Tag Archives: legislation

July 14, 2016

Why we need a 1:1 ratio of healers to lawyers when designing reforms for “comp”

While Linda Rudolph was Medical Director of the California workers’ compensation regulatory agency in the mid-1990’s, she defined workers’ compensation as a medically-driven legal system.  I still use that definition when I give my annual lecture on work comp at the Harvard School of Public Health.   Based on my interpretation of what that succinct and elegant summary really means, I believe that any group setting out to improve the workers’ compensation system should have a roughly equal number of people at the table who were originally trained in a healing art and the law — because of the way their minds were indelibly imprinted by that training.

As you may have heard, I was among 38 workers’ compensation experts of various stripes who participated in the Workers’ Compensation Summit co-hosted by blogger Bob Wilson from workerscompensation.com and blogger Judge David Langham, Deputy Chief Judge of the Florida workers’ compensation system.

I was surprised as we went around the room introducing ourselves.  I was one of only two physicians in the room.  There were no others with healthcare professional training.  There was one person whose original training had been as a vocational counselor.  By far the largest group had had legal training, although many of them were now in other jobs — judges, legal scholars, workers’ compensation system administrators, corporate executives.

Training in both law and in medicine shapes a student’s worldview, teaches a precise vocabulary, builds a foundation of factual knowledge as well as rigorous intellectual discipline, and defines how things work in a certain part of human life.  The training also establishes a finite range of things that seem possible, and offers a particular inventory of potential solutions.  A behavioral acculturation process accompanies it, too.  The point here, though, is that the actual shape and content of those worldviews, vocabularies, knowledge bases, intellectual disciplines, possibilities and solutions — and behavioral cultures — differs in most respects between the two professions.

Earlier in life, I spent 20 years as a physician married to a lawyer.  For many reasons, it was kinda like a nice cat being married to a nice dog.  We had a primordial kind of incompatibility.  But I did get to know what made that particular dog tick pretty well.

Lawyers seem to have a predilection for solutions that involve clarifying rights, justice, entitlements, boundaries, and who is responsible to pay for what.  Lawyers are trained to advocate for their clients’ rights and interests.  Most lawyers seem to spend an awful lot of their time and energy anticipating arguments or actually arguing, fighting, and trying to win  — because the everyday grist of their vocational mill is broken promises and disputes.

As I was pondering the difference between the “head set” of medicine and law, I found a quote from an article in the May 31 Boston Globe about a 35 year old man, a published author and poet, now  graduating from Yale Law School — who at age 16 had hijacked a car at gunpoint and served 8 years in prison.   He said “The law is a way to think and argue, and a way to find solutions….. Law is the language of power, and understanding that language is important to understanding power.”  This quote struck me — not because he’s so amazing (which he obviously is) but because he articulated so precisely what I had predicted a lawyer would say.

Physicians and others in the healing professions have a predilection for solutions that reduce peoples’ suffering and restore the integrity of their bodies/minds.  Medicine has nothing to do with winning.  The first precept of medicine is to do no harm.  Physicians are trained to advocate for their patients’ health, to meet their immediate needs today and maximize their future well-being in the future.  The everyday grist of their vocational mill is providing comfort, relief, and reassurance to a stream of patients coming through the door with symptoms, with bodies or minds that aren’t working right, distressed and worried about the meaning of those things for their health and everyday activities (and often secretly fearing death).

In my view, a good “medically-driven legal system” for people injured at work should concern itself primarily with helping injured workers get back on their feet.  That requires paying roughly equal attention to

  1. Helping them manage any life predicament the injury has caused (reducing worry, suffering, and distress, arranging good care promptly that maximizes healing and restores function as quickly as possible, preserving daily routine, minimizing work disability and job loss or providing assistance to find a new job quickly.  The goal is to get everyday life back to normal as soon and as completely as possible.  Time spent in limbo is destructive.
  2. Minimizing their short-term financial stress as well as long-term financial loss, sorting out their rights, and dealing with disputes.

Everyone’s goal should be to expedite the activities in #1 even if there are difficulties in #2, instead of allowing #2 to delay #1 as is common today.


June 14, 2016

Take an important step BEFORE the sausage making starts …….

Do you know the Bible story about wise King Solomon and his response to the two mothers fighting over two babies — a living one and a dead one?   Each claimed the living one was hers and the dead baby belonged to the other.  King Solomon offered to cut the living baby in half and give each mother a fair share. The real mother was revealed when she said she would give up her claim to the baby rather than have it die.

