Welcome to Webility!

This article has been slightly modified from one that originally appeared in the Winter 2000 issue of The Journal of Workers Compensation and is reprinted with permission from Standard Publishing Corporation of Boston, MA.

Return to Webility Library Page

Curing Medically Unnecessary Disability

At any one point in time, an estimated 8 million American workers are at home and not working because of illness or injury. The resulting paid disability leave costs employers more than $100 billion per year through sick pay, salary continuation, workers compensation indemnity benefits, and long-term and short-term disability benefits. Much of that paid time off from work is in fact medically unnecessary and results from the interplay of the following non-medical features:
• employers and physicians communicate poorly about injured and ill employees' ability to work;
• employers fail to address environmental and motivational problems, causing injured employees to stay out of work longer than medically necessary; and
• physicians do not see disability leave as an outcome for which they are responsible.

The purpose of this article is to discuss these three major non-medical features of the existing system and to point out the opportunities we have to correct them.

In this article, “disability” will be used to mean time away from work due to a loss of full physical or functional capacity — whether minor or major, whether temporary or permanent — on the part of an employee or an employee's dependent. This definition includes loss of full capacity to an employee's dependent because a dependent's medical problems can affect an employee's productivity as well. The terms “medical condition,” “infirmity,” and “incapacity” will be used to describe the physical conditions that create the possibility of disability.

A Desire to Work

Our discussion of disability and medically unnecessary time off from work begins with a reminder that people who are amputees, on crutches, in wheelchairs, blind, deaf, in constant pain and crippled with rheumatoid arthritis, weakened and slowly dying from diabetes, cancer, or AIDS, or otherwise substantially limited in doing life activities insisted so strongly on their right to work that Congress passed the Americans with Disabilities Act. Christopher Reeves, who is now quadriplegic, is still working as an actor. Steven Hawking is so profoundly handicapped by his Lou Gehrig's disease that he cannot move, talk, or breathe on his own, yet he communicates by use of code and continues to write books about the cosmos.

More personally, my friend, Mark, uses a wheelchair because he is paraplegic and commutes by jet to his management job in an oil field on the North Slope of Alaska. My business colleague, Linda, is totally blind and flies around the country as a sales consultant and motivational speaker. The woman who used to clean our house, Rosa, went back to work as a nanny after she had both her knee joints replaced because of bad arthritis.

So, here is where we will start: People can have devastating health problems but nonetheless overcome the obstacles that their infirmities create. They can remain fully engaged and productive in society. Medical conditions themselves — the anatomical or physiological loss of some functional capacity — do not automatically create disability. Or, as a wise doctor once told me, there is no medical problem so severe that there isn't at least one person, somewhere, working successfully despite it.

Why We Should Care

Unnecessary days lost from work mean unnecessary dollars lost in workers compensation and disability benefits. Nationally, the average workers compensation lost-time claim costs more than $19,000 in medical expenses and indemnity payments, compared with the average medical-only claim that costs less than $400.¹ Of course, the most effective way to reduce the cost per claim is to prevent injuries; but the next most effective way is to reduce the percentage of all workers compensation claims that involve lost time. As an example, consider 100 injuries of which 25 percent involve lost time (at $19,000 per injury) and 75 percent involve only medical expenses (at $400 per injury); the total cost would be $505,000. Now consider those same 100 injuries, but reduce the percentage of lost-time claims to 10 percent and increase the percentage of medical-only claims to 90 percent; the total cost would come down to $226,000.

The same reasoning applies to non-occupational disabilities. The best way to save money is to prevent injuries and illnesses. The next most effective way is to reduce the percentage of cases within any particular diagnostic grouping that results in enough lost time to trigger short-term or long-term disability benefits.

Employers and Physicians Fail to Communicate

When asked in a survey how many workers with work-related injuries need more than a couple of days off from work for strictly medical reasons, occupational health physicians placed the percentage at 10 percent at most, based on their own clinical experience.² Almost half the doctors surveyed placed the percentage at 5 percent. This range of 5 to 10 percent contrasts markedly with the actual percentage — 24 percent nationally — of injured workers who spend more than a couple of days off from work following an injury.³ The disparity suggests that the majority of lost-time cases — 60 to 80 percent — involves medically unnecessary time off from work.

The survey also asked the specialists to give the specific non-medical reasons keeping injured workers out of work in their communities. More than two-thirds of the physicians gave the following reasons:

• the treating physician is unwilling to force a reluctant patient back to work (the most common reason cited);
• the treating physician is not equipped to determine the right restrictions and limitations on work activity;
• the employer has a policy against light-duty work;
• the employer can't find a way to temporarily modify a job;
• the treating physician feels caught between the employer's and the employee's version of events;
• the treating physician has been given too little information about the physical demands of the job to issue a work release for the patient; and
• a conflict exists between the opinions of two physicians.

