by Mark Larson

A list of five physician-ordered procedures dubbed by the American College of Occupational and Environmental Medicine as wrongly overdone and sometimes harmful, are just “the tip of the iceberg” of many more unnecessary procedures commonly ordered, say analysts. But such wrongheaded doctor-ordered treatments for work-related injuries or illnesses are also hard to police and can be a physician’s defensive move to help pay office bills or avoid malpractice lawsuits, analysts said.

ACOEM on Monday cited an Institute of Medicine report that up to 30% of health care spending is “duplicative or unnecessary.” Some unnecessary tests and medical procedures can cause harm while driving up costs, according to ACOEM.

The list, an offshoot of the ACOEM’s Choosing Wisely campaign aimed at improving patient care and communication on treatment options, is the latest addition to another 245 tests and procedures the campaign has listed since 2011 as overused and inappropriate.

ACOEM’s latest addition to the list came from evidence gathered on management and treatment options. It recommends that physicians do not:

  • Prescribe opioids to treat chronic or acute pain for workers who perform safety sensitive jobs, such as operating motor vehicles, forklifts, cranes or other heavy equipment.
  • Initially obtain X-rays for injured workers with acute non-specific low back pain.
  • Order low back X-rays as part of a routine pre-placement medical examination.
  • Routinely order X-ray for diagnosis of plantar fasciitis/heel pain in employees who stand or walk at work.
  • Routinely order sleep studies (polysomnogram) to screen for or diagnose sleep disorders in workers suffering from chronic fatigue/insomnia.

“This is a step in the right direction, but it’s just the tip of the iceberg,” said Brian Klepper, a Florida-based health care analyst.

In an August presentation he gave to the Florida Healthcare Coalition Conference, Klepper cited 2008 research by the PriceWaterhouseCoopers study “The Price of Excess” which calculated $1.2 trillion, or 54.5% of the $2.2 trillion spent in the U.S., comes from “wasteful spending in the health system.”

Al Lewis, a Boston-based author of “Surviving Workplace Wellness” and president of the Disease Management Purchasing Consortium, said he agrees with the problem procedures listed by ACOEM.

“It’s common knowledge that testing in workers’ compensation is way overused,” he said, adding that in addition to scans and X-rays, magnetic resonance imaging tests are also overprescribed. But while doctors are being advised by ACOEM to hold off on certain procedures, Lewis noted there’s nothing deployed − at least for now − to enforce a reduction in unneeded procedures.

“One way is you pay one price for a visit that’s higher than the cost for just a doctor,” said Lewis. “But then you get the opposite problem − undercare. There is no easy answer.”

David Donn, a San Francisco-based managed-care consultant for large private employers and public agencies, said some physicians overdo it with X-rays because they have “an ATM mentality,” to get the most money from care plan reimbursements as they can.

In treating patients, said Donn, doctors can do what they feel is the appropriate medical procedure, they can decide to do an unneeded procedure to avoid the possibility of being sued, or they can intentionally order unneeded procedures as a way to boost income.

Donn said that in his several years in the business, he’s been aware of very few cases in which doctors in a medical provider network hold off needed treatments to patients as a cost-cutting favor to employers.

“It’s very rare that you find that kind of collusion,” said Donn. “It’s like with any field, you get some bad actors.”