The efforts being made now to “modernize” workers’ compensation and other large scale disability benefits programs may end up dividing the live baby in half by becoming prematurely dominated by the sausage-making and log-rolling among powerful vested interests on all sides.  In particular, past efforts at “reform” in workers’ comp have been feeding frenzies for those who live off system inefficiencies and inequities.  The result is the continuing sacrifice of the metaphorical living baby — the well-being and long-term quality of life of the individuals these systems are intended to protect, and the economic and social health of our society as a whole (as represented by the taxpayers).

By their nature in a pluralistic and democratic society, legislative and regulatory reform ARE sausage-making and log-rolling activities.  As a regulator commented at last month’s Workers’ Comp Summit, good government must “account for the multiplicity of interests”.  That said, we have a better shot at creating a more satisfactory system IF we give the sausage-makers a North Star to guide their efforts.   As they write legislative language, they need to be using a written “spec sheet” of requirements that the solution must meet — a list of the major design principles or performance specifications that a twenty-first century replacement would need to satisfy.  A credible group needs to come up with a draft System Design and Performance Specifications document which could then be circulated for comment and revision in community meetings and industry groups all around the country.

The people invited to create the spec sheet should be well suited for this kind of socially responsible foundation-laying project:  thoughtful, expert in the matters at hand, with real world and front line experience, each respected in their own sector, able to see things from a broad perspective — and preferably NOT elected officers or designated representatives of organizations.  The participants must feel completely free to advocate for what they think is best for the two parties most vulnerable to system dysfunction (the affected individuals and society as a whole).  The people sitting at the table must not allow themselves to be swayed by the vested interests of their own livelihood, profession, enterprise, trade association, or industry — but should be worldly wise enough to acknowledge the power that those interests have to distort and defeat naive solutions.

As an example of the KIND of document that might result, see this preliminary draft for a set of design principles for the nation’s healthcare system.  This list was developed in the late 2000’s — before Obamacare was passed and signed into law.   It expands and refines an initial set of ideas that bubbled up from a small group of people in different walks of life in my “social set.”

As citizens and taxpayers, we were uncomfortable at the country’s lack of a core document articulating widely-accepted values, principles or expected outcomes against which to judge the merit of various details in the legislative proposals.  We also felt that a document with core principles like these could later be used to determine whether a law is creating the desired changes, and to guide later amendments and regulatory changes.   After creating this document, I envisioned groups around the country holding community meetings, to either consider and modify it or come up with their own versions.

Widespread engagement in dialogue at the community level — a “from the ground up” development of the US population’s vision of what a well-functioning health system would look like — would have given the USA a coherent values-based and outcomes-based population health policy at long last.  The results being produced by the ACA today could be compared with that vision/policy in order to judge whether Obamacare has moved us towards or away from that vision, and to identify places where changes need to be made.  (And you do realize that the US still doesn’t have a population heatlh policy, right?)

Similarly, while there is wide acknowledgement that modernization of our nation’s workers’ compensation system is needed, why don’t we take this tack and start building a vision of how a good system SHOULD operate, and the results it SHOULD produce?

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

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

October 9, 2015

A Health & Work Service could prevent or reduce impairment/disability


There is definitely an opportunity to make a positive difference BIG ENOUGH to make the expense and effort of developing, launching and delivering a nationwide community-focused Health & Work Service (HWS) worth it — in my opinion.   (Our proposal for establishing the HWS was among 12 ideas selected for development as part of the Committee for a Responsible Federal Budget‘s SSDI Solutions Initiative on Capitol Hill.)  There are two main reasons why this opportunity exists.

First reason:  Years of research have shown that some of the unfortunate secondary consequences of illness and injury — certain kinds of impairment and work disability — CAN sometimes be prevented or reduced.  This is particularly true in people with the most common chronic musculoskeletal conditions (MSK) especially low back pain, and the most common mental disorders (CMD) like depression and anxiety.  And research has also shown that intervening early in the unfolding of an injury or illness episode can have a very favorable impact on the long-term outcome.

Second reason:  Millions of workers in America fall through the cracks in our society because they have no access to services or expertise that might protect them against job loss after injury or illness, or they experience service failures.  Many of them work for employers that do not offer health or disability insurance, or that are excluded from the requirement to buy workers’ compensation insurance.  Many work for small companies that are exempted from the Family Medical Leave Act which protects jobs for 12 weeks when employees have health problems, or the Americans with Disabilities Act which requires employers to make reasonable accommodations for employees with disabilities.  In addition, there are many people who are the victims of neglect or poor decision-making by those with authority over some aspect of their situation.  Sub-par employees headed for termination exist among the administrative staff, professionals, supervisors, and managers in every organization, including every medical care facility, workplace, and benefits claims administration organization.  Before leaving, each of these sub-par employees has probably had an impact on hundreds of vulnerable workers.

