Tag Archives: job loss

June 23, 2018

Don’t miss out! RETAIN grants are a big opportunity

RETAIN is a five year and $100 million Federal Grant program that state agencies must nominally lead.  However, the leadership team must be multi-stakeholder and include an organization that actually delivers hands-on medical care.  Moreover, the states will probably end up contracting for delivery of the many services by individuals or organizations in the private sector. Proposals are due in ONE MONTH – so if you’re tempted to get involved, join our list-serv now and learn what you need to do!  See more below.

RETAIN is the biggest opportunity for physicians who practice occupational medicine since the 1970’s — when NIOSH and OSHA were established. It’s also a huge opportunity for other professionals with expertise in preventing needless work disability during the early phase of the stay-at-work/return-to-work (SAW/RTW) process:  the first few weeks and months of an injury/illness episode.

RETAIN requires states to get involved VERY EARLY in new injury and illness episodes among workers they haven’t had on their radar — and arrange provision of several kinds of services with which these agencies have had little/no familiarity. Most of the state agencies that received the RFP (and must lead RETAIN in their state) have been confused and caught flat-footed by it. They really need professionals with expertise at the interface between healthcare and the workplace to pitch in at several levels:

– to help NOW with project design and proposal writing
– once the project launches, to help oversee, manage and tweak the project at the top level,
– in individual cases, to deliver specific services during the first weeks and months of work interruption. (In fact, eligibility for RETAIN program services ends after 6 months of work absence.)

I’ve set up a free list-serv for everyone who is interested in the possibility of getting involved with their state’s RETAIN project. My personal goal is to help as many states as possible to recruit appropriate leadership teams and write successful bids. The project is so unusual, I don’t think there will be many. The Feds plan to accept EIGHT bids (from eight states).

JOIN US — if you’re an occ doc or SAW/RTW professional who is willing to wade in, introduce yourself to strangers, and then join the small team that will be developing your state’s overall project design and writing its proposal (bid) between now and July 23. Once you join the list-serv, go to our website and read the small number of earlier and information-filled emails that will get you oriented and on the right track. You’ll find links to the RFP itself along with many other resources.

To join the RETAINers list-serv, go to https://groups.io/g/RETAINers and click on JOIN THIS GROUP

NOTE: Think big.  This is the beginning of an effort to knit together some holes in our social fabric to meet the needs of people who have been falling through the cracks.  The Feds are looking for proposals that will help workers with new health problems — regardless of what caused them.  The point is to help ANY worker for whom a new health condition is causing work interruption and, if the right things fail to happen, could threaten their job. Needlessly losing one’s livelihood and ending up on SSDI is a very poor outcome of a health condition — ESPECIALLY when it didn’t need to happen.

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September 27, 2017

Job loss due to medical care calendar vs. FMLA calendar

Extending medical leave beyond the FMLA period may be an UN-reasonable accommodation under the ADAAA, according to a recent decision of the US 7th Circuit Court of Appeals. The court wrote: “ADA is an anti-discrimination statue, not a medical-leave entitlement.” And it said that since the purpose of reasonable accommodation is to allow an employee to work, which a medical leave does not do, then a leave does not accomplish the law’s purpose. However, the EEOC opposes the position of the court, and is unlikely to change its view that a long-term leave IS a reasonable accommodation when it is: (a) of specific duration, (b) requested in advance, and (c) likely to result in the employee being able to perform essential job functions upon return.

ATTENTION ALL CLINICIANS and CLAIM PROFESSIONALS: Please notice this one key fact in the case before the court. A guy exhausted his 12 weeks of FMLA leave during the “conservative care” phase of treatment for his back pain. In fact, he had his back surgery on the LAST DAY of his FMLA leave — which was protecting his job!

We really have to think more about the intersection between the calendars of “evidence-based medical care” and job loss. For most of the common musculoskeletal problems (like straightforward back, knee, shoulder and ankle pain for example), the scientific evidence says that the doctor should begin by prescribing simple things like aspirin or motrin, ice packs, physical therapy, and exercise.  Unless there are clear signs of a potentially dangerous or progressive problem, the best thing is to wait for 6 weeks and give the patient’s body time to heal itself naturally.

But maybe we should be keeping our eye on the clock, and monitoring progress more actively during that 6 weeks.  When we see recovery not proceeding as hoped, we may need to ANTICIPATE the need for an orthopedic referral, make the appointment for that 6 week mark, and cancel it if things turn out better so it’s not needed.  If not, we may burn through several weeks before the specialist can be seen.

