insurer, pp 28-30, 2013