Monthly Archives: May 2016

May 18, 2016

It’s time to establish accountability for job loss

My report on Establishing Accountability to Reduce Job Loss After Injury or Illness (commissioned by the US Department of Labor’s Office of Disability Employment Policy) was originally conceived as a simple effort to lay out the rationale for adding work and participation in life to the list of positive health outcomes.  (I suspect that I was asked to write it because they thought a physician like me would focus on medical practitioners and the healthcare delivery system.)

Almost immediately, it became obvious to me that in order to make a solid contribution to the on-going public dialogue about health outcomes, the paper would have to explore the meaty issues of explicit expectations, accountability, metrics, credible data, rewards for best practices, and incentives for both participation and performance.

Soon after that, the absurdity of discussing expectations and accountability for the healthcare system alone became obvious —because organizations in other sectors of society play a role in the SAW/RTW process, each of which has enough discretionary power to support or thwart it.

Thus, over time, the purpose of the paper shifted to answering this question:  What has to happen in order to engage the professionals at the front-line  — the ones who work directly with affected individuals and make discretionary decisions about how much effort to make and for what purpose — so they start making a real effort to help people stay employed?

Who are those front-line professionals?

(1) Healthcare professionals.  Most of us view our purpose as making accurate diagnoses and providing appropriate treatment.   We are generally not trained to assess work capacity and prevent work disability.  Yet our opinions about work have considerable weight under law, regulations, insurance policies and traditional business practices.  We generally don’t spend much time and energy thinking about issues outside the exam room.

(2) Workplace supervisors or HR professionals.  Their focus is the business of the organization, producing its goods or delivering its services,as well as abiding by company policies and applicable laws. They can decide how much effort to make to help the employee stay at work and keep their job.  With rare exceptions, they are neither aware of the preventable nature of most work disability, nor are they trained how to negotiate and arrange stay at work or return to work plans, identify alternative temporary tasks or reasonable accommodations.  And they are not incentivized to do so.

(3) Claims/benefits administrators.  Their focus is administering the benefit programs correctly, establishing eligibility, compensability, meeting deadlines, making payments, and other requirements. In between these duties, they decide how much effort to make to help the beneficiary/claimant. Like the workplace professionals, with only rare exceptions, they are neither aware of the preventable nature of most work disability, nor are they trained how to negotiate and arrange stay at work or return to work plans, identify alternative temporary tasks or reasonable accommodations.  And they are not incentivized to do so.

Job loss is the third worst outcome of an injury or illness

As I thought about these players and those who influence their behavior, the biggest realization dawned more slowly:  job loss is a potentially devastating secondary consequence of a health-related employment disruption or a failed SAW/RTW process — because it often leads to permanent withdrawal from the workforce.  In fact it is the third worst outcome of a health condition, the other two being death and loss of limb or core functions like sight and hearing.

Yet we have not seen it that way.  Unlike death and serious injury, job loss is generally not noticed.  It’s actually a hidden outcome.  The frequency with which it occurs can only be estimated indirectly — because it is untracked and thus invisible.  When someone loses their job due to long-lasting illness or injury, they often end up leaving leave the workforce permanently, becoming dependent on public benefits programs like SSDI.

Some years ago, a senior Social Security Administration official commented to me that SSDI is the largest insurance fund IN THE WORLD and yet it has no risk management program, no loss prevention program.  Private sector insurance companies view these as core functions of their organizations.  They know they must identify and take steps to reduce risks and mitigate losses in order to meet their responsibilities and stay solvent.

In my view, government should be likewise obligated to take steps to protect SSDI (and the taxpayers who fund it) from the economic consequences of the dysfunctions, inadequacies and gaps in the upstream social structures and programs — because their failures end up on public benefit programs.

Government will make a major contribution to reducing demand on SSDI by:
(1) establishing policy that job loss/withdrawal from the workforce is a very unfortunate outcome of a health problem and should be avoided whenever possible,
(2) enabling all parties to see more clearly when it happens by requiring reporting of these events; and
(3) establishing consequences of some sort when involved organizations are non-responsive (negative incentives such as financial penalties, loss of privileges, or public exposure) or do take appropriate action (positive incentives such as credits, privileges, or favorable publicity).

This combination of outcomes visibility and accountability should then start to shift how parties in the private marketplace choose vendors and suppliers.

How will things look different when there IS real accountability for job loss?  