In my experience, it is more typical to see the initial treating clinician SLOWLY notice the passage of time and realize that conservative care hasn’t cut it.  Then they start talking to the patient about a referral to a specialist for consideration for surgery.  Then, when the surgeon sees the patient, they may talk about surgery and wait for the next appointment before requesting authorization from the payer.  They usually wait for a yes before scheduling the surgery — which is often some weeks in the future.   Maybe somebody ought to do a study of the weeks of time lost in this process.

Or maybe you have a better idea? How do we make sure that people’s FMLA clock doesn’t run out because of an ADMINISTRATIVE delays on OUR end, not medical ones on THEIR end? Our goal is to have them NOT lose their jobs – and right now I’m afraid we are really not paying enough attention to that critically important and NEGATIVE result of an injury/illness.

Read more about the 7th Circuit Court of Appeals decision here: https://www.natlawreview.com/article/ada-not-medical-leave-entitlement-seventh-circuit-declares

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January 5, 2017

Why Public-Private Collaboration Is Necessary to Prevent Work Disability

My goal now is to raise awareness about the need for concerted governmental, philanthropic, and private sector action to find better ways to support the millions of workers who lose their livelihoods each year due to injury or illness.  In many cases, this outcome could have been prevented.  And in the New World under President Trump, it will probably be more important than ever to make sure that people get the help they need to KEEP earning a living and STAY in the workforce.

You may be wondering … why work disability is a problem?  Let’s start with the basics. As a practical matter, we already know that lack of work is bad for people and for communities.  Just think about the many millions of dollars the government spends to create jobs and reduce unemployment!  But now, formal research has started confirming how harmful worklessness really is for adults — documenting the consequences for their physical and mental health as well as for their marital, family, social and economic well-being.

Since that’s so obvious…. let’s agree that preserving people’s ability to function and work should be a fundamental purpose of health care services.  Successfully doing so should be seen as an especially valuable health care outcome, second only to preserving life, limb, and essential bodily functions.  And the failure to do so should be called a poor outcome.

Today’s reality is … that whether or not a person with an newly-acquired medical condition is able to function and work afterwards is not even counted as a health outcome!  And there are gaps in our social fabric that are actually creating job loss and work disability.

Here’s one big example of a gap: … None of the three professionals typically responding to workers who are dealing with life disruption due to injury or illness feel any responsibility for actively supporting the workers to keep their jobs or find new ones if necessary. That includes health care professionals, employers, and benefits administrators.  Occasionally, some of these professionals actually advise against work — not realizing the consequences, of course.  The workers are left to fend for themselves;  some lack the confidence or skills to do so successfully.  We need better public policy, stronger governmental efforts, and more support from the private sector in order to prevent this needless work disability.

Do you realize… that roughly half of the people now receiving Social Security Disability Insurance (SSDI) and other prolonged disability benefits started out with very common health problems like back pain, depression, and anxiety?  And do you realize that the vast majority of people in the country who develop those same conditions don’t even take any time off work or are able to return after just a short absence?   So the people who end up on SSDI are members of a subgroup that has had unexpectedly poor outcomes — including job loss.

You might ask …why does this sub-group have such poor outcomes of conditions that normally don’t cause much work disability at all?  It’s logical to assume that these people had the most severe cases of back pain or depression and so on, but in most cases there’s actually no objective data to support that idea.  For every person now on long-term disability there are others who started out with the exact same condition, but are still working.  From the strictly medical point of view, they looked identical at the beginning.  What is different is the way the illness episode unfolded in the two groups:  what happened; how others talked to them and treated them; the decisions they made about the best way to manage this life challenge; the effectiveness of the medical treatment they received; the other kinds of support they got and the opportunities that were or weren’t available.

My personal hope is that … more employed people who are dealing with new injuries or illnesses are going to get what they need at the right time to avoid needless impairment work absence, job loss, withdrawal from the work force, and long-term reliance on disability benefits — which really means a life of poverty.  That would be good for them, for the tax payers, and for our society as a whole.

Now that these issues are in the spotlight …. It is time for policy makers, employers, healthcare providers, health and disability insurers, other service providers, and affected individuals to start talking together about solutions — and then do their part to make those things happen.

For the last three years, Mathematica‘s policy researchers Yoni Ben Shalom, David Stapleton, and I have been collaborating in the SAW/RTW Collaborative sponsored by the Office of Disability Employment Policy in the US Department of Labor.  On September 13, 2016, Mathematica held a forum and webinar during which several speakers presented some actionable policy options that can improve outcomes and prevent needless work disability.