This list shows us that there is a gap between the employer's work site and the physician's office (see Figure 1). Closing this gap will reduce disability days. Let us now examine this gap and how to close it (see Figure 2).

Figure 2 - Bridging the Gap

The Physician-Employer-Employee Triumvirate

The three most influential people in a disability case are the doctor, the patient, and the employer. The doctor diagnoses the medical problem, prescribes the care, and releases the employee back to work. The employee decides whether to try to get better as quickly as possible or to let the medical problem become a life-limiting event. The employer decides whether to support the recovering employee and whether to provide fair work within the employee's restrictions.

The work that employers and physicians do early in the course of a case can be some of the most valuable work they do. During those critical first few days, the tone is set. There is an expectation about a quick return to work — or not; there is an appropriate response to the employee's injury — or not; there is effective planning towards achieving a return to work — or not. A lost-time injury can often be avoided if the physician and the employer or insurer are in communication and are in collaboration with getting the employee's life back to normal.

Claims adjusters and case managers — those charged with “managing” the situation — really can only attempt to influence the behavior of those who make the key decisions — the employer, the employee, and the physician. Adjusters and nurses raise possibilities, facilitate communications, state opinions, get others involved, refuse to pay, call in lawyers, and so on. Many of these activities are attempts to recover from poor decision-making by the powerful threesome. But any “saves” they make are inherently inefficient. The hallmark of an optimally functioning system is right decisions being made the first time, minimizing both variability and redundant work.

Physician-Employer Interactions

Mixed in with the huge volume of medical bills and other medical transactions that now pass between health-care providers, insurers, and employers is a little-noticed, poorly managed, and undervalued stream of quasimedical information. This stream consists of disability-related communications about sick and injured employees — inquiries and responses to inquiries about what is the matter with them and whether they can work. By law, policy, or common business practice, these inquiries about disability cases must be answered by the treating physician before benefit payments can start or stop and before disabled employees can return to work. This information travels via telephone, voice mail, fax, mail, and e-mail. Two million of these transactions occur every week in America. (This assumes doctors write just four work excuses a week. Surveys of physicians indicate that they may actually write eight to ten per week.⁴

These transactions usually take the form of requests for written reports as the patient leaves the room or for “just two minutes” of time-consuming conversation with case managers or claims managers, disrupting already tight patient schedules. Moreover, most claims payers do not routinely compensate physicians for providing disability-related information — a practice that most physicians resent. They respond with passive-aggressive delays and carelessly scribbled notes. The lack of positive participation by physicians on claims has led to bureaucratic workarounds and a communication flow that is burdensome and redundant (see Figure 3).

Keeping Physicians Informed

Most of the time, a physician has no source of information other than the patient when deciding whether to delay a return to work. The employer — with its version of events, alternative work options, and desire to have the employee back at work — is not represented, not even on paper. The physician has only a 10-to-15-minute interval scheduled to talk to the patient, do the examination, make a diagnosis and treatment plan, answer the patient's questions, then dictate the chart — and then start over again with the next patient (see Figure 4). In all this, return-to-work notes seem like a trivial piece of irritating administrative paperwork.

Six Patients per Hour

In 60 minutes the average physician must complete the following 10 items six times:

  1. Read the notes in the patient's chart
  2. Take the patient's statement
  3. Ask the patient questions about the condition
  4. Conduct the physical examination
  5. Consider the facts, make a diagnosis, and devise the treatment plan
  6. Explain the diagnosis and plan to the patient
  7. Make plans for the next appointment
  8. Answer all the patient's questions
  9. Fill out forms, lab orders, etc.
10. Dictate notes for the patient's chart

Most physicians have no familiarity with the workplace or the techniques used to keep vulnerable patients safe while working. Even many occupational health specialists are unaware of the resources potentially available to return a previously disabled patient back to appropriate work. If any additional information that should be consulted before releasing the employee to work is not at hand, the physician will not go looking for it — there is no time and no incentive. (Imagine what it would be like if physicians and employers communicated perfectly. See “The Way Physicians and Employers Will Communicate in the Future” below.)

The Way Physicians and Employers Will Communicate In the Future

When one of your injured employees presents at the physician's office, the receptionist will begin by asking the employee for whom he or she works. The receptionist will then use the office computer to find out information about your company and the employee. The receptionist will:
• confirm that the employee is covered, determine the extent of coverage for benefits, and retrieve billing instructions
• print out the necessary forms
• look for any special instructions, requests, or information the company wants the doctor to know when he or she sees the patient
• obtain any other pertinent information for the physician's use.

