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By Susan E. Clarke
Helpful information — information that will assist the fraud-fighting professional — is often available if you just know where to look. A case in point is the article “The Hidden Costs of Medicolegal Abuses in Neurology” in the July 1994 Archives of Neurology by Peritz Scheinberg, M.D., a neurologist affiliated with the University of Miami School of Medicine and Mt. Sinai
Hospital in Miami, Florida.
Scheinberg cited the widely variable ratios between bodily-injury and property-damage claims, reported in the Insurance Research Council’s 1990 report “Trends in Auto Bodily Injury Claims,” as evidence that the costs of bodily injury from auto accidents are due to something other than the degree of bodily injury itself. These costs, which have increased more than 250 percent in recent years, can be as much as two to five times higher in one city than they are in another city within the same state. Scheinberg believes there is a “societal rather than a physical explanation” for these increases and variations. A large number of lawyers in a given community may play a part or there may be an incentive to increase the awards for trivial injuries due to a depressed economy.
Whatever the cause, physicians — either actively or passively — play a part in the escalation of these costs. But what can be done about it? Scheinberg suggests that a “common sense and logical approach, dictated by repeated experience,” may be helpful. He advises that patients who continue to complain of back or neck pain when there is no objective evidence of any injury — no x-rays showing any abnormalities; no signs or symptoms of neurologic injury — after a minor accident should be told that there is no serious problem and that they will recover naturally without further treatment or intervention. (Contrast Scheinberg’s approach with the all-too-common scenario in which the patient is treated to a full complement of MRIs, a variety of electrical studies, possibly even thermography, in an attempt to diagnose otherwise unproveable injuries. And remember who gets the bill for all these tests.)
Often, these tests will find some evidence of a physiologic change — perhaps a bulging disc or two — that is usually not related to the patient’s reported injury. While the findings cannot be assumed to be caused by the accident, in many instances it cannot be proven that the findings are unrelated.
Many patients who complain of back and neck pain receive a program of physical therapy. Scheinberg notes that there is no scientific evidence that such therapy is either cost-effective or beneficial to the patient. Yet the therapy continues to be
ordered and provided to these patients, sometimes for months at a time, at a substantial cost to the insurance company. And an unexpected side-effect of this excessive testing and unlimited physical therapy and chiropractic manipulation is that it may help convince the patient that there really is something wrong with him.
A commonly seen diagnosis in cases of persistent back or neck pain is “myofascial pain syndrome.” Scheinberg calls this a catch-all diagnosis with no known pathology and wonders how athletes who engage in high-contact sports such as basketball or football are able to function when they so frequently experience soft-tissue trauma.
Another questionable area addressed by Scheinberg is the growing tendency to claim cognitive defects caused by minor head injuries. Because this type of disability is difficult to diagnose but can result in a significant disability payment, these claims are becoming more common.
Typically, according to Scheinberg, a patient is involved in a minor accident, with no known head injury or loss of consciousness. Days or weeks later, although there is no objective evidence of any neurologic problem, the patient begins to complain of memory loss. The patient is then subjected to extensive neurologic work-up, including MRI, evoked potentials, and — two relative newcomers to the diagnostic work-up — quantitative EEG and single photon emission computed tomography. Such testing, particularly the latter two tests, is not considered reliable for this purpose by the American Academy of Neurology.
Scheinberg notes that attributing a cognitive defect to an accident in which there was no known brain injury is illogical; especially when studies have shown that in cases of minor head injury, complete recovery in six months or less “is practically universal.”
In addressing these issues, Scheinberg states that the commonly used approach to these patients is costly, ineffective and counterproductive. He notes that common sense and concern for the patient’s best interest should guide all providers who deal with these cases.
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