If you want to go deeper … Read my short Work Disability Prevention Manifesto by downloading it from the “Current favorites I’m Sharing” section on my blog homepage.  Or you can look at / listen to the recording of the SAW/RTW Collaborative’s September 13 forum/webinar..  Some of the ideas presented by the policy researchers came from surprising angles — and were quite creative / innovative!

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September 9, 2016

Pithy 4-min Video & 1-page Manifesto for you to use

Mathematica just released a 4-minute video of me pointing out why the work disability prevention model is important — in plain language.  The video was made at the request of the US Department of Labor’s Office of Disability Employment Policy (ODEP).  The main messages in the video are:

  1. MILLIONS of Americans lose their jobs every year due to injury and illness;
  2. Worklessness and job loss have been shown to harm physical and mental health as well as personal, family, social, and economic well-being;
  3. Worklessness and job loss should therefore be considered poor healthcare outcomes;
  4. Unexpectedly poor outcomes can often be prevented and there is good research evidence about how to do that;
  5. Changes need to be made so that vulnerable people get what they need at the time when they need it — and as a result are able to have the best possible life outcome, stay in the workforce, and keep earning their own living.

In addition, the video also explains WHY and HOW some people have unexpectedly poor outcomes of conditions that do not normally cause significant work disruption and job loss.  Unless you’re in my line of work, it is hard to understand why things turn out badly in some cases and not in others — especially if they looked exactly the same at the beginning.

The video is loosely based on a one-page Work Disability Prevention Manifesto I wrote.  I put a draft of it on this blog last spring and got many useful comments.  After many revision cycles, it is now as succinct and compelling as I know how to make it.  ODEP had no hand in the Manifesto; it’s my independent work.

I’m glad I can now share these two items with you because the WORLD needs to know more about these issues—and most PEOPLE in the world have a very short attention span and no interest in the topic to begin with.   I hope you will pass this stuff along to the people whose thinking you want to change or whose buy in you need. Then maybe THEY will pass it along to others as well.  Social norms ONLY SHIFT when people share powerful mind-opening ideas with one another.

Lastly, let’s all stop speaking ABOUT these problems.  It is time for us all to start speaking FOR action and FOR changes.

WORK DISABILITY PREVENTION MANIFESTO
©Jennifer Christian, MD, MPH August 2016

Preventable job loss demands our attention

  • Millions of American workers lose their jobs each year due to injury, illness or a change in a chronic condition.
  • Preserving people’s ability to function and participate fully in everyday human affairs, including work, is a valuable health care outcome, second only to preserving life, limb, and essential bodily functions.
  • A new medical problem that simultaneously threatens one’s ability to earn a living creates a life crisis that must be addressed rapidly and wisely. Most people are unprepared for this double-headed predicament. It can overwhelm their coping abilities.
  • When medical conditions occur or worsen, especially common ones, most people are able to stay at or return to work without difficulty. However, many prolonged work disability cases covered by private- and public-sector benefits programs began as very common health problems (for example, musculoskeletal pain, depression, and anxiety) but had unexpectedly poor outcomes including job loss.
  • Loss of livelihood due to medical problems is a poor health outcome. Worklessness is harmful to people’s health, as well as to their family, social, and economic well-being.

Why do such poor outcomes occur?

  • Medical conditions by themselves rarely require prolonged work absence, but it can look that way. Both treatment and time off work are sometimes considered benefits to be maximized, rather than tools to be used judiciously.
  • Professionals typically involved in these situations (health care providers, employers, and benefits administrators) do not feel responsible for avoiding job loss.
  • Unexpectedly poor outcomes are frequently due to a mix of medical and nonmedical factors. Diagnosed conditions are inappropriately treated; others (especially psychiatric conditions) are unacknowledged and untreated. The employer, medical office, and insurance company (if there is one) operate in isolation, with little incentive to collaborate.
  • Without the support of a team focused on helping them get their lives back on track, people can get lost in the health care and benefits systems. With every passing day away from work, the odds worsen that they will ever return. After a while, they start to redefine themselves as too sick or disabled to work.
  • When people lose their jobs and do not find new ones, they barely get by on disability benefits and are vulnerable to other detrimental effects.

How can we fix this problem?

  • Good scientific evidence exists about how unexpectedly poor outcomes are created, how to avoid them, and how health care and other services can protect jobs.
  • Health-related work disruption should be viewed as a life emergency. Productive activity should be a part of treatment regimens.
  • When work disruption begins, it can be both effective and cost-beneficial to have a coordinator help the individual, treating physician, and employer communicate and focus everyone’s attention on maximizing recovery, restoring function, accommodating irreversible losses, and making plans for how the individual can keep working, return to work, or quickly find a more appropriate job.
  • We must urgently establish accountability for work disability and job loss in our workforce, health care, and disability benefits systems and build nationwide capacity to consistently deliver services—just in time, when needed—that help people stay at work or return to work.
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July 6, 2016

Where does working age end? Who is too old to work?