During and after the employee's appointment, the physician or office staff can find other useful material that has been provided by the company. From this information, the physician or medical office staff can:
• make referrals within the company's chosen healthcare provider network by using the on-line directory
• compare the employee's work capacity with the description of his or her job description or available light-duty job or task descriptions
• find the treatment protocols the company wants the physician to use
• find the phone number or e-mail address of the supervisor, claims adjuster or case manager
• locate other resource and reference information for handling the employee's situation, such as case studies, on-line roundtables, peer discussion forums, databases of medical information, and directories of pharmaceutical products and other products and services; and
• send a completed report regarding impairment and return-to-work ability back to the company.

Paying Physicians to Provide Better Information

Reluctance to pay physicians for worthwhile information about returning a disabled employee to work seems silly — what seems even sillier are the statutory prohibitions against paying physicians for their reports in some states. How can the same answer to the same question be worth nothing when it comes from the treating physician and worth $1,250 when it comes from the independent medical examiner?

It doesn't hurt the physician if the return-to-work report is late or poor; but it does hurt the employer (and frequently the employee). Those reports can mean hundreds or thousands of dollars to the employer or insurer because they trigger action — or lack of action — on the claim. Delay and inaccuracy cost employers a lot of money. Wouldn't it be wiser to pay a little more for quicker and more complete answers rather than continuing to pay benefits to workers who are sitting at home, even though they are well enough to do something useful? Paying, say, $35 for a prompt answer that can resolve a case tomorrow beats paying $100 to $300 per day in disability benefits and hundreds of dollars more in case management and independent medical exam fees.

Obviously, we are not talking about paying more for favorable answers; that is unethical. We are talking about paying for prompt, complete, and thoughtful answers. For example, insurers and employers should consider paying higher fees for reports done in a standardized format that answer certain questions, such as, “What are the obstacles that need to be removed before this employee can return to work?” instead of less relevant ones, like “What test or treatment is scheduled next?” Physicians should also be paid more when:
• their reports are done by a particular date
• they have special training in disability management; and
• they take on more than strictly the patient's medical care and concern themselves with the practical issues that get the patient's life back to normal, including a return to work.

A Case Study in Paying Physicians More

Rewarding physicians for better work can pay off. I have helped one managed care organization take an innovative approach to a network of what we called Primary Occupational Physicians (POPs). This small network of elite initial care providers was paid a small flat rate to prevent and mitigate disability in work-related injuries and illnesses. The flat fee was in addition to the usual fees for medical care and treatment.

We called it a “situation management fee” and paid $30 on every case they treated, whether minor or major. Moreover, we did not discount their medical fees. We asked them to reduce medically unnecessary time off from work and told them that we would monitor the fraction of their claims that incurred indemnity payments. Our report card also monitored the total cost, utilization, and quality of medical care, as well as patient, case manager, and employer satisfaction. We wanted no incentive for skimping on care and gave low marks for underutilization as well as overutilization. In essence, the POPs were made accountable for the final results of the claims for which they provided initial care.

The POP network was built around the customer base of the managed care organization. In any 10-mile travel zone, only one or two initial care facilities (chosen from those with the best reputation for service and competence) were allowed to serve as POPs in order to ensure they got the largest possible case volume. The POPs agreed to manage the situation created by an injury or illness as well as the medical care. Their charge was to run with the baton and allow, arrange, and assure a return to work — not just respond when asked.

We asked the POPs to work closely with the employer and our case and claims managers. Our medical directors and provider network trained them and their office staff at their own offices and at group meetings. They received materials to support their mission in the POP program — for example, directories containing the phone numbers and names of the employers, claims adjusters, and case managers that the POPs would be working with. The only problem was that it was a logistical nightmare keeping the POPs up-to-date. In fact, the administrative costs associated with building this working relationship continues to limit the full implementation of the POP program.

The overwhelming majority of the POPs did very well and qualified for the flat fee. The POP network's lost-time injury rate was about 14 percent, compared to the managed care organization's overall rate of 20 percent and the national rate of 24 percent. The POPs' total combined cost per claim (lost time and medical expenses) was $1,000 less than the company's overall average and $2,000 less than the national average.

POPs really liked the philosophy of the program and felt important in their roles. They told us we had improved their practices. The POPs cared little about the amount of the incentive payments ($30 hardly reflected their hourly rate), but they cared a lot about whether they qualified for the payments because they were thirsty for feedback. They intently scanned the report card to compare themselves with the other doctors.

The competition we witnessed among the POPs should have been predictable. Managed care companies have found that physicians respond as much to peer pressure as they do to financial rewards. Office staff in POP practices were interested in the amount of the bonus payment and used the money in creative ways — celebratory parties, patient education materials, and staff-training programs. This interest in more money and competition should be exploited more often by managed care organizations and claims payers.

