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Disability Management: What is it and why do we care?. Gideon Letz, MD State Compensation Insurance Fund San Francisco, California Tel: 415 565-1677 e-mail: [email protected] April, 2002. Take Home Message.

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Disability management what is it and why do we care
Disability Management: What is it and why do we care?

Gideon Letz, MD

State Compensation Insurance Fund

San Francisco, California

Tel: 415 565-1677 e-mail: [email protected]

April, 2002


Take home message
Take Home Message

Communication and Teamwork are essential for successful rehabilitation and prevention of delayed recovery after disabling occupational injury or illness.


Direction
DIRECTION

  • Perspectives on the rehabilitation process

  • Transitional work as a key element in the treatment of work injury/illness

  • Common barriers to successful return to work

  • Practical suggestions to overcome these barriers with focus on tactics to improve communication


Perspectives
PERSPECTIVES

  • Worker

  • Health Care Provider

  • Employer

  • Claims Administrator

  • (Attorney)


According to a recent survey of Industrial Medicine Physicians

Up to 80% of paid indemnity expense is unnecessary ...

Stated Reasons

Employer has a policy against light duty

The treating doctor is not equipped to determine the right work restrictions

Too little information about the physical demands of the job is provided to the physician

Managed Comp Survey of Industrial Med Physicians April 1998


Direction1
Direction Physicians

  • Common problems in the implementation of return to work prescriptions

  • A model program for triage and prevention of delayed recovery


Barriers to rtw the patient
Barriers to RTW - The Patient Physicians

  • Fear of re-injury or aggravation (pain avoidance)

  • Job satisfaction

  • Sense of entitlement (worker’s comp, personal injury)

  • “Illness behavior”

  • Motivation level

  • Financial issues


The pain ladder

Sick Role Identity Physicians

Loss of Identity

Withdrawal

Chronic

Depression

Helplessness

Anger

Blame

Fear

Acute

Uncertainty

The Pain Ladder

(Weiser, 1997)


Barriers to return to work the doctor
Barriers to Return to Work - The Doctor Physicians

  • Role as patient advocate vs “company doctor”

  • Treatment goals focused on feeling better rather than getting better

  • Failure to include transitional work in the treatment plan

  • Lack of information re physical demands of the job


Barriers to rtw the employer
Barriers to RTW - PhysiciansThe Employer

  • Fear of liability for re-injury or aggravation

  • Failure to appreciate transitional work as therapy

  • Use of benefits system (WC, STD, LTD) to manage personnel problems

  • Lack of information re: the economic benefits of transitional work


Barriers to rtw the claims adjuster
Barriers to RTW - The Claims Adjuster Physicians

  • Focus on benefit delivery rather than rehabilitation

  • Poor communication with providers, employers and injured workers

  • Delays in treatment authorization

  • Caseloads too high given administrative complexity of WC system


Wc shift in focus
WC Shift in Focus Physicians

  • Last Decade - Bill Audits and Utilization Review

  • Currently - Functional Recovery and Disability Management


Strategies for improving functional recovery
Strategies for Improving PhysiciansFunctional Recovery

  • Channeling patients to doctors with best outcomes

  • Financial Incentives for Employers (premium) and Doctors (fees)

  • Communication between injured workers, doctors, employers and claims administrators - with a focus on disability management


Disability management where the perspectives merge
Disability Management: Where the perspectives merge Physicians

  • Injured Worker

  • Doctor/Therapist

  • Employer

  • Claims Administrator


Injured worker concerns
Injured Worker Concerns Physicians

  • Pain

  • Fear/Anxiety

  • Lost Wages

  • Job Security

  • Return to Work


Physician concerns
Physician Concerns Physicians

  • Diagnosis and Treatment

  • Authorization

  • Reimbursement

  • Administrative responsibilities

  • Return to Work


Employer concerns
Employer Concerns Physicians

  • Liability

  • WC premium

  • Lost Productivity

  • Return to Work


Adjuster concerns
Adjuster Concerns Physicians

  • Liability

  • Benefit Delivery

  • Reserving

  • Settlement

  • Return to Work


Delayed recovery the search for predictors
Delayed Recovery: Physiciansthe search for predictors

  • Early intervention facilitates successful recovery

  • Appropriate triage for non-routine care

  • “Holy Grail” for insurance industry - cost efficiency of managed care


Aces accelerated case claim evaluation system workers compensation model
ACES PhysiciansAccelerated Case/Claim Evaluation SystemWorkers’ Compensation Model

  • by

  • Industrial Health Strategies

  • Providence, Rhode Island


Aces model focus on cumulative trauma
ACES model Physicians: Focus on Cumulative Trauma

  • Etiology often obscure

  • Treatment frustrating

  • High Risk for Delayed Recovery

  • Disproportionate Costs


Aces 3 steps
ACES - 3 Steps: Physicians

  • Three Point Contact by Adjuster

  • Profiling with ACES software

  • Tasking and Triage


Three point contact by claims adjuster
Three Point Contact Physiciansby claims adjuster

  • Injured worker

  • Employer

  • Treating physician


Value of 3 point contact
Value of 3 point contact Physicians

  • Information gathering

  • Customer service (accessibility, education)

  • Identification of “red-flags”


Aces modifiers
ACES Physicians MODIFIERS

  • Injury Diagnosis,Duration

  • Modified Duty Availability

  • Physician, or Therapy Issues

  • Claims History

  • Attorney Presence

  • Employer/Employee Issues

  • Job Demands

  • Obesity, Smoking, Age


90 / 10 THEORY Physicians

10%

GOOD

BAD

90%

Purpose ofACESProfiling

  • Identify claims at high risk for “delayed recovery”

  • Refer for appropriate level of claims management and/or worksite assessment

  • Refer for Loss Control or Fraud Investigation when appropriate


CLAIMS MANAGEMENT Physicians

DECISION-MAKING

(Tasking)

ACES Reports

Level 1

  • Worksite Assessment

  • Diagnostics/Therapy

  • Second Opinion/IME’s

  • Functional Capacity

  • Vocational Services

  • Fraud Investigation

  • Loss Control Activity

Level 2

Level 3

  • .