I’ve been trying to draw more attention to the special healthcare needs of the working age population since they power the engine of the economy.  The healthcare industry needs to expand its focus beyond symptoms and select treatments that rapidly restore the ability to function in this group  — to help them recover faster and more completely, to keep their jobs and livelihoods, and avoid the negative consequences of prolonged worklessness for them and their family!  Doctors and other healthcare professionals often don’t really THINK ENOUGH about the impact of their treatment regimens on working people’s lives outside the office.

But as I advocate, I’ve begun pondering that definition: “working age”.  It seems safe to use 18 as the low end of the range (even though kids younger than that do work, most of them are still in school).  But what about the top end?  At what age should we stop seeing work as the norm?  Stop expecting anyone to work?   Start thinking it’s silly to insist on working?  What term should we use to describe those who have lived for a really long time but are still very active and working?  What term should we use to describe people who are the exact same age but the press of years has made them too feeble to work anymore, even though they are “healthy”?  We all know people in both of these categories.  Simply calling them both old seems inaccurate.

I found a thoughtful article from the World Health Organization (WHO) exploring how to define “old” or “elderly” — in Africa!   Have you noticed how often we notice oddities about our own culture when we look outside it?  That’s when we notice the automatic assumptions and blind spots we’ve been living with.

I think you’ll enjoy reading the excerpts I’ve pasted below from the full WHO article.  I have colored in red the parts I found most eye-opening.  They are a breath of realistic and straight-spoken fresh air about how humans age.

Bottom line as I see it:  In developing societies where the administrative and legal fictions of retirement and pensions do not exist, the people tend to define old and elderly straightforwardly and on a case by case basis depending on the actual circumstances of humans as they accumulate years (and as younger generations come behind).  Old age begins when one assumes the social role of an elder, when one withdraws from social roles either because it is time for someone younger to take over or because of decline in physical / mental capability.  And finally, when it is no longer possible to actively contribute, one is definitely well into old age.

By that reasoning, if you are still able to play the roles and carry the same load of a person a decade younger, you are not old yet.  I still don’t know what to call you though.  Or, more truthfully, I don’t know what to call myself.  I am still in there pitching though I turn 70 years old this year.  I did recently give up one of my roles to make room for a younger person who deserved her day in the sun.  Didn’t want to hog it and hold her back.

Proposed Working Definition of an Older Person in Africa for the MDS Project

Most developed world countries have accepted the chronological age of 65 years as a definition of ‘elderly’ or older person, but like many westernized concepts, this does not adapt well to the situation in Africa. While this definition is somewhat arbitrary, it is many times associated with the age at which one can begin to receive pension benefits.

Although there are commonly used definitions of old age, there is no general agreement on the age at which a person becomes old. The common use of a calendar age to mark the threshold of old age assumes equivalence with biological age, yet at the same time, it is generally accepted that these two are not necessarily synonymous.

As far back as 1875, in Britain, the Friendly Societies Act, enacted the definition of old age as, “any age after 50”, yet pension schemes mostly used age 60 or 65 years for eligibility. (Roebuck, 1979). The UN has not adopted a standard criterion, but generally use 60+ years to refer to the older population (personal correspondence, 2001).

The more traditional African definitions of an elder or ‘elderly’ person correlate with the chronological ages of 50 to 65 years, depending on the setting, the region and the country. ….. In addition, chronological or “official” definitions of ageing can differ widely from traditional or community definitions of when a person is older.  Lacking an accepted and acceptable definition, in many instances the age at which a person became eligible for statutory and occupational retirement pensions has become the default definition. ….

Defining old
“The ageing process is of course a biological reality which has its own dynamic, largely beyond human control. However, it is also subject to the constructions by which each society makes sense of old age. In the developed world, chronological time plays a paramount role. The age of 60 or 65, roughly equivalent to retirement ages in most developed countries, is said to be the beginning of old age.

In many parts of the developing world, chronological time has little or no importance in the meaning of old age. Other socially constructed meanings of age are more significant such as the roles assigned to older people; in some cases it is the loss of roles accompanying physical decline which is significant in defining old age. Thus, in contrast to the chronological milestones which mark life stages in the developed world, old age in many developing countries is seen to begin at the point when active contribution is no longer possible.” (Gorman, 2000)

Categories of definitions
When attention was drawn to older populations in many developing countries, the definition of old age many times followed the same path as that in more developed countries, that is, the government sets the definition by stating a retirement age. Considering that a majority of old persons in sub-Saharan Africa live in rural areas and work outside the formal sector, and thus expect no formal retirement or retirement benefits, this imported logic seems quite illogical. Further, when this definition is applied to regions where relative life expectancy is much lower and size of older populations is much smaller, the utility of this definition becomes even more limited.

