Dr. J.'s Jottings: Upgrading Workers' Comp & Disability Benefits Systems

Dr. J's Jitters / "First Class Comp"

I've got the pre-speech jitters -- again!  Am en route to Phoenix to serve as keynote speaker for the National Council of Self-Insurers conference.  I'll be talking about the new ACOEM* Guideline on Preventing Needless Work Disability by Helping People Stay Employed and Webility's 60 Summits Project. The NCSI audience will be mostly executives and managers who are responsible for their company's self-insured workers' compensation programs.  Since companies have to be pretty large to self-insure, they tend to hire people who are work comp experts.  Thus, this audience will be "system savvy."  I wonder if they're so savvy about the status quo that they won't be attracted to my story about a potentially brighter future.

Something's been missing in both workers' comp and disability benefits systems: a detailed vision of how the system ought to work -- what ought to happen from the employee's point of view as well as the employer's.  Mostly the participants in these systems talk about what is wrong or what we don't want to have happen.  Remember how shocked you were when people first told you about how the "comp system" works? --- the way that people's faces hardened and that cynical note in their voice?   Today, when you tell people you meet that you do a lot of work in the workers' comp or disability benefits system, do they say: "Gee, that's so cool; I wish I could do that!"?  Many people think of these systems as boring and beaucratic, or corrupt and adversarial, or sleazy or unattractive, right?

So, just for a shocker to get people thinking differently, I'm going to invite the NCSI audience to play with this idea:  "What would a first class workers' comp system look like?" By first class, I mean a system that is the equivalent of Nordstrom or LLBean for retail, the Four Seasons or the Ritz Carlton for hotels, or BMW or Mercedes Benz for cars.

Key point:  Nordstrom, the Ritz, and BMW believe that if they give people a wonderful product and fabulous service, they'll want to buy more and keep coming back.  In the game we'll be playing at NCIS ("First Class Comp"), the assertion is that if we give people fabulous service, they'll want to buy LESS because we'll meet their needs so completely and appropriately.  Injured/ill employees will stop "buying" unnecessary and inappropriate medical care, and both injured/ill employers and their employers will stop "buying" unnecessary time away from work.

Second key point:  This is NOT JUST about being polite to injured workers' and their supervisors -- though that's part of it.  And it is CERTAINLY NOT about catering to their every whim and demand.  We're talking about starting from the position that workers and their supervisors are each important  individuals who powerfully influence the outcome, and that we are being curious about how they see the situation, earning their trust, engaging them in the search for solutions, and really meeting their legitimate needs. 

When we're delivering "First Class Comp", we'll have shifted the focus to include more than simply watching what the worker does and how the employer responds and then deciding what that means for our workers' compensation or disability benefits claim.  We will now be planning ahead, anticipating people's needs and reactions, focusing on the whole situation created by the worker's injury or illness, envisioning the realistic best outcome given the circumstances, and then using best practices strategies and protocols to drive the situation towards that optimal resolution.   

The Guideline and The 60 Summits Project are designed to build a widely-shared positive vision of how the stay-at-work and return-to-work process could work.  Will that appeal to the NCSI audience?  Will the blueprint for improvement that the Guideline lays out make sense -- and lead them to take action? Will the grass-roots approach of the 60 Summits Project strike them as hopelessly naive, or as a good way to get action going in their own company, community and state?  Exactly how cynical and resigned are they?   

My goal is to leave the NCIS meeting having had at least 25 conversations with companies who are intrigued by The 60 Summits Project and say they want to get involved.  (Of course, I also hope some employers will be curious about how Webility's training and consulting services might assist them internally.) To date, the most enthusiastic Summit planners in Oregon, California, Arizona, and Ohio have been large employers.   Stay tuned . . .

(*ACOEM = American College of Occupational & Environmental Medicine, the professional society for occupational medicine physicians.)

Designated Guessers

Talked the other day with a doctor who works for a large workers' compensation carrier.  He's been asked to design and teach a course for physicians on how to set work restrictions and limitations.  He hesitated and stammered a bit and then confessed that he's realized that the emperor has no clothes in this area  -- that in fact no doctor (not one) REALLY knows how to do this accurately (in advance) because there is little or no evidence-based science on this topic, nor are there any studies supporting any of the specific estimates that the doctors make about work capacity.   In fact, the few studies there have been either refute or fail to address the predictive accuracy of the methods in common use.

So, the doctor from the insurance company and I laughed ruefully, and I found myself describing the doctors as "designated guessers."  Someone's simply gotta give advice to workers, to their employers, to benefits claims adjudicators and sometimes the courts about what an injured or ill person should avoid and what they can do safely.  I suppose it's actually better to have doctors doing the guessing than carpentry supervisors or benefits clerks.  At least the doctors have been trained in anatomy, physiology, and they have watched lots of people get sick and then heal and get better.   Orthopedists and occupational physicians (those who treat lots of work-related injuries) are more practiced at making these SWAGs (scientific wild-**sed guesses) than most other doctors are.  But they are still making guesses.  What's really weird is how quickly these guesses become the "revealed truth" written in stone.