HOW DO WE GET PEOPLE BACK TO WORK? Physicians

Worker’s Functional Ability

Functional Job Demands

A SIMPLE SOLUTION TO A COMPLEX PROBLEM


Worksite assessment
Worksite Assessment Physicians

  • Identify areas of stress related to diagnosis

  • Can be minimized through changes by Employer?

  • Can be minimized through changes by Employee ?

  • Identify appropriate modified duty


Case example 1 47 year old high tech manufacture plant worker
Case Example #1: Physicians47 year old high-tech manufacture plant worker

  • She had been off work 4 months with shoulder injury (rotator-cuff tendonitis)

  • Being treated by an orthopedic surgeon;

  • Employer apparently had no “modified duty.”


Case example 2 23 year old jewelry worker
Case Example #2: Physicians23 year old jewelry worker

  • On/off work due to wrist tendonitis

  • Then took extended leave during pregnancy and after birth of 3rd child

  • Was released for regular work by her treating physician

  • Employer was concerned about her attendance and believed absences were secondary to child-care issues


Communication is key what treating physicians need from the employer
Communication is Key - PhysiciansWhat treating physicians need from the employer:

  • Detailed job descriptions for all positions

  • Prompt reporting and referral when an injury occurs

  • Opportunities for workplace visits

  • Cooperation with transitional dutyrecommendations


Communication is key what employers should expect from treating physicians
Communication is Key - PhysiciansWhat employers should expect from treating physicians:

  • Detailed description of work restrictions

  • Estimate of duration of work restrictions

  • Estimate of duration of temporary total disability (rare)


Communication is the key

Patient Physicians

Provider

Employer

Communication is the Key


Screening tools for delayed return to work
Screening Tools for Delayed Return to Work Physicians

  • Watch the calendar

  • Grocery Store Test

  • Obstacle Question

  • Molehill Sign

  • (Christian J, 2000)


The obstacle question
The Obstacle Question Physicians

  • Paperwork delays

  • Job placement delays

  • Can’t figure out how to….

  • Patient is reluctant (Molehill Sign)

  • Patient is lost in medical system

  • Patient is focused on legal issues (Grocery Store Test)


Paperwork delays
Paperwork Delays Physicians

  • Waiting for authorization, referrals

  • Missing information, waiting for answer

  • Questions you can’t answer (diagnosis,functional capacity)

  • Job demands, availability of modified work not known

  • Employer dragging on modified work placement

  • Forms in “To Do” pile


Job placement delays
Job Placement Delays Physicians

  • ER has “no light duty” policy

  • ER has policy but ignores it

  • ER uses modified work but this supervisor can’t find any

  • Doctor’s restrictions too rigid, hard to understand

  • Doctor’s work slip doesn’t get to ER promptly


Can t figure out how to
Can’t Figure Out How To... Physicians

  • Perform key task at work

  • Get to work

  • Be comfortable at work

  • Be safe at work


Patient is reluctant molehill sign
Patient is Reluctant: PhysiciansMolehill Sign

  • Too many medical appointments

  • Afraid of re-injury (exertion, persistent hazard, pain)

  • Afraid of poor treatment at work

  • Afraid of jeopardizing benefits

  • Afraid of disciplinary action, being fired


The real issues are not being addressed grocery store test molehill sign
The Real Issues Are Not Being Addressed: Grocery Store Test, Molehill Sign

  • Job conflict (personalities, performance, discipline)

  • Job dissatisfaction

  • Life dilemmas (aging, career choice)

  • Domestic disruption/obligation

  • Pending layoff/intentional fraud


References
References Test, Molehill Sign

  • Texts

    • The Comprehensive Guide to Work Injury Management. Isernhagen SJ, ed. Aspen Publishers, 1995.

    • Principles and Practices of Disability Management in Industry. Shrey DE & Lacerte M, eds. St. Lucre Press, 1995.

    • Risk and Disability Management in the Workplace. Randolph DC & Ranavaya MI, eds. Occupational Medicine, State of the Art Reviews. Vol 15:4, Oct-Dec 2000.


References1
References Test, Molehill Sign

  • Articles

    • Abenhaim L, Rossignol M, Valat JP et al. The Role of activity in the therapeutic management of back pain. Report of the International Paris Task Force on Back Pain. Spine 25(4S):1-33. Feb, 2000.

    • Krause N, Dasinger L and Neuhauser F. Modified work and return to work: A review of the literature. J Occ Rehab 8(2):113-139, 1998.

    • Weiser SR. Psychosocial aspects of occupational musculoskeletal disorders. In, Nordin, Andersson & Pope (eds), Musculoskeletal Disorders in the Workplace: Principles and Practice. CV Mosby, 1997:51-61.


References2
References Test, Molehill Sign

  • Articles

    • Campello M, Weiser S, vanDoorn JW, Nordin M. Approaches to improve the outcome of patients with delayed recovery. In, Nordin, Cedraschi & Vischer (eds), New Approaches to the Low Back Pain Patient. Baillere’s Clinical Rheumatology. Harcourt Brace, 1998:93-113

    • Christian J. Reducing disability days: healing more than the injury. J Work Comp. 9:30-55, 2000.

    • Frank JW, Brooker A, DeMaio SE, et al. Disability resulting from occupational low back pain. Part II: What do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins. Spine 21:2908-17, 1996.


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