Study results published in 1980 provides a basis for a definition of old age in developing countries (Glascock, 1980). This international anthropological study was conducted in the late 1970’s and included multiple areas in Africa. Definitions fell into three main categories: 1) chronology; 2) change in social role (i.e. change in work patterns, adult status of children and menopause); and 3) change in capabilities (i.e. invalid status, senility and change in physical characteristics). Results from this cultural analysis of old age suggested that change in social role is the predominant means of defining old age. When the preferred definition was chronological, it was most often accompanied by an additional definition.

…… If one considers the self-definition of old age, that is old people defining old age, as people enter older ages it seems their self-definitions of old age become decreasingly multifaceted and increasingly related to health status (Brubaker, 1975, Johnson, 1976 and Freund, 1997).

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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

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March 7, 2016

Manifesto – Preventing Needless Work Disability (DRAFT)

I’ve tried to squeeze all the main ideas of the work disability prevention (WDP) model into one page (see below). The model has matured over the last several years as key dynamics have become more apparent.  I’m curious to hear your reaction to this new version.

After promoting the WDP model in the private sector for a long time, I started introducing it to the Federal / State disability sector in 2011.  Now seems like the right time to get a compelling and very succinct document circulating so it gets in front of many more eyes  – for example, lots of eyes on Capitol Hill and in regulation-creating / law-making (sausage making) circles.

The members of the Work Fitness & Disability Roundtable are also helping me craft a 3 or 4 bullet “sound bite.”  However, in my view it will take more than that to get influencers and decision-makers to decide to explore these issues further. They need a quick summary of WHAT the problem is, WHY things look the way they do, and WHAT might be possible instead — but just a bit.  Thus, this one-pager.

I’m not yet clear what to do with this draft – other than to post it here and solicit your comments.   Am also hoping to get your ideas for the best organization to issue and disseminate a manifesto like this — so it has the maximum impact.  What are the chances of it going viral?  Please leave a comment below or email me your ideas and suggested revisions.

Work Disability Prevention Manifesto (DRAFT)

  • Preserving people’s ability to function and participate fully in everyday human affairs, including work, is a valuable health care outcome, second only to avoiding loss of life, limb, and essential bodily functions.
  • Loss of livelihood due to medical problems is a poor health outcome because worklessness is harmful to people’s health as well as their personal, family, social, and economic well-being.
  • A new medical problem that threatens the ability to continue earning a living is a big challenge – a life crisis that must be addressed. Most people are unprepared, never having faced this double-headed predicament before. It can overwhelm their coping abilities.
  • When medical conditions occur or worsen, especially common health problems, most people are able to stay at or return to work without difficulty because the right things tend to happen during the first few days or weeks.
  • However, many of the prolonged work disability cases in both private and public sector sickness programs, disability benefits, and workers’ compensation programs began as very common health problems (for example musculo-skeletal pain, depression, and anxiety) but had unusually poor outcomes.
  • Unusually poor outcomes are frequently due to the interplay of sub-optimal health care and non-medical factors. Without a team focused on helping them get their lives back on track, people can get lost in the healthcare and benefits systems. Remediable issues in the situation are overlooked and not addressed. Incentive alignment among the involved parties is poor.
  • Medical conditions by themselves rarely require prolonged work absence, but it can look that way. And with every passing day away from work, the odds are worsening that people will ever return to work. After a while, they start to see themselves as too disabled to work.
  • Unlucky people lose their job and do not find a new one. They leave the workforce and eke by on disability benefits, in poverty, and vulnerable to its detrimental effects.
  • Today, most professionals typically involved in these situations (healthcare professionals, employers, and benefits handlers) do not feel responsible for avoiding job loss.
  • Good scientific evidence exists about how unusually poor outcomes are created, how to avoid them, and the health care and other services that can optimize function and protect jobs.
  • When work disruption begins, it is both effective and cost-beneficial to have a coordinator assist the individual, their treating physician, and their employer with communications, as well as focus everyone’s attention on restoring function, accommodating irrevocable losses, and making plans for how to keep working, return to work, or quickly find a more appropriate job.
  • Urgent priority should be given to establishing accountability for work disability and job loss as well as building nationwide capacity to consistently deliver services that help people stay at work or return to work – just in time, when needed.
  • Helping more people with medical problems to keep their jobs or find new ones in a timely manner will benefit them and their families, and will benefit our society as a whole.