Employers Fail to Address Environmental and Motivational Problems

Many businesses today are looking for ways to increase the productivity of their work forces. One obvious way to do this is to maximize work force availability, which means having as many employees as possible healthy, present, and working productively. Employers faced with unscheduled absences face both workflow and staffing disruption. Supervisors are distracted by the need to find and supervise substitute workers. Mistakes, oversights, and delays frequently occur. Both the quality and volume of work may suffer. Labor costs increase because of the wages paid to replacement workers or the overtime paid to co-workers picking up the extra load. As the frequency and duration of unplanned absences increase, they steadily drain the human and financial resources of the company.

Most unscheduled absences — unplanned days away from work — are said to be health-related. However, for many of those cases, the problem that needs to be addressed has nothing to do with the diagnosis or treatment. It's the situation that needs healing, not the body.

The Grocery Store Test

When an employee seems to be staying out of work longer than necessary, I use the Grocery Store Test. To apply the test to the employee, I ask: “If the employee owned a corner grocery, would he or she be able to find a way to work safely?” If the answer is yes, then absence from work is probably not medically required.

Also, when the answer is yes, it no longer makes sense to focus on medical diagnosis, prognosis, appropriateness of care, and what the AMA Guides to the Evaluation of Permanent Impairment says. All these issues distract from the underlying question that needs to be answered: Are there environmental and motivational problems preventing or discouraging the employee from returning to work?

Addressing the Environment: The Obstacle Question

To see if there are environmental problems, I recommend asking the Obstacle Question: “What is the specific obstacle preventing this worker from working today?” This question shifts the focus away from justifying or rationalizing the disability and puts the focus on finding a way around it. Environmental problems mean problems with the outside world, not the employee. Environmental problems are logistical, mechanical, financial, spatial, economic, social, cultural, legal, and political.

Surprisingly, many of the problems uncovered by the Obstacle Question are simple to fix. A logistical problem, like having trouble driving the car with a cast on the right foot, can be remedied by finding the employee a ride to work or paying for a taxi. In another scenario, a physician may have been told that there is no transitional duty when in fact there is. A conversation can fix this problem. Another common obstacle is the supervisor who cannot figure out how to temporarily modify a job in order to meet a physician's work restrictions. In one case, a worker with an injury that confined him to a wheelchair was going to be out on leave indefinitely because he couldn't get to where his job was on the second floor. Then someone discovered a wheelchair that climbs stairs. Disability case managers, physical therapists, vocational rehabilitation counselors, or in-house medical or safety staff can guide supervisors to see possibilities that they may have overlooked.

Sometimes, the answer to the Obstacle Question reveals an opportunity for further investigation and mediation. For example, an employee may be reluctant to return to work because she is worried that her co-workers will make fun of her. Another employee may be staying at home because he predicts his supervisor will press him to work over his limits. The Obstacle Question should prompt employers to investigate these possible tensions among co-workers or with the supervisor. If the employer provides a return-to-work advocate, the injured employee may feel better about returning to work — which, in turn, will improve the employee's attitude, if not the injury itself.

The existence of a return-to-work advocate at a company (perhaps a designated person or department) would also encourage physicians to issue a release to work. It is not ethical for a physician to issue the release if there is a substantial risk of reinjury. A physician will feel more confident returning the patient to work if he or she knows that the patient has someone at work to appeal to if the work restrictions are not respected.

Addressing Motivation: The Molehill Sign

The Molehill Sign helps find motivation problems. It is named after the saying “making a mountain out of a molehill.” If employees seem unduly disabled by trivial-seeming injury or illness, then a search should begin for the source of their apparently weak motivation to return to work. There is pay dirt lurking behind this question. Every employee with apparently low motivation is a potentially productive one, especially if the situation is viewed as an opportunity for performance improvement. Why isn't the employee motivated? What intervention is possible?

A problem with motivation means a problem with incentives, feelings, the ability to cope, or the will to survive. We hear many rehabilitation success stories about patients who were determined to recover, but we hear very few about unmotivated patients. In one example, an unusually large numbers of workers reported soft tissue injuries a few weeks before a strike because workers compensation benefits were more generous than strike benefits. In another instance, a man was on disability leave for a year, complaining about continuing back pain. It was eventually determined that the root of the pain was that he had lost his nerve and his confidence that he would ever be strong again.

Keep in mind that the person with the motivation problem is not always the person with the injury or illness. It can also be someone who has control over the resources and opportunities for recovery but refuses to use them. Most commonly, this someone takes the form of a passive, incompetent, uncooperative, or even hostile first-line supervisor or employer. At my previous job, when we investigated the root cause of individual disability cases, we discovered that the problem rested with the company about half the time. Supervisors generally had dropped the ball because they had never been trained or weren't supervising. Sometimes, they had avoided — or weren't supported by their human resources department in — confronting or disciplining employees with performance problems and then saw a subsequent disability leave as a godsend — a back-door severance. This was particularly true in companies that did not impose financial accountability for disability benefit costs at the departmental level.

