Despite the philosophical and clinical appropriateness and necessity of supportative care, few reimbursement systems compensate for it as a medically necessary form of treatment.

Supportive care is defined in the Mercy proceedings as "the care or treatment for patients having reached maximum therapeutic benefit, in whom periodic trials withdrawal fail to sustain previous therapeutic gains that would otherwise progressively deteriorate." Most payers consider supportive care the same as maintenance care and refuse compensation.

The Ohio Bureau of Workers' Compensation system traditionally has considered supportive care appropriate and compensatory treatment. Regulations state that the claimant who has reached maximum medical improvement and has permanent impairment may require supportive care to maintain the level of improvement achieved.

Historically, reasonably applied supportive care in the Workers' Comp system has been challenged infrequently. With the advent of the BWCHPP managed care system, the necessity and appropriateness of supportive care for the work injured is more frequently, if not always, questioned by the MCO responsible for "managing care."

You should consider the following information when documenting the necessity of supportive care for the workers' compensation patient.

1. Nature of the Original Incident
The severity of the initial injury or incident may play heavily into the extent of the pathophysiology associated with the claim. The greater the tissue damage associated with an injury, the greater likelihood of permanent tissue damage.

Answer these questions in your documentation: Was there substantial acceleration with the injury? What was the initial period of disability? Was significant weight load involved? How many systems where involved (muscle, ligament, disc and nerve)? Arguably, the more significant the initial injury or incident, the more likely the need for supportive care.

Since almost all claimants feel their injury is severe, research the nature of the injury completely. Initial pain may be severe, but the pathophysiology may be slight.

2. Nature of Employment
The type of employment may bear heavily on the need for supportive care. Certain job tasks expose the patient to repeated risk. Repeated handling of heavy loads has been shown to increase risk. Patient handling occupations, such as aides, are exposed to risk due to weight loads and awkward lifting. Highly redundant activities coupled with poor ergonomic design result in a high incidence of injury. Even prolonged static posture coupled with vibratory stresses increase risk with occupations such as truck driving.

It is imperative that the nature of the patient's work is considered when assessing the necessity of supportive care. A long history of work in a high-risk occupation may lead evidence to the occurrence of multiple injuries over the claimant's work history rather than the occurrence of singular injury.

Continued work in a risky occupation following substantial injury may warrant supportive care. No occupation, however, is without risk. Assess rationally the claimant's work activities to determine its effect on the necessity of supportive care.

3. Delay of Appropriate Treatment
Withholding appropriate treatment may heighten the likelihood of permanent residual and, as a result, necessitate supportive care.

Modern guidelines promote aggressive, conservative treatment to return the patient to full function as soon as possible. The days of treating musculoskeletal injuries by bed rest and analgesics are gone. Yet, how many old workers' compensation patients are we treating who were unable to work for 3-6-12 months but received no active treatment or rehabilitation? Document concisely the history of the patient's previous treatment. Was it appropriate by contemporary standards? Assess honestly how you are managing your new claim.

4. Aggravation of or by Pre-existing Conditions
Did the patient have significant pre-existing conditions that were destabilized by the injury (spondylolisthesis or degenerative facet arthropathy)? Does that patient have pre-existing organic diseases that prevented complete recovery? These factors must be considered and may be made part of the claims allowance. Be prepared to assess realistically what the patient's past symptomatic picture was. Did the patient have subjective complaints prior to the work injury? If they did, can you really state that the necessity for supportive care id related to the work injury?

5. Exacerbation of the Work Injury
Given certain types of employment, the patient's history may be complete with history of multiple work-related re-injuries or exacerbation of the same condition. In the old workers' compensation system, these conditions were generally treated under the "old claim." The new system may demand that new claims are filed for these "exacerbations," but I will save that subject for a future article.

For the current issue of substantiating necessity of supportive care for the old BWC cases, the history of repeated work related injury is imperative. If, however, the "exacerbation" is not work related, is it a new injury or condition? Is it reasonable to bill the employer for these episodes? The answer is maybe yes, maybe no. Each case is different, and it is your responsibility to make an appropriate, defendable decision.

6. Evidence of  "Different Approaches"
All reasonable options and variations of treatment should be exhausted before remanding the patient to supportive care. Does the patient's treatment history demonstrate that all reasonable efforts were made? Were medical or physical therapy approaches tried on the patient but failed to fully respond to your care? Has the patient earnestly applied self-help active techniques? Have you assessed the psychological profile of the patient to screen for chronic pain behavior or psychological overlay? Are you filling the patient's dependency or providing necessary physical treatment? Is it considered inappropriate by definition to transfer the patient to a supportive care basis without utilizing all reasonable treatment options first.

7. Withdrawal of Care
The necessity of supportive care can be demonstrated only if the patient's condition is shown to deteriorate with the withdrawal of care. Are you able to document withdrawal from treatment? What measurement tools are you using to demonstrate that their condition does in fact deteriorate? Are you using Visual Analog Scales and Functional Assessment Surveys? Do you take through narrative notes? Or do you document simply the patient's "LBP increased, stiff and sore since last visit"?

Perhaps I have raised more questions than I have answered. But, in my opinion, these are the key elements that you must address if you are to justify the necessity of ongoing supportive care. Following are additional considerations:

• Some consider "pre-scheduled" supportive care, for example every two weeks, an oxymoron. They consider appropriate supportive care to be delivered only when the patient's condition deteriorates.
• Supportive care should be of low frequency (perhaps at approximate 2-4-6 week intervals). The use of higher frequency care years after the injury may indicate that the treatment is ineffective and fosters patient dependency.
• Some question the appropriateness of multiple passive modalities used in conjunction with supportive care. Therapies such as heat and EMS may have little actual physiological benefit for the patient. True supportive care may get back to the basic premise of chiropractic - to improve function and health through the physical treatment of the dysfunctional motor unit.
• If frequent exacerbation is the norm, this too may indicate that proper patient counseling has not occurred or that the patient is not motivated to self-help, self-reliant mechanisms. The highest goal of any profession should be to prevent the need for its service. If you are leaving the patient at a constant repeated exposure, you must reevaluate your treatment philosophy.

When your request for supportive care is denied, and you feel that you can document necessity based on the criteria I have discussed above, use the two tiered process built into the MCO system. Beyond this, you and the claimant still have the Bureau of Workers' Compensation Alterative Dispute Resolution process. Further, you can utilize the Industrial Commission to appeal denied treatment.

We must fight for what our patients - in this case injured workers - deserve and need. But we must also pick our fights for the cases that are demonstratively right and can be proved.

Tri-County Chiropractic Association would like to thank Dr. Robert Poteete for allowing us to use his article that appeared in the April 1998 issue of OSCA's On Target

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