Bluntly, doctors are being asked to predict the future, and to predict performance based on fragmentary knowledge of objective medical/physical factors only in an area where motivation, cultural and personal beliefs, individual tolerance for discomfort and fatigue, environmental and emotional suppport, skill/training/expertise, natural ability, and many other non-medical factors play a major role in what actually happens.  Realistically, the best way to tell if someone can do a job safely and comfortably is to let them try doing it, assuming they want to succeed.  Sadly, retrospective advice is not what is usually required, and not every worker wants to succeed at the tasks.   And, the fact that someone has been safe/comfortable "so far" is not a guarantee that they will continue to be so.

Studies have shown that doctors' advice tracks more closely with their own beliefs about the value of work, how to behave when ill, and the hazards of activity in general than with any factual information.  And, in the lone study of which I am aware that addressed the issue of the predictive ability of functional capacity evaluations (FCEs), they were found NOT useful in predicting people's actual ability to perform successfully at work. 

Things will get better if we start from the reality that the doctor is guessing.  How can we help the doctor make the best quality guess? 

Wouldn't you think that the best way to figure out what workers can do is to ask them?   But what about medical risks in the situation that the workers can't anticipate because they don't understand the process of wound healing or the side effects of their medications or overestimate their stamina or length of recuperation?  This is where we really do need medical expertise, but the problem is that almost all doctors have never been taught either a logical or a standard method for figuring these issues out (and there IS no generally-accepted method yet).  Also, as pointed out on page 11 of the new ACOEM Guideline on Preventing Needless Work Disabiltiy by Helping People Stay Employed, there is NO authoritative and comprehensive resource available that lists the medical risks for workers with particular diseases or in particular work environments or trades.  (The new book A Physicians Guide to Return to Work by Talmage and Melhorn from the AMA Press is the closest approximation available.)

Another reason why employers/payers don't want to ask the workers what they can do is that they don't trust the workers to be truthful.   This is where things REALLY get complicated.  Unfortunately, the doctors' ususal reaction to being put on the spot is .. . . . to ask the workers what they can do!  So what good did it do to put the doctor in the middle?

If we assume for the moment that ill-prepared doctors around the country (and world, for that matter) are being pressed into service as the "designated guessers", then it seems to me that it would make sense:

1. to train as many of them as possible how to think through these situations, and to develop some standard models to teach them.  I've been giving basic lectures on this topic to clinicians who laugh with relief when I acknowledge that we're all making guesses, then pay rapt attention and are grateful for the material -- they feel awful about having to make these decisions day in and day out without any conceptual or clinical model to rely on.  Remember, these are people who went into their chosen profession because they like feeling expert and masterful.

2.  for the other parties with personal knowledge about the situation to help the doctor as much as possible -- to contribute the data and background information they have, to point out aspects of the situation that are of concern or seem pertinent, etc. 

3.  to treat the doctor's advice as a tentative first cut, instead of the truth written in stone.  If the doctor's opinion seems off base to others with personal knowledge of the situation or experience in giving guidance in similar-seeming situations, then provide that data in a helpful manner to the doctor and ask for a re-thinking in light of the additional information.  Or, even better, have a conversation and work together in dialogue instead of sending formal missives back and forth to resolve the issue.

If we all start thinking of the stay-at-work and return-to-work process as a team sport with team members in different sectors of society, and if we have compassion for the doctors who are doing their best with an impossible task, and start collaborating on putting together a complete picture of the situation, the decisions that get made will at least be (a) based on richer data about the actual situation at hand and (b) more credible to all parties because they have all played a role in developing it.

Definition of "disability" in the ACOEM SAW/RTW Guideline

Two people have communicated "upset" to me recently about the negative way that disability is referred to in the new ACOEM Guideline on Preventing Needless Work Disability by Helping People Stay Employed.  When the second one spoke up, I got curious and checked the text of the Guideline.  Oh my gosh!  A critical definition was eliminated when the editor cut about 20 pages from our committee’s original white paper in order to make the final Guideline a more manageable length.  That omission has created understandable confusion.  And it turns out other key background information was also eliminated that helps clarify the context for the document.

On page 9 in the original white paper that was the source material for the Guideline, we defined “disability” this way:

"In this paper, we use the word 'disability' the same way that employers use it in their benefits programs and employment policies, and the same way that insurance laws, regulations, and policies do. We use 'disabled' to mean someone who is absent from work or not working at full productive capacity for reasons related to a medical condition. Please note that confusion is common regarding the word 'disability' since it is sometimes used to describe physical or functional impairments. For example, a person who has an impairment that affects one or more life functions is considered to have a disability under the Americans with Disabilities Act (ADA). However, people with ADA-qualifying impairments who are working at full productive capacity would NOT be considered 'disabled' according to our definition, because they are at work."