A senior vice president of operations once told me that, in his opinion, most bad workers compensation claims are filed by employees who should have been fired the day before they were injured. Mediocre, problematic, or just plain unpopular employees who get injured can end up totally ignored while sitting at home — or treated coldly or belittled and harassed when they try to make a comeback at work. Disability cases are often a theater in which previously invisible workplace frictions turn into dramas. They can turn into a two-sided passive-aggressive war of revenge that gets very costly for the employer.

In my experience, a sizable fraction of patients with prolonged recoveries have been in difficult supervisor-employee relationships. Employers should routinely conduct the following inventory on cases involving lost time:
• How compassionately has the supervisor and the company responded to the employee's medical condition and the disruption to his or her life and job?
• How effectively has the situation been managed?
• Is there a performance or work-life issue that hasn't been effectively addressed?
• Is the employee or supervisor in need of training (e.g., for safety, return to work, conflict resolution skills)?
• Has there been a breakdown in the relationship between the supervisor and the employee that counseling may improve?
• Is the lost time the result of a supervisor who has defeated the employee's motivation?
• Is the working climate of the employee's immediate department or group unsupportive?

Key Competencies for Reducing Lost Time

Management's lack of commitment to injury prevention and absence management programs is a critical part of why injuries and lost time occur. Therefore, most discussions about how employers can reduce unnecessary health-care and disability costs emphasize the fact that successful programs depend on leadership from the top. However, these discussions often fail to lay out the key competencies needed at other levels in the company in order for programs to be effective.

Managing Difficult Employees

Those who work in risk management, health and safety, benefits, and human resources (i.e., the corporate staff) typically have limited expertise in healing disrupted situations — coaching management and supervisors in their roles, mediating conflicts between employees and supervisors, and providing extra support to vulnerable employees or work groups under stress. In my experience, these departments are too busy or unprepared to turn around a bad situation. They know about policy-compliance issues and legal rights and risks, but they are less interested in evaluating a highly charged situation and arriving at the fairest or most responsible course to restore peace. Most supervisors generally receive little training, supervision, or support in managing difficult employees. The first time human resources typically gets involved is when the situation has gone on for weeks or months, has become polarized, or has boiled over and become irretrievably ruptured, such as with a contested workers compensation claim or a lawsuit.

Employers that want to reduce medically unnecessary time off from work need to make supervisors feel that they can ask for and get support for dealing with unpleasant or awkward personnel issues. Otherwise, supervisors will continue using paid medical leave as a de facto retirement or severance package for employees they can't manage. Healing disrupted situations is an art. If corporate staff are not experts at handling these high-risk cases, outside help may be required.

Compassion for the Injured or Ill Employee

Supervisors need to be trained to properly respond to the initial report of an injury or disability. Their response will be remembered by the employee for a long time. Human beings make very strong memories of what happens at key moments like these. Supervisors who practice the golden rule and treat the employee as they would like to be treated will set the claim on the straight trajectory toward recovery. Expressions of concern — accompanying the employee to the doctor, suggesting where to go for medical care, reporting the injury or absence promptly, helping the employee find out about benefits — are the things that employees appreciate. Setting the claim on the straight trajectory in the beginning is the more efficient way to control costs than case-management rescues and independent medical exams later in the claim (see Figure 5).

Action and Accommodation Toward the Recovery

Most recovering employees can return to work with minor, temporary changes to their job. Some recovering employees have medical conditions that require major job modifications or careful supervision. Being able to think up transitional duty and manage physically and emotionally vulnerable employees are skills that most supervisors have not learned.

Too often, an employer's return-to-work policy (temporary accommodation through light-duty work) is subverted by supervisors who cannot or will not find light-duty tasks for a recovering employee. The employer's policy also may be subverted when an employee returns to work feeling physically vulnerable and defensive about doing light-duty work and is pressured by his supervisor and teased by his co-workers until he violates his work restrictions, reinjures himself, and goes back home hurting. One brief training session about transitional duty can prepare supervisors for easy cases. For supervisors faced with more complicated scenarios, access to further training will be needed.

Appointing a Return-to-Work Advocate

Employers also need to appoint someone to help recovering employees when their supervisors are not meeting their needs — and employers need to make sure that employees on transitional duty know about this person. A health and safety, risk management, or human resources staff person or the company nurse can play this role. So can the employee's treating physician or the company's physician. If not, the role will be played by the union or the injured employee's lawyer.