March 7, 2016

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November 19, 2015

Early EVENTS influence outcomes: You have power to make good things happen!

Few people realize how important early EVENTS are in determining the eventual outcome of a work disruption due to a health problem, particularly the most common kinds of conditions:   low back pain and other kinds of muscle and joint sprains and strains, depression, and anxiety.

Let’s call this a poor outcome:  a failed medical recovery that results in over-impairment and excessive “disability” accompanied by work absence and loss of employment that could have been avoided.  And let’s call this a good outcome:  the fullest possible medical recovery with the least possible physical or mental impairment and the smallest possible impact on the rhythm of everyday life, including minimal lost work time and continued employment.   Do you agree?

Here’s the exciting “so what” about this news that EVENTS influence outcomes:  all three of the professionals who respond to an individual CAN influence what some of those EVENTS are going to be.  Those three professionals are:  the treating doctor, the workplace supervisor, and the benefit claims handler.  This news means that each of them actually has some POWER to nudge things in a good or bad direction!!

See below for a brief description of why early events are so important, and how the experience of  people destined for lucky or unlucky outcomes differs.  In fact, these ideas are some of the main concepts of the work disability prevention model.  (NOTE:  The scientific articles that support the  evidence-based concepts are briefly noted in parentheses.  Their full literature citations appear in the list of References in our report that recommends the establishment of a nationwide Health & Work Service.)

When a working person’s life is disrupted by a new or changed illness or injury, the first few days and weeks after onset are an especially critical period.  The likelihood of a good long-term outcome is being influenced, either favorably or unfavorably, by some simple things that either do or do not happen during that interval (Bowling 2000; Cornelius et al. 2011; Franklin et al. 2013; Loisel and Anema 2013; Nicholas et al. 2011; Shaw et al. 2013; Waddell and  Burton  2004; Waddell,  Burton,  and  Main  2001).  It  is  the  optimal  window  of  opportunity  to improve outcomes by simultaneously attending to the worker’s basic needs and concerns (Shaw et al. 2013)  as  well  as  by coordinating  the  medical,  functional  restoration,  and  occupational  aspects  of  the situation in a coordinated fashion (Wickizer et al. 2011).

The  way  the  episode  unfolds  over  time  in  all  dimensions — biological,  psychological,  social,  and economic — can have a big impact on the outcome. Events that occur can either mitigate or aggravate existing  risk  factors  in  the  situation,  leading  to  better  or  worse  outcomes.  There  are  usually  many opportunities to actively influence the course of events immediately after onset of a health problem (and  many  fewer  opportunities  later  on),  but  today  there  are  few  resources  devoted  to  finding  and exercising these opportunities.  Most of the current attempts to steer situations to a better outcome are made long after the best opportunities have passed by.

The best opportunity for basic intervention appears to last about 12 weeks or three months (DeWitt 1995; Franklin et al. 2013; Hashemi et al. 1997; Johnson and Fry 2002; Loisel and Anema 2013; Turner et  al.  2008)  although  some  data  shows  it  ending  by  6  months  (Rumack  1987;  Waddell  and  Burton 2004). A modest set of simple services —that embody an immediate, systematic, pro-active, integrated, and multidimensional approach — can mitigate the potentially destructive impact of common injuries, illnesses, and chronic conditions on quality of life among the working population (Burton et al. 2013; Hill et al. 2010; Iles, Wyatt, and Pransky 2012; Kendall et al. 2009; Lagerveld et al. 2012; Loisel and Anema  2013;  McLaren,  Reville,  and  Seabury  2010;  Mitchell  2012;  Nicholas  et  al.  2011;  Shaw  et  al. 2013; Sullivan et al. 2005; Turner et al. 2008; Waddell and Burton 2004; Wickizer et al. 2011).

This new approach will allow people to avoid the kind of adverse secondary consequences of medical conditions that they too often experience today (Institute of Medicine 2001; Dartmouth 2008; Franklin and  Mueller  2015).  Those  consequences  are  not  usually  obvious  until  months  or  years  later,  after unfortunate things have happened. The unlucky ones have received sub-optimal health care, been left with undertreated or iatrogenic impairment, become dependent on opioids, found themselves socially isolated, lost their jobs, withdrawn from the workforce, lost economic independence, and ended up on long-term disability benefits programs or SSDI in order to survive (Darlow 2011; Franklin et al. 2008; Franklin et al. 2014; Franklin and Mueller 2015; Habeck, Hunt, and VanTol 1998; Nguyen et al.)

