Presentation for the International Association for the Study of Pain

1. An International Perspective on Disability Benefit Programs and PainIlene R. ZeitzerOffice of Disability and Income Security ProgramsU.S. Social Security Administration Presentation for the InternationalAssociation for the Study of Pain

2. Disability Policy in an International Perspective • A country’s disability programs must be viewed within the context of its social, labor and judicial policies and as a reflection of the given society’s values and way of life. • How a country treats its most vulnerable citizens whether they are elderly, children, poor, or disabled is also very much influenced by complex and sometimes competing notions.

3. Disability Policy (continued) • Among these complex and competing goals are: • a societal strong work ethic versus • deep charitable tendencies versus • notions of solidarity based on a social minimum, rather than on charity.

4. Disability Policy (continued) • In truth, virtually no country has opted for one approach and ignored the others. • Instead, in almost all countries, disability programs and policies are an attempt to find the right balance among all of these competing notions.

5. Therefore, eligibility for social insurance disability benefits is very much governed by these same issues of a work ethic, versus what conditions are deserving of support, versus concerns to provide a strong social safety net. The struggle is to find an equitable system of deciding who is entitled to receive benefits as well as what is an adequate level of benefits. Disability Benefit Assessment in an International Context

6. Some Basic Questions: (1) How does a claimant enter into the work- related disability benefit system? (2) What is the test for work incapacity (disability definition)? (3) What evidence is needed? (4) Face-to-face interview, physical examination or paper review? (5) What is the level of training of the decision-makers? The Specifics of Disability Assessment

7. The Disability Assessment Process in Selected Countries The United Kingdom The Gateway in: Sick Pay • Most people who are employed when they become sick or incapacitated for work are eligible for 28 weeks of Statutory Sick Pay (SSP) paid by the employer from the 4th day of sickness.

8. During the first 7 days of SSP, our Bobby here can self-certify using approved forms. After the 7th day, the form must be accompanied by a doctor’s certificate. The form requires information about the person’s usual occupation and how his or her sickness or injury prevents working. The Disability Process (continued)

9. The Disability Process (continued) • The test used at this point is the Own Occupation Test (OOT). It applies to the first 196 days of the claim provided that the person has been in paid work for more than 16 hours a week for more than 8 out of 21 weeks immediately before the first day of the claim.

10. The Process (continued) The definition of the OOT is: • “whether s/he is incapable by reason of some specific disease or bodily or mental disablement of doing work which s/he could reasonably be expected to do in the course of the occupation in which s/he was so engaged”

11. The Process (continued) • Certification for the OOT is from the claimant’s General Physician. • If the work conditions required for the OOT are not met, or after the 29th week of incapacity, the medical assessment is through the use of the Personal Capability Assessment (PCA) which will be discussed in greater detail next.

12. The Process (continued) • The Personal Capability Assessment (PCA) and How it is Applied • The test considers the extent to which a person, by reason of some specific disease or bodily or mental disablement, is incapable of performing certain specific activities that are considered relevant to the ability to work, however, there is no reference to a work situation.

13. Incapacity is assessed under 14 categories: walking; sitting; lifting & carrying; speech; continence; walking up & down stairs rising from sitting manual dexterity Vision remaining conscious without having epileptic or similar seizures during awake hours; standing; bending & kneeling; reaching; hearing The PCA (continued)

14. For each of these activities, there is a set of ranked statements, known as descriptors that illustrate different levels of functional limitation. Each descriptor is given a point score. An applicant needs 15 points for receipt of a benefit. The points can come from one area or a combination of lesser impairments in several areas. PCA (continued)

15. Claimants are sent a questionnaire (called the IB 50) that asks them to select those descriptors that best describe any functional limitations that they may have in each physical or sensory area listed. The Benefits Agency office provisionally scores the questionnaire. If the score is under 15, or if there is doubt about the stated level of incapacity. The Medical services advice is sought and the claimant may be required to appear for a medical exam - 40% of cases undergo a clinical exam. The PCA (continued)