Implementing the broad range of actions recommended in the Establishing Accountability report will require a significant long-term effort because of their comprehensive, complex, and varied nature.  Taken as a whole, these actions have the potential to create truly transformational change.

Success will mean that more workers living with adult-onset chronic conditions and impairments (acquired disabilities) will be able to stay fully and productively engaged in their own personal, family, and community life; protect their household’s standard of living; remain economically self-sufficient contributors to their local area economy; and avoid dependency on government programs—which will in turn protect their future health and well-being and improve their children’s future prospects.  At the national level, success has the potential to stem the tide of declining labor force participation, lighten taxpayer burdens, and bolster the nation’s social fabric and the vitality of the economy.  All in all, the initiatives proposed make good use of limited government resources.

The ultimate success of the initiative will hinge on the ability of Federal policy leaders and supporters to create and sustain real multi-stakeholder buy-in and enthusiasm for achieving the future vision described in the paper.   A good next step is for the federal and state governments to decide whether and where to start.  It will take time and effort to achieve consensus among key stakeholders that this kind of initiative is necessary, timely, and deserves priority for person-power and funding.  Once that preliminary groundwork is laid, more detailed planning work can get underway.

Whoever you are, I hope you read the Establishing Accountability paper and agree that change and action is needed.  If my suggested recommendations spur you on to creative thinking, you do NOT need to wait for the government to act.  You can start factoring these issues into your decisions about who to collaborate with now.

May 16, 2016

New study: adherence to guidelines leads to better outcomes

One of the issues raised at the multi-stakeholder Work Comp Summit I attended in Dallas last week (more on that later), was this question:  “Are Treatment Protocols and Evidence-Based Guidelines a Benefit or a Burden?”  Evidence-based medicine (EBM for short) and evidence-based treatment guidelines have been controversial in some quarters, especially when they don’t support popular (and lucrative) treatments.  Skeptics have pointed to the lack of “real world” proof that following these guidelines actually does produce better outcomes.

As a near-miraculous coincidence, we have HARD FACTS to contribute to that discussion as of today. A landmark paper has just been published that will / should attract wide attention — particularly in the regulatory and commercial marketplaces.  The new study says it is describing the development of a methodology for assessing the impact of treatment guidelines — but in so doing it has produced the first tidbits of hard evidence that adhering to EBM treatment guidelines significantly improves outcomes of work-related injury claims, in terms of both medical cost and duration.

There’s an easy-to-read article about it entitled Study Supports Benefits of Evidence-Based Medicine in this week’s on-line Workers’ Comp Forum published by Risk & Insurance.  According to that article, the researchers believe this is the first scientific proof that consistently applied treatment guidelines are more effective in treating injured workers — when compared to non-evidence-based care. If you’re a details type, read the original article entitled A New Method of Assessing the Impact of Evidence-Based Medicine on Claim Outcomes.  It’s in this month’s issue of the Journal of Occupational & Environmental Medicine.

To the methodologists and kvetchers among us – any comments on this merits of the methodology they used?  Do we have an opportunity to IMPROVE the methodology?  And just in case there are any advocates of EBM among us, anyone want to yell YAHOOOOOOO? I do!

The study was supported in part by AF Group, formerly Accident Fund Holdings Inc which owns a family of workers’ compensation companies and is itself a for-profit subsidiary of Blue Cross Blue Shield of Michigan.  It was AF Group’s workers’ comp claim data that was analyzed using ODG’s treatment guidelines.

ACOEM membership includes a subscription to JOEM, so if you know an ACOEM member, ask them to get the article for you.   It may be simpler to purchase your own copy on JOEM’s website.    The authors are Hunt, Dan L. DO; Tower, Jack MS; Artuso, Ryan D. PhD; White, Jeffrey A. MS; Bilinski, Craig MS; Rademacher, James BA; Tao, Xuguang MD, PhD; Bernacki, Edward J. MD, MPH.   Dr. Bernacki works at both the University of Texas and Johns Hopkins University, and has done some superior research in the past on questions of real practical interest.  The full citation is JOEM: May 2016 – Volume 58 – Issue 5 – p 519–524 doi: 10.1097/JOM.0000000000000718.

I sure wish this study had been done based on ACOEM’s Occupational Medicine Practice Guidelines which are the clearly superior product from my (informed) point of view.  That’s the NEXT study that should be done.

May 11, 2016

Best & worst states for people with disabilities who want to work

Have you heard of RespectAbility?  When I went to their website, I found a COOL CHART showing some HOT NUMBERS:  the best and worst states for people with disabilities who want to work.