CLARIFYING KEY TERMS

Figuring out where the opportunity to improve outcomes actually lies will be easier if we first clarify some terms that are often used carelessly or that mean different things to various audiences.

Work Disability vs. Disability
In the world of employment and commercial insurance, the word  “disability” is carelessly used.  In this world, the correct term is often “work disability” –which means absence from or lack of work attributed to a health condition.

According to the ADA, disabilities are impairments affecting major life functions (such as work).  Having a disability need not result in work disability.  This is a core concept embodied in the Americans with Disabilities Act. Similarly, having symptoms or a diagnosis need not (and usually does not) result in work disability.

Medical Recovery vs. Functional Restoration
Medical recovery refers to the resolution (disappearance or remission) of the underlying pathological process. Functional restoration refers to reestablishing the usual rhythm of participation in everyday life including the ability to go about one’s regular daily business: performing necessary tasks and enjoyable activities at home and work, and participating fully in society. Functional restoration often accompanies medical recovery, but not always.  Even when medical recovery is not possible, restoration of function often is.   In some cases, it may require separate and specific professional attention.  Functional restoration may include rehabilitation (broadly defined), the successful use of assistive technology, adaptive equipment, and/or reasonable accommodation in the workplace.

Anticipatory  programs  that  ensure  the  right  things  happen  from  the  start  and  include  early identification of those needing extra support are the simplest and most effective way to prevent later adverse secondary consequences of these conditions. A professional needs to provide the following services throughout the immediate response period (which typically ends with stable RTW or 12 weeks post onset).  These services are not generally available today, especially to lower-wage workers and those who work for small firms:

  • oversee and champion the affected individual’s stay-at-work and return-to-work (SAW/RTW) process until it is successful.
  • conduct a quick initial assessment and planning session that considers the individual’s entire situation, screens for known risks for poor outcomes, helps the individual and/or employer make a  SAW/RTW plan and  support them  in  carrying  it  out;
  • drive towards the best outcome by:
    — expediting and coordinating external medical,  rehabilitative  and  other  kinds  of helping services, including referrals for specialized services as needed to address remediable obstacles in a variety of life domains;
    — facilitating communications among all involved parties, ensuring they get the information they need so everyone has a shared picture of the situation and the goal;
    — taking a problem-solving approach with affected individuals, treating physicians, employers, and payers.

If RTW has not occurred by the time the 12 week period has ended, that should trigger a hand-off  to another professional with broader expertise for a deeper assessment which is likely to reveal the need for a different strategy, revised goals, a new approach, or the involvement of other disciplines.

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November 18, 2015

Our proposal for “upstream” services to reduce “downstream” inflow onto SSDI

Kim Burton, Tom Wickizer, and I have a good idea for how to reduce the inflow onto Social Security Disability Insurance.  Ours was among only twelve proposals selected for further development during a “competition of ideas” held by the SSDI Solutions Initiative sponsored by the Committee for a Responsible Federal Budget.

Once selected, we fleshed out the proposal in a written report.  It recommends the development, testing, refinement and launch of a nationwide Health & Work Service (HWS) that would assist workers who have recently developed potentially disabling conditions to maximize their functional recovery, stay at or return to work — and either KEEP their jobs or FIND new ones!  Our report describes why the service is needed and how it would work.  It includes many literature citations that provide a solid foundation for our proposal as a whole as well as specific design features of the HWS.

SSDI Solutions Initiative

The full reports have just been released to the public.   You can find all 12 of them here:   http://ssdisolutions.org/selected-papers.

And you can find ours here:  http://ssdisolutions.org/sites/default/files/christianwickizerburton.pdf  There is a main report and 3 (juicy) appendices.  One oddity is that the editors removed all biographical or organizational info about the 3 authors.  We could be 3 dogcatchers or 3 priests or 3 unemployed hula dancers for all the readers will ever know.  Here’s info about me and my co-authors:  Jennifer Christian, Thomas Wickizer and Kim Burton.

I verbally presented our idea in just 6 MINUTES at the SSDI Solutions conference on August 4, 2015.   Here’s a video of the entire event.  (My presentation starts about minute 36).

Do you happen to know any professionals who would LOVE to be part of a national effort to help people mitigate the impact of illness and injury on their lives and futures — and prevent needless work disability?  I do!!!  Among them are many of my physician and psychology colleagues in the American College of Occupational & Environmental Medicine, the many professional members in a wide variety of disciplines on the Work Fitness & Disability Roundtable — and most especially the 100 Founding and Charter members of the nascent but still unfunded Praxis Partners Consortium.