16. All the Benefits Agency doctors are physicians who receive a diploma in an accredited post graduate course in the area of disability assessment. A good part of their training involves the interview of the claimant specifically taking a detailed history. They spend about an hour with the claimant with about half the time devoted to asking claimants what they do or do not do to assess the effect of the pain. They also ask another person, NOT a family member. They give VERY LITTLE weight to the treating physician. The Benefit Agency Doctors

17. Those terminally ill (death expected within 6 months) People suffering from: tetraplegia paraplegia or uncontrollable involuntary movements or ataxia dementia registered blindness People in receipt of: the highest rate care component of the Disability Living Allowance Constant Attendance Allowance war pension; industrial injury or Severe Disablement Allowance (all at the 80% level) Exceptions to the PCA(the following are automatically included for benefit)

18. The PCA (continued) • On the other hand, there are specified categories that always require the Decision-Maker to consider the advice of an approved doctor as to whether the claimant is suffering from the alleged condition.

19. Severe mental illness severe learning disabilities severe and progressive neurological or muscle-wasting disease active and progressive inflammatory polyarthritis progressive impairment of cardio-respiratory function that severely And persistently limits effort tolerance dense paralysis of the upper limb, trunk & lower limb on one side of the body multiple effects of impairment of function of the brain and/or nervous system causing motor,sensory or intellectual deficits. Physician Advice Required if:

20. Manifestations of severe and progressive immune deficiency states characterized by the occurrence of severe constitutional illness, opportunistic infections or tumor formation - NOTE: this category does not relates solely to HIV and AIDS PCA Physician Advice Required

21. The Role of the Claimant’s Physician in the PCA Process • If a PCA is to occur, the claimant’s own doctor must see him or her on the day of, or one day before issuing a Med 4 form. • The form must include: main diagnosis; other relevant medical conditions; an indication of the disabling effects; current treatment or progress; advice given to the patient concerning ability to perform their own occupation; & if travel for an exam is possible.

22. Under the British system, pain is not an impairment but a symptom. Therefore, there has to be a reason for the pain either an underlying pathologic condition or a psychosocial one.Then the effort is to assess its impact. The Benefit Agency is looking to see if there is enough evidence from what the claimant says s/he cannot do, is it consistent, and does it follow from the pathology, etiology, etc. Decision is made by Decision maker. The Role of Pain in the Disability Adjudication Process

23. The Disability Assessment Process in the Netherlands • Employees who become sick or incapacitated for work simply call their employer and report sick. • The employer is responsible for paying the first year of sickness benefits. • Benefits are between 70 -100 % of former pay up to a ceiling and depending on labor contracts or agreements.

24. Disability Assessment in the Netherlands • A doctor’s certificate or report is NEVER required during that full year that the worker is out on sick leave. • Employers are required to contract with an • Occupational Health Service (OHS) who are supposed to intervene with sick or incapacitated workers if the case seems likely to become disabling.

25. After 13 weeks, the employer’s OHS physician is supposed to send the social insurance agency a report on the sick worker’s progress and prognosis but the reports tend to be rather perfunctory at this point. At 38 weeks on sick pay, the OHS physician is required to provide a detailed report letting the social security agency know if the worker is likely to file for disability benefits at 52 weeks. Disability Assessment Process

26. The Definition of Disability • “Disabled, full or partial, is s/he who as a direct and objective medically determinable consequence of sickness, impairment, pregnancy, or delivery, is fully or partly unable to earn in employment what healthy persons with comparable education and experience in the same region usually earn.”

27. At the 52-week point, the worker who is applying for a disability benefit must appear in person for an examination by a social insurance doctor. These physicians receive further training, beyond their medical training and specialties, in the specifics of the disability program requirements. Disability Adjudication Process and the Role of Physicians

28. The Role of Medical Evidence in the Process • Dutch social insurance physicians examine the claimant to determine his/her remaining functional abilities and then complete a form that goes to a vocational expert. • These doctors have the legal authority to order any tests or consult with the treating physician if they feel it appropriate.

29. Medical Evidence (continued) • In practice, however, they almost never exercise these options. • I recently concluded a research project for the International Labor Organization in which the physicians told me they reach their decisions almost solely based on what claimants tell them about their condition and do not make any attempt to verify it.