Before you look at the chart (I’ve pasted it below):
•    Guess which state has the highest employment rate for people with disabilities – 50.1%?   Do you think it’s a blue or a red state?
•    Guess which state has the lowest rate – 25.6%?   Is it blue or red?
•    Answer:  Almost all of the best AND the worst states for people with disabilities with regard to employment are in the red zone of the USA.

So, what else might be the reason for the differences between states?   Hmmmmmmmm. Is it the underlying health of the state’s economy?  I went to Mr. Google to find a ranked list of state economies.  This list on Business Insider was the first one I found.  Yay, here’s the answer, I thought (for a moment).   The WORST state for people with disabilities is the LAST state in the ranking – the state with the weakest economy over all (West Virginia).

BUT then I noticed that two other states among the bottom 10 of Business Insider’s list of state economies are in RespectAbility’s the TOP FIVE for employment of people with disabilities:  North Dakota and Wyoming.    And at the other end, of the 10 states that Business Insider ranked most economically healthy, only 1 was also in RespectAbility’s top group for people with disabilities (South Dakota).

I started to wonder whether Business Insider’s list was the “right” one, and found three other lists, here, here, and here — all of which purported to describe the health of state economies.  Each one has a VERY DIFFERENT RANKING of the states!!   The difference seems to be the method they used:   the underlying data sources and the formula used to calculate the results.

So I said uncle.  As an economic babe-in-the-woods who is unable to sort through this stuff, I have given up my extremely short amateur quest to understand WHY some states are better places to be if you have a disability and want to work!   For now, it is what it is, to use the jargon of today.

CLICK ON the table from RespectAbility pasted below and check out the numbers.  Then go to the full article on the RespectAbility website to read their analysis of why the numbers look the way they do – and what it all means.  And while you’re there, RespectAbility has also asked the current candidates for President of the USA to answer questions about their position on people with disabilities.  Their answers were NOT all the same!

Table-Best and worst states for disabled employment

May 8, 2016

Key but hard-to-find esoterica in evidence-based medicine

Mother’s Day Brunch is over, and I am feeling appreciated and loved, though a bit bored and lonely now that the “kids” have left for home.   So I’m catching up on stuff.

I went back to finish reviewing a draft practice guideline via an on-line questionnaire.  The authors wrote that I was selected to participate because of my particular field of expertise.  I started but didn’t finish the questionnaire last month.  When I logged in again today, the software jumped me straight to a question that asked whether I agree with a statement that begins: “There is OCEBM Grade C supporting evidence that ……”

This terminology was only semi-famliar to me, so I Googled OCEBM which wasn’t much help.   I still haven’t found the criteria for Grade C (which implies there exists criteria for Grade A, B, and maybe other grades beyond that too).    More Googling will probably help.  But to be truthful, I decided to give up on this effort.   When the researchers asked me to participate, they didn’t tell me the survey has SIXTY FIVE questions each of which seems to require a whole lotta cognitive work including evaluating a set of brief descriptions of the scientific literature pertaining to the subject of each question.   I am NEITHER an academic type nor a methodologist (a person who critiques the experimental design and analytical methods used in research).

HOWEVER, while Googling around I did find a document  entitled “Understanding GRADE: An Introduction” that MAY BE USEFUL to you.  It was for me.  It succinctly describes  (in LESS than 1,500 words) the steps that developers of systematic reviews and practice guidelines should use to assess and rank the quality and strength of evidence supporting a particular practice or treatment.  This method is widely used in appraising scientific studies.  Worth a read – particularly if you are confused by competing guidelines.

Methodology is KING in evidence based medicine — if the scientific quality of a study sucks, you shouldn’t view the results as reliable/valid/believable — no matter how much you love them.  So if you’re like me and not a methodologist yourself, you need to make sure that the committee that produces an “evidence-based guidelines” has members who really do know that stuff.

In theory, I like the idea of wide participation of experts in development and review of practice guidelines.  But based on my (limited) experience with development of the ACOEM practice guidelines for occupational medicine, the work is so hard, detailed, and time-consuming that it tends to be done by a small group of committed experts who put in a TON of hours, and then send their finished product out for comment.  Part of the reason why I felt so uncomfortable reviewing the practice guideline today is that there was so little background information and context provided to me as a reviewer.  Like:  (a)  what were the 65 questions going to be like; (b) how long would it take me; (c) where are they in the development process, and (d) what use is going to be made of the on-line reviewers’ input?