Therefore, it is not correct to assume that all of the people who are now on SSDI due to these common health problems had the worst (most severe) form of their particular MSK or CMD from a biological/pathological perspective, and that nothing could have prevented their entry into SSDI.  While undoubtedly true in many cases, it is also likely that a sizable number of them lost their footing in the world of work and ended up on SSDI because of events that occurred in response to their health condition—not the condition itself. Their lives fell apart due to a cascade of adverse secondary consequences of the initial medical problem, and after a time SSDI became the best option for survival.

Remediable or Avoidable Reasons for Poor Outcomes

At the moment when the common health problems of this subgroup of SSDI recipients first started, these people would often have looked very similar to other patients with the same diagnosis and objective clinical findings—but who then experienced good recoveries.  This is because the factors that predict poor outcomes (serious impairment and prolonged work disability) as a consequence of MSK, especially low back pain, are not tightly related to either the specific diagnosis or the extent of the pathology. Although less research has been done on factors that predict poor outcomes in CMD, and diagnosis does play a more significant role, there are other important non-medical factors.

Some of the factors that predict poor outcomes are immutable (such as age, past medical history, work history, and geographic location). But other factors are potentially remediable such as elapsed time out of work, uncertainty and distrust due to lack of communication or information, uncoordinated or inappropriate medical care and advice, low expectations of recovery, excessive vigilance, catastrophic thinking, false beliefs, fear of movement, self-limitation, perceived injustice, and lack of employer support. Today, those who handle these situations do not typically look for any of these remediable problems and address them.  And none of the professionals involved has been trained to feel responsible for driving the situation forwards towards a good outcome .

The standard medical care process is simply inadequate to help people in these situations avoid poor life outcomes. What is needed is coordinated activity during a fleeting opportunity to address and resolve a set of pivotal issues (both medical and non-medical) around the time the condition starts interfering with work—issues that will set the situation off onto the right or wrong path.

The first few days and weeks after onset are an especially critical period during which 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. It is the optimal window of opportunity to improve outcomes by simultaneously attending to the worker’s basic needs and concerns as well as coordinating the medical, functional restoration, and occupational aspects of the situation in a coordinated fashion.

The best opportunity for basic intervention appears to last about 12 weeks or three months, although some data shows it ending by 6 months.  Many studies have show that 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.

In summary, the way a health-related episode that disrupts work 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.

If you’d like the references for the research mentioned above, get a copy of our full report when it is published by the CFRB later this month (electronically) or in January (in print).

Bottom line:   If you agree that the USA needs a community-focused Health & Work Service, contact your Congressional representative, tell them you like our proposal and recommend that it be included in the 2016 SSDI reform legislation package.  Or even better yet, take a grass-roots approach.  Team up with other like-minded people to see if a local charity or foundation will fund your efforts start a HWS in your own community!




July 20, 2015

My “mini-manifesto” to reduce spine disability

You may be interested in the “mini-manifesto” I delivered this past Saturday 7/18 at the Spine 10×25 Research Summit in Chicago hosted by the North American Spine Foundation.  They have declared a worthy and very ambitious goal:  to reduce spine disability by 10 percent by the year 2025.  Thus the name: Spine 10×25. Pronounce it like you’re buying lumber – “10 by 25”.

(You can see the video and listen to my talk —  or even the ENTIRE 8 hour event because it was live-streamed and recorded.  Click here to do so.  Advance the recording by moving the blue dot along the horizontal line.  My talk starts at 5:31:50 and goes until 5:51:30.)

Do you know of any other medical group that has drawn a bold line in the sand like that?  I don’t.  It had never occurred to me that a professional society would set out to measurably move the needle.  They just don’t take on that type of project.  Most healthcare professional associations content themselves with pontificating:  being experts and telling other people what to do and how to do it.

My own professional society (ACOEM – the American College of Occupational & Environmental Medicine) has made many significant contributions to society.  In particular, our evidence-based treatment guidelines are very well regarded and in use by several states.   ACOEM has produced many other useful publications that have had a positive impact.  In fact, some of them were developed under my leadership.  But, in the end, they all amount to pontification.