30. The Disability Process (continued) • Furthermore, Dutch social insurance physicians complain that, because of the emphasis on productivity, they rarely have time to do much more than interview the claimants as to their functioning. • As a result, claimants allegations of pain are generally accepted and included verbatim in the doctor’s report. • Finally, in actuality, the physician’s decision is far more influential than the vocational expert’s.

31. Some Policy Implications Concerning Pain from a Comparative Study on Return to Work After Back Problems • Background: • The project, called the Work Incapacity and Reintegration Study was conceived by the International Social Security Association in Geneva, Switzerland in the early 1990’s.

32. ISSA Work Incapacity and Reintegration Study • Background: • Motivation for the study was the increasing social expenditures on disability and the decreasing work participation rates of people with disabilities in most industrialized countries.

33. Background (continued) • Many industrialized countries are experiencing large increases in long-term social security benefit payments based on work incapacity • Also, the common experience is that once on the disability rolls, hardly anyone ever leaves to return to work

34. Goals of the Project • To determine what type of work interventions are effective • Specifically, to determine whether the various interventions used in different countries make a difference as to work resumption patterns and if so, • what are the best interventions?

35. The Uniqueness of this Study • The first time a research project on comparative disability policy incorporated a quantitative approach to study the efficacy of various interventions • Specifically, the core design required recruitment of like cohorts in each study country and longitudinal follow up at specified intervals

36. The Study Countries

37. The Selected Disability = Back Problems

38. Why a Study on Back Problems? • In the industrialized countries, back problems are typically the leading physical cause of receipt of disability benefits and the second leading cause of disability benefits for any reason. • Although most back problems are of short duration, for a minority, the problems become chronic (i.e. longer than 3 months).

39. Prognosis for Back Problems • Also, generally the prognosis for recovery is inversely dependent on time, i.e., the longer the duration of the problem, the more decreased are the chances for a complete recovery. • Not surprisingly, the longevity of the problem is the strongest predictor of high costs.

40. Summary of Key Findings • medical interventions ran the gamut from mud baths to surgery, BUT: • medical interventions added little to what was already predicted by initial health and a few significant baseline characteristics; • with one exception, there was no significant relationship between medical treatments and return to work.

41. Effect of Medical Interventions • The only positive effect from medical interventions occurred with the Swedish cohort, where surgery during the first 3 months provided small improvement in back function. • The subjects in the U.S. cohort were treated with surgery 5 times more often than those in Sweden but with no better outcomes.

42. The Role of Pain in the Back Study • The WIR project based their scales on the Von Korff pain intensity scales. The WIR scales were 1 (“hardly any pain”) to 10 (“unbearable pain”). • The German subjects reported the highest intensity of pain with a mean value of 6.4; followed by Israel at 6.3. The U.S. Netherlands and Sweden were about the same at 5.8 or 5.9. The Danes reported the lowest intensity of pain at 5.6.

43. The level of pain intensity was lower (less pain) in a statistically significant way among subjects who had resumed work after one year than among those who had not. Subjects who had had back surgery in the Swedish, German and American cohorts had statistically significant less pain if working than if not working. They also had less pain than those who had not had surgery, irrespective of working or not. Policy Implications about Pain from the Study

44. The most common interventions were pain medication and pain relieving injections in all cohorts, especially in the first year. It could not be shown, however, that the pain relievers used had any positive effect on the return-to-work rate, neither during the first nor the second year. All associations between health indicators at the initial (3 month point) and work status after 2 years were consistently linear in all cohorts -- the less pain & better functioning, the higher the resumption rates. Pain Interventions

45. Pain Findings (continued) • Nevertheless, there were marked differences among the cohorts as to resumption rates within equal levels of pain intensity and functional capacity. • In some countries, the resumption rate of subjects with severe pain and low functional capacity at onset was twice that of those in the other countries.

46. Final Remarks on Pain and the Back Study • Work resumption itself can help to improve functional capacity. • Those cohorts who had the opportunity for flexible and adapted work resumption interventions (such as reduced working hours, less physical demands, etc.) had the best likelihood for successful permanent return to work outcomes. • This finding suggests the importance of keeping the ties to the workplace and of a gradual approach to return to work.