Mechanisms to Stop Cases From Drifting

It is typical for some new cases to hang on and gradually become old ones - and for old ones to pile up indefinitely because employers do not have effective mechanisms to close them. While I was the director of health and safety at Bath Iron Works (shipbuilders in Maine), we established two decision-making groups. One was the “Six Week Review” and the other, the “Rehabilitation Roundtable.” They both worked very well.

The Six Week Review

The Six Week Review group consisted of safety, benefits, occupational health, and workers compensation claims personnel, including a physician. We met once a week for no more than an hour and reviewed all claims that were less than six weeks old. Our goal was to collect and establish the facts in all cases as soon as possible. Our intention was either to get the worker back to work or to agree on a management strategy that included proposed milestones for the claim. As soon as either of those conditions was met, the case was dropped off the list. The four disciplines around the table would hustle to get their part done before the meeting and would point out red flags or extenuating circumstances that the rest of the group needed to be aware of. As a result of the Six Week Review group, the number of cases that lasted longer than six weeks dropped precipitously.

The Rehabilitation Roundtable

The Rehabilitation Roundtable made decisions on the longer-lasting cases. We began the group while we still had a significant inventory of cases that had lingered for more than a year. We eventually cut a swath through them and began considering cases as new as six months. In fact, six months is probably the right cut-off because, under the Americans with Disabilities Act (ADA), an employee whose medical condition persists that long may actually be eligible for the so-called “reasonable accommodation” under the statute. Many companies have a weak spot in their transition from return-to-work efforts to ADA-compliance activities. A decision-oriented group like the roundtable can highlight the need for a transition.

Members of the roundtable included medical, benefits, human resources, workers compensation claims management, rehabilitation, and labor relations personnel. Each month, we agreed on which employees' cases we would consider at the next month's meeting. The foremen of the affected departments were invited to sit in for the discussion of those cases.

Everyone had homework to do for the next roundtable. The foremen had to inquire about the particular employees' reputation and history of contribution to their work groups or departments. Human resources and labor relations personnel had to review the employees' official record. Benefits and workers compensation claims management personnel had to summarize the facts of the claims management process to date, including how the employees had behaved, e.g., litigation posture, amount of cooperation. Rehabilitation personnel had to call in the employees and evaluate their transferable skills. Medical personnel had to summarize the medical charts, with a particular focus on the employees' behavior in the medical system as well as outstanding medical issues and impediments to returning to work. My role was to interview the patients to see if I could ascertain how they felt about the situation they were in, what their goals were, and whether there was a “hook” somewhere in their psyche that we could use to pull them back to health and productivity. In other words, I had to determine whether there was a real possibility that we could heal the disrupted situation.

We viewed what we were doing as a high-risk, high-reward activity because we knew what severe claims management problems we had already had with these cases. We knew that the employees' odds of returning to work after two years on disability were only 1 or 2 percent. As each case came up, the roundtable chose one of three options:
• full commitment, where we would put the full weight of the company behind employees to help them successfully return to work
• provisional commitment, where we would give employees a chance to demonstrate their own commitment or give them enough rope to hang themselves, or do a trial of work to resolve a work-capacity question, or
• no commitment, where we would proceed with a strictly claims management solution, frequently meaning settlement or litigation.

At the end of the first year, we had 40 percent of the cases back to work and 75 percent of them with above-average performance reviews by their departments. Company management loved the roundtable because they had been so frustrated by their inability to resolve these cases. The multidisciplinary evaluation of the cases gave us a fuller picture of each case. And our commitment to decision-making on every case meant that the meetings really got something accomplished.

The roundtable also gave members new insight. For example, the foremen saw how inexperienced and incompetent supervisors had allowed poor performers to linger on until they were injured instead of being disciplined or fired. Top management saw how ill-conceived company practices and inadequately trained managers had alienated previously loyal employees after they were injured. Human resources personnel were confronted with their failure to provide options for good employees whose bodies had started to give out with age and heavy wear in the manual trades. And, as always in workers compensation, we were confronted with how hard it is to adequately document even obvious fraud.

Physicians Fail to Take Responsibility for Lost Time

At the Fall 1998 Workers' Compensation and Disability Management Conference, sponsored by Business Insurance, a panel of industry experts identified barriers to the success of disability-reduction programs. Prominent among the barriers mentioned were:
• no incentive for physicians to produce results
• resistant or unresponsive physicians
• limited physician knowledge about disability, functionality, or workplace conditions, and
• inability of telephonic case managers to change physician behavior.

The Influence of Group Health Managed Care

The growing dominance of group health managed care technology is making it less and less attractive for physicians to participate constructively in disability management. Because the managed care industry developed in order to meet buyers' demands for lower medical-care costs, physicians are encouraged to reduce medical costs, not the overall costs of illnesses and injuries, which would include disability benefits.