Hey, I have an idea!  If you like the idea of a HWS service, why not get in touch with the people at the Committee for a Responsible Federal Budget and tell them so!   Here’s a link to their “contact us” page:  http://ssdisolutions.org/contact/ssdi

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October 30, 2015

Turning private tragedies into a public concern: job loss after injury or illness

Do you realize that NO professional feels responsible when a working person loses his or her job because of a health problem — neither the doctor, nor the employer, nor the person handling the claim for healthcare, disability, or workers’ compensation benefits?  At most, the professionals may say “that’s a shame” assuming they are even aware it’s happened.  Job loss is often invisible; the person just drops off the radar.  The government insists that employers track workplace injuries and illnesses, hospitalizations and fatalities — but no-one is tracking job loss.  Among the public purposes of the Americans with Disabilities Act is promoting employment of people with disabilities.  The millions of workers now silently disappearing from the workforce due to newly-acquired disabilities deserve more visibility — and more help.

An estimated 2.5 million people leave the workforce each year for health reasons, most frequently due to things like low back pain and other common musculoskeletal conditions, as well as the most common mood disorders of depression and anxiety.  And none of the professionals who are called on to respond when those individuals start having difficulty are being held accountable for making an active effort to help them keep their jobs. Obviously, some people really can’t continue to work (for example those who have a terminal illness or have suffered an incapacitating injury).  But some of those lost jobs COULD have been averted if any of those three professionals had devoted more of their skill and discretionary effort to finding a better solution.

In my opinion, this hole in our social fabric through which people with newly-acquired disabilities are falling has been invisible until now — and is unacceptable.

To put this in perspective, as Western societies have evolved over the centuries, other kinds of private tragedies have become public concerns.   Do you realize that until roughly the 19th century, no one felt responsible when a pregnant woman died in childbirth, or her newborn infant did — which was very common?  “That’s a shame,” people said.  It was each family’s private tragedy.   Today,  several professions, many hospitals, and whole departments within public health agencies in every single state focus on keeping pregnant women healthy, providing prenatal care, assuring a safe childbirth, and proper care of newborns.  Maternal and infant mortality rates are now considered basic indicators of the health of a country’s entire population  — and the adequacy of its public health / health care systems.  In the developed countries, maternal and infant deaths are 50 to a 100 times lower than the rates in still-developing countries.  Here is data from the CIA’s World Factbook.

Pic of Mat Infant Mortality rates 2015-10-30

Wouldn’t it be interesting to see a comparable table showing job loss rates for the countries?  What do you think it would show?   I bet the developing countries are doing less well by comparison — because their social safety nets tend to be weaker.  And I doubt workers that in the US are a 100-fold better off.   I’ve heard that European countries make it much harder to “throw away” unwanted workers.  It is not only important for workers and their families to stay employed.  Every time a worker loses his or her footing in the world of work, our society takes a DOUBLE hit:  we lose an economic contributor AND at the same time we gain another person dependent on taxpayer funded benefits.

I’ve been part of a two-year effort to start thinking seriously about ways to reduce job loss due to illness and injury among U.S. workers while serving as a member of the US Department of Labor’s Stay-at-Work/Return-to-Work (SAW/RTW) Policy Collaborative. This year three of us (economists (David Stapleton,  Kevin Hollenbeck, and I) were asked to develop policy papers, each on a specific aspect of the issue.

My task was to think about how to establish accountability for job loss among the professionals who have the best opportunity to influence the outcome.  I felt so LUCKY to be PAID to take the time to explore this topic in depth — it was really fun to put my “thinkatorium” into high gear.  Stimulating conversations with more than 30 experts in various fields and sectors of society helped shape my thinking (thank you all — their names are listed in the report).  The final product is three main recommendations and a set of specific suggestions for action — how to accomplish the recommendations.  I hope you will read my paper to see where this line of inquiry leads you.  I bet you will be surprised — because I was.

On October 22, the U.S. Department of Labor’s Office of Disability Employment Policy (ODEP) and Mathematica’s Center for Studying Disability Policy (CSDP) hosted a policy forum to introduce the three policy papers and all of their recommendations. You can view the 90 minute video of the event here.  It includes some very good questions from the audience and subsequent dialogue. All three policy papers are available on Mathematica’s website.

Please consider joining me in transforming these 2.4 million hidden and all-too-private tragedies per year into a public challenge for change.

And before you go — did you notice that the data I cited on maternal and child death rates came from the US Central Intelligence Agency’s INFORMATION WEBSITE???  Who knew?  I just stumbled on it.

Photo announcing policy rec - video of event 2015-10-29

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