In 2006, I told ACOEM I didn’t want one of those documents to just sit on an electronic shelf. We had developed it in order to introduce the work disability prevention paradigm and shift the way all stakeholders think about work disability.  Entitled “Preventing Needless Work Disability By Helping People Stay Employed“, that report needed to go out into the world.  Thus, the 60 Summits Project was born to carry it into the 50 US states and 10 Canadian provinces of North America.  We created groups of volunteer professionals who planned and held 20 multi-stakeholder summit-type conferences in 12 states and 2 provinces.  We invited the attendees to consider ACOEM’s 16 recommendations for improving the stay-at-work and return-to-work process.  We asked them to decide if they liked each recommendation, and if so, to make a plan for how they were going to carry it out in their own business, community, and jurisdiction. (60 Summits eventually ran out of money and was mothballed.)

Then last month, the boldness of the Spine 10x 25 initiative made me realize that even The 60 Summits Project had a pontification angle to it.  Propagating a new way of thinking and discussing a set of recommendations for change is not the same thing as CARRYING them OUT.  I felt compelled to go and check out these NASF people and participate in their Spine 10×25 Research Summit.

My assigned topic was “Precedents and Prospects for Success” in a 15 minute time slot that got expanded to 20.  It seemed important to speak straight and share my ideas about what needs to be true in order for their goal to be realized.  I offered the audience a (draft) conceptual foundation to use as a context for change, as well a summary-level vision of the way things will look in the future WHEN things have ACTUALLY changed and spine disability is BEING REDUCED by 10%.  View it here. Remember to advance the recording to 5:31:50.

I may expand a bit on some of the main points of that mini-manifesto in later posts.  I developed all of those slides at the conference in order to take into account what the speakers said who had gone before me!  Luckily, I also had some time at lunch.  The tight time limit meant a few big ideas got short shrift.



May 9, 2015

2 good signs: Momentum building & mechanisms appearing

You’ll be pleased to hear about two developments that are good signs for the transition away from the fee for service payment model in healthcare and towards payment for outcomes.  Buy-in among healthcare CEOs is clearly growing, and Congress just passed MACRA — a new law will increase the mechanisms available to support value-based healthcare reimbursement, particularly for physicians. See below for more details on these two developments.

But first:  If you believe that a FUNDAMENTAL purpose of healthcare services is to enable people to participate as fully as possible in life –which for most working age people includes earning a living — then ability to function & work should be on the list of accountable health outcomes.  Thus, it is CRITICAL to ensure that SOMEONE is sitting at the table advocating for those outcomes — when the nitty-gritty details of the new mechanisms called for in MACRA are worked out!  As you read on, consider what you can do to increase the likelihood that someone IS sitting there.

First, a recent survey of healthcare CEO’s revealed that the VAST majority of them LIKE the idea of value-based payment – even though a substantial fraction of them predict difficulties and revenue reductions as a result.   Almost 8/10 of them said this statement best reflected their attitude:   “Value-based reimbursement models should play the dominant role in healthcare reimbursement with fee-for-service medicine playing a declining and minor role.” The CEO’s also predict that value-based reimbursement will improve quality of care (93% agree).  Overwhelmingly, they think the pace of change is NOT going too fast (91% agree).  NOTE:  Almost all of the CEO’s think we can’t throw away the existing CPT-based payment system entirely – because physicians need an incentive to work hard, and because the metrics that underlie value-based payment don’t work well when there are statistical challenges (unusual  conditions, rare events, low practice volumes, and other reasons for small numbers and high variability).

In another development, while repealing the dreaded Medicare fee cuts called for under the SGR legislation (Sustainable Growth Rate), Congress opened the door to some (potentially) HUGE changes in physician payment.   MACRA – the Medicare Access and CHIP Reauthorization Act of 2015 – lays out a general plan for changes in CMS’ physician reimbursement methods.   MACRA replaces the uncertainty about SGR and its draconian 21 percent cut to physician fees this year with tiny but predictable payment increases for the next four-and-a-half years. Then, starting in
2019, MACRA removes some irritating and burdensome penalties and gives physicians two ways to earn performance based incentive payments, either by participating in a new Merit-based Incentive Payment System or an Alternative Payment Model, like a Patient-Centered Medical Home.

Here’s how the White House blog portrayed this legislative achievement.  And here is a brief summary of the key features from the point of view of the American College of Physicians (the ACP) which also provided a more detailed discussion of the law’s provisions concerning physician payment   And here is a one page handout summarizing these provisions of MACRA prepared by ACP for its member physicians.

Lots more to come on this!