In addition, the method that health maintenance organizations use to select physicians and check their professional credentials has been adopted by many workers compensation managed care organizations, even though their goals are very different. The group health network selection criteria are medical credentials and a willingness to deliver lower medical costs. The credential-checking process usually consists of verifying that doctors are medically trained, licensed, and have not been sued too often. Most workers compensation networks simply look for physicians who are willing to treat occupational injuries and then check whether they have met group health credentialing standards. Although the American Medical Association reports on physician education and licenses and the National Practitioner Data Bank reports on malpractice and disciplinary claims, there is no equivalent independent source for reports on which doctors have received training in disability management.

Moreover, group health contractual relationships and economic incentives have induced many physicians to change the way they practice medicine. In an attempt to maintain income levels, most physicians have sped up their pace and shortened the time they spend with each patient — now commonly below 15 minutes. Paradoxically, the techniques which have been successful in reducing the overuse of health-care services now stand in opposition to successful disability management.

Not Judged According to Disability Outcomes

The physician survey discussed earlier implies that many lost workdays are potentially preventable, although not by strictly medical intervention. More accurate diagnoses and more effective treatments are not the solution to the 60 to 80 percent of lost-time claims that should have been medical-only claims. Physicians who fail to address quasimedical and non-medical factors that cause time off from work are creating and prolonging needless disability. In fact, disability neurosis — the conviction of incapacity without commensurate biological limitations — is frequently an iatrogenic disease. The word “iatrogenic” means caused by medical care. Other examples of iatrogenic disease include drug side effects, surgical mistakes, hospital-acquired infections, and so on. For the most part, physicians are unaware that the longer a worker is off from work, the more likely they are to be permanently disabled. They do not realize that by the time a worker has been off from work for 12 weeks, he or she has only a 50 percent chance of ever returning to work (see Figure 6).⁶

Physicians tend to judge progress according to events or the interval since the patient first sought treatment, not by total elapsed time. As long as physicians are not judged by whether their patients return to normal life activities, including work, this behavior will continue. Today, most insurance companies and employers do not expect help with disability management from treating physicians because they typically have never received any help from them before. Workers compensation companies typically focus their attention on first finding doctors to provide initial care after an injury and then finding others to answer the medical questions in disputed cases (the independent medical examiners). Disability insurers rely on information from those doctors that the patients have selected, although sometimes they look for an independent examiner to answer their questions.

“It's Not Part of My Job”

More fundamentally, most physicians do not think that helping patients return to work is part of their job. In fact, the subject of preventing and mitigating disability has really never been part of the scope of the medical profession. It is not generally taught in medical school or during residency training. In a recent survey of primary care physicians, less than 15 percent reported getting any training at all in managing disability.⁷

Most specialties consider the subject irrelevant to them and are uninterested. Most physicians are reluctant to venture outside their traditional medical comfort zone, which usually consists of making diagnoses and prescribing treatment. Even occupational health specialists may not actually be effective at preventing disability. These specialists are reasonably comfortable determining work capacity or fitness for duty and have developed considerable expertise in impairment and disability evaluations. However, these same specialists typically believe that their jobs end with the return-to-work slip. Very few of them are curious about how often a given worker actually gets back to work, stays there, and is successful. Most doctors view the practical sorting out, devising, implementation, and supervision of return-to-work plans as “not medical” and, therefore, not their job.

As a result, whatever disability management occurs in this country is being done by nurse case managers, claims adjusters, litigation support firms, vocational rehabilitation counselors, and other nonphysicians who have responded to the needs of employers, insurers, and lawyers. However, none of them has the authority under law, the professional credibility, or the emotional impact on the patient and the employer that a physician can have.

Patients Want Physicians to Take Responsibility

Patients often look to their physician for guidance on more than just technical matters; they want to know how to fit their particular injury or illness (and their recovery) into the context of their lives. Physicians have remarkable personal power to influence outcomes by building patient trust, naming the problem, recommending a course of treatment, forecasting the eventual outcome, and making practical suggestions about how to cope with the situation in the interim. With cardiac and low-back conditions, physicians have been shown to have a significant influence over patients' disability behaviors. Medications and surgery have both been shown to be more effective if the patient knows that the physician predicts that they will be effective. Recovery times are quicker when patients hear their physicians predict that they will be short. Patients are more likely to quit smoking and enter alcoholism treatment when their physician recommends it.

Human beings tend to use illness and injury as an excuse for avoiding things they do not want to do. One example is the small child who typically gets a stomachache when worried about school. A good parent spots the excuse and teaches the child to face the particular fear. Likewise, a good doctor helps patients make sense of their loss of physical capacity and fit it into the context of the whole their lives.