On page 10 in the original white paper, we also made it clear where the main focus of the Guideline was intended to be.  Here’s what we said:

"The focus of this paper is on the surprisingly large number of people who end up with prolonged or permanent withdrawal from work due to medical conditions that normally would cause only a few days of work absence. Many of those who end up receiving long-term disability benefits of one sort or another have conditions that began as common everyday problems like sprains and strains of the low back, neck, shoulder, knee and wrist, or depression and anxiety. As we will discuss below, prolonged work withdrawal (disability absence) by itself can produce unfortunate consequences, and this is one of our major concerns.
"On the other hand, many of the people who receive disability benefits have severe illnesses like a major cancer or schizophrenia or have suffered catastrophic injuries such as amputations, blinding, major burns, or spinal cord injuries, or have had major surgery. These people, too, are susceptible to the influences described in this paper, although the effects may be overshadowed by the obvious difficulties of coping with medical problems of this magnitude, and the need to learn skills and methods to deal with any resulting impairments. In these cases, a prolonged period of work absence is often unavoidable. The traditional rehabilitation approach delivered by an array of professionals was designed to meet the needs of these people. The question still arises: what amount of this work disability could be prevented?
"We contend that a considerable amount of the work disability due to common everyday conditions (and an unknown fraction of the disability that follows more serious conditions) is avoidable, as are its social and economic consequences. We believe that a lot of work disability can be prevented or reduced by finding new ways of handling important non medical factors that are fueling its growth."

So, I have added these important sections to the “Introduction to the Guideline.”   The revised version will appear on our website  (www.webility.md) in the next day or two. I will also make a point of clarifying the definition of disability whenever I talk about the Guideline in the future.

I'm grateful to the people who spoke up, especially because they spoke up passionately enough that I got curious.  I was sure that definition was in there, and couldn't figure out why they didn't "get it."  Their speaking up helped me correct a misunderstanding that has been hurtful to people who don’t need more problems -- and that might have weakened the Guideline’s effectiveness. 

My personal goal -- and imagine that I speak for the 20 other physicians who developed this Guideline with me -- is for this Guideline to help all people who experience illness, injury, age or any other kind of “differentness” -- particularly those for whom this represents a change -- to get the support they need so they can continue to have productive lives in society and the fullest practicable participation in life. 

ACOEM Cornerstone Summit Report

Dr. J’s First Jottings

Last Friday, a report arrived in the mail entitled “Shaping the Future of Occupational Medicine: Finding Opportunities for Collaboration”.  It summarizes the results of the American College of Occupational & Environmental Medicine’s Cornerstone Summit held in late January 2007.  The by-invitation-only meeting was the College’s first step towards building relationships with employers and payers.

The culmination of about five years of effort, the Summit began as a blinding flash in which I realized that ACOEM, the professional society for occupational physicians, had no “face” turned towards employers and payers, despite the fact that they write the checks for virtually all occupational medicine services.  ACOEM had traditionally focused on its own members, the public policy arena, and in particular the legislative and regulatory arena, especially federal agencies like OSHA and the DOT.  Things are changing:  today the ACOEM website has some portion of its pages designed for purchasers or users of occupational medicine services.

After leading a couple of preliminary smaller projects in this area, I chaired the committee that planned the Cornerstone Summit, and facilitated the daylong session.  The 7 employers who attended were not just large national organizations (Wal-Mart, Tyson Foods, Marriott International, the US Postal Service), but also regional (Reinhart Food Service, First Energy) and local (Duke University) employers.  The 8 payers present included some really big ones (Liberty Mutual, AIG, State Compensation Fund of California, Sedgwick CMS) but also some local ones (the Texas Association of School Boards, Unisource Administrators from Florida, Workforce Safety & Insurance (the North Dakota state workers’ compensation fund), the Food Industry Self-Insurance Fund of New Mexico.) Ten ACOEM members attended, representing the three funders of the project: the ACOEM Board of  Directors,  the ACOEM Private Practice section and ACOEM Work Fitness & Disability section.

Originally intended to be a wide-ranging discussion about the future of occupational medicine, the employers and payers in the room mostly wanted to focus on the new ACOEM work disability prevention guideline and how the three parties at the table might be able to work together more effectively in the stay-at-work and return-to-work process.  Four work groups, each with physician, employer and payer members, were formed and will continue to work together develop, refine, and try out new ideas that emerged during the Summit.   They are:  (a) forms and tools; (b) education; (c) processes and models; and (d) incentives and legislative mechanisms.

You can get a copy of the Cornerstone Summit report by calling ACOEM at 847-818-1800.