Physician Training

Training that changes physicians' view of their own role vis-a-vis the injured worker needs to be developed. This training should be designed and provided by physicians who have embraced the new role. It should be delivered in a professionally credible way and in a manner in keeping with traditional medical education.

Physicians need to be reminded that the fundamental purpose for which people seek care is really not accurate diagnosis and effective treatment but assistance in getting out of the “sick” or “injured” state and into the “normal” state. In the context of this broader view, anything the physician can do to help speed the transition back to the normal state becomes part of the healing process. Pushing unwilling patients back to work is the same as rousting them out of bed to walk after surgery or refusing to give in to their requests for unnecessary medicines or surgery. These are potentially life-saving maneuvers and a vital part of patient management.

Physicians need to start using the Grocery Store Test and asking the Obstacle Question as they care for patients in order to accurately diagnose why a patient is not at work. They also need to learn how to supply the information employers and insurers need in order to do their jobs. Of the seven core questions physicians are expected to answer in disability cases, they have been trained to answer only one, which is about necessary medical care (see Figure 7).

The Seven Questions for Doctors

1. Can you corroborate the employee's version of the situation?
2. Is absence from work medically required?
3. When can the worker return to work safely?
    (Is there any obstacle or issue that needs to be addressed?)
      Does the employee need special protection?
      Does the employee have limited capability?
      Does the employee need special accommodation?
4. What medical care is necessary?
5. Is the medical problem work related?
6. Has the case reached maximum medical improvement?
7. Is there any permanent impairment?

A Call for New Specialist Expertise

Two specialties — physiatry (also called physical medicine and rehabilitation) and occupational medicine — have the best potential to rapidly develop significant expertise in disability management. Occupational health can move beyond its traditional focus on work-related health problems and become the specialty concerned with job problems because of health as well as health problems because of work. Physiatry can build on its existing appreciation of vocational issues raised by medical conditions and develop more effective interventions for the non-medical causes of vocational disability.

Summary and Recommendations

Disability management has been a medical blind spot. However, a broad range of physicians are likely to accept the role of disability manager once the consequences of their neglect are brought to their attention — and once the work of disability management can be shown to be similar to other, more familiar medical models. Because the fundamental precept of medicine is “First, do no harm,” many physicians will see that they are accountable for preventing and mitigating the impact of injury or illness on patients' daily lives.

There has been too little listening and talking between employers and physicians on this topic. Employers need to tell physicians more clearly how much their assistance is needed. Physicians are also more likely to see how important the issue is to employers if employers band together. A request affecting dozens of cases from multiple claims payers is much louder than a request from any one employer or insurer. Physicians will be more willing to do things differently when their reputation for mastery and stream of income are at stake. But employers must also be willing to listen to physicians' needs and be willing to demonstrate the value of their participation in disability management with dollars.

In order for physicians to first recognize and then master their new role in disability management, they must be trained. Companies that have existing relationships with physicians — for example, large employers, insurers, and health-care provider networks — are in an excellent position to sponsor, encourage, or even require physicians to obtain training in disability management.

Physicians make better and more objective decisions about returning employees to work when the employer or insurer is a visible participant in the process. Physicians can play a more timely and useful role in a case when the information and resources needed to enable a successful return to work are accessible to them.

Employers who work with physician disability managers will get more cases handed back to them with the medical excuse for disability leave stripped away. However, employers will still need to develop more capability than they have today at healing their end of the situation — problems with the workplace environment and motivation.

Endnotes

1 National Council on Compensation Insurance, Inc., Annual Statistical Bulletin (1998).
2 The survey was a written instrument distributed among physician attendees at a conference sponsored by the American College of Occupational and Environmental Medicine in 1997. The survey was designed, administered, and analyzed by ManagedComp, a care management organization specializing in workers compensation. The organization handed out 250 surveys, and 98 physicians returned them. Of these, 90 said that they practiced occupational medicine and 57 were board-certified in the specialty. The respondents practiced in 43 U.S. states, the District of Columbia, Puerto Rico, Canada, and Australia.
3 National Council on Compensation Insurance, Inc., Annual Statistical Bulletin (1998).
4 Merrill, R.N., G. Pransky, et al., “Illness and the Workplace: A Study of Physicians and Employers,” The Journal of Family Practice 31 (1:1990): 55-59; G. Pransky, “Physician Disability Management Practice: Challenges and Opportunities” (in press).
5 Burgdorf, M.P., “The Importance of Quality Results in Workers' Comp Medical Care,” Managing Employee Health Benefits 4 (2: 1996): 54.
6 See note 5 above.
7 Pransky, G., “Physician Disability Management Practice: Challenges and Opportunities” (in press).

Reducing Disability Days: Healing More Than The Injury Jennifer Christian, M.D., M.P.H.