Preventing Needless Work Disability by Helping People Stay Employed

Introduction/Background Each year, millions of American workers develop health problems that may temporarily or permanently prevent them from reentering the workforce. In most cases, employees are able to stay at work or return to work after a brief recovery period. However, approximately 10% of these workers incur significant work absences and/or life disruptions that can lead to prolonged or permanent withdrawal from the workforce. During this nonworking period, these individuals are described as “disabled,” and many become involved in one or more of the existing disability benefit systems and laws, eg, sick leave, workers’ compensation, short-term disability, long-term disability, Social Security Disability Insurance, the Family Medical Leave Act, or the Americans with Disabilities Act (ADA). The estimated total annual cost of disability benefits paid under all these systems exceeds $100 billion. This report focuses on the large number of people who, due to a medical condition that should normally result in only a few days of work absence, end up withdrawing from work either permanently or for prolonged periods. For many of these workers, their conditions began as a common problem (eg, a sprain, strain, depression, or anxiety) but escalated, resulting in short-term, long-term, or permanent disability. This potentially preventable disability absence has unfortunate consequences for both the employer and the employee. The fundamental reason for most medically-related lost workdays and lost jobs is not medical necessity, but the nonmedical decision making involved in and the poor functioning of a little known but fundamental practice used by U.S. and Canadian disability benefits systems: the stay-at-work/return-to-work (SAW/RTW) process. This process determines whether a worker stays at work despite a medical condition or whether, when, and how a worker returns to work during or after recovery. The SAW/RTW process presently focuses on “managing” or “evaluating” a disability rather than preventing it. This report describes the SAW/RTW process, presents recommendations to improve the process, and provides information on current best practices and initiatives. What Is the Stay-at-Work/Return-to-Work Process? The usual steps included in the SAW/RTW process are as follows: The SAW/RTW process is triggered when a medical conditionD or another precipitating event occurs—in this example, a worker with a badly infected cut on his or her foot—raising the question whether the worker can or should do his or her usual job today. The worker’s current ability to work is assessed on three important dimensions: Functional capacity—what can he or she do today? Has the infection made him or her so sick he or she simply cannot function at all? If not, what can he or she do in his or her current condition? Functional impairments or limitations—what can the worker not do now that he or she normally could? The acute pain makes it uncomfortable to wear regular shoes and conduct activities that require being on one’s feet. Medically based restrictions—what he or she should not do lest specific medical harm occur? Would walking, standing, and being on his or her feet all day actually worsen the infection or delay healing? Next, the demands of the usual job and/or available temporary alternative tasks are compared with the worker’s current functional capacity, limitations, and medical restrictions. To make this comparison, the functional demands of the tasks or job must be known, including what knowledge, skills, and abilities—physical, cognitive, and social—are required. Specific medical qualification standards (such as those for airline pilots), legal requirements (such as those for truck drivers and crane operators), company policies, or concerns about the safety of coworkers, the public, or the business may also apply. Finally, the actions necessary to resolve the situation and return the worker to work are identified. If the worker can be safe and comfortable doing his or her usual job or can independently make any necessary modifications, he or she should be able to return to work. If the worker is only able to do temporary alternative work that requires the cooperation of others, or if permanent modifications to the job must be made, the employer must make arrangements and implement them. If that happens, the worker can go to work. If not, the worker remains out of work until either the medical condition resolves or the situation changes. If the job does not demand too much use of the impaired body part or function, the medical condition is minor, and the worker wants to go to work, the preceding steps are accomplished rapidly. However, some situations do not resolve as quickly and require additional steps. At this stage, the SAW/RTW process evolves into a negotiation between the employee (and his or her advisors) and the employer (and its advisors) regarding whether the employee can return to work. Therefore, steps 2 through 4 may need to be repeated at each level. During each repetition, more participants tend to become involved and the situation can escalate with progressively more opinions, data, resources, and time being required to decide when and if the employee can return to work. For example, in more difficult situations, successive passes require additional assistance from more specialists such as a nurse case manager, physical therapist, an occupational medicine physician, an independent medical examiner, a lawyer, and/or other experts. Functional capacity evaluations may be required to document work capacity. Job analyses may need to be done to document the job demands. The additional effort and resources often produce a paradoxic effect of clouding the situation rather than clarifying it by obscuring basic issues, causing confusion, hardening positions, and polarizing participants. Table 1 displays the escalation levels of the SAW/RTW process moving from simplest to most complex. The process ends when a definitive answer is reached—the worker will or will not return to work. However, the three basic questions requiring factual answers always remain the same:TABLE 1: The Stay-at-Work/Return-to-Work Process Escalation Levels What are the worker’s current work capacity, medical restrictions, and functional limitations? What are the functional demands of the intended job? If the worker’s functional capacity matches the functional demands, what is required to affect an actual return to work? Medical conditions vary considerably as do their impact on work. Table 2 provides examples of the circumstances under which the SAW/RTW process takes place.TABLE 2: Examples of the Variability of Medical Conditions and Their Impact on WorkThe SAW/RTW process does not occur in isolation. Although it has been overlooked because of the incorrect assumption that if the medical condition is promptly and properly treated, the worker will naturally return to work, the process occurs in parallel or is influenced by four other well-known processes (Table 3):TABLE 3: Five Parallel Processes Triggered by a Health Event That Affects Ability to Function Personal adjustment process deals with the disruption resulting from the illness or injury. If the medical situation calls for treatment, the SAW/RTW process occurs in parallel with the medical care process comprising diagnosis and treatment. If the initial SAW/RTW process results in the worker staying home and if coverage under one or more disability benefit programs is possible, the disability benefits administration process begins operating in parallel with SAW/RTW. If permanent or long-term alteration of work capacity occurs, the ADA “reasonable accommodation” process might be triggered. It operates in parallel with SAW/RTW. If ADA applies, it will heavily influence what occurs in SAW/RTW. The outcomes produced by the SAW/RTW process profoundly impact the overall health and well-being of patients, their families, employers, and communities by determining whether people stay engaged in or withdraw from work and all the consequences that derive from that decision. However, the SAW/RTW process has been hidden by complex technical, financial, and legal details of multiple disability benefit programs. This little studied and underresourced process has enormous personal and economic consequences for millions of people and deserves attention. Observations and Recommendations The following portion of this report, grouped under four general recommendations, discusses 16 specific areas in which the SAW/RTW process can be improved: Adopt a disability prevention model; Address behavioral and circumstantial realities that create and prolong work disability; Acknowledge the contribution of motivation on outcomes and make changes to improve incentive alignment; and Invest in system and infrastructure improvements. For each of the 16 parts, specific recommendations for achieving optimal outcomes are described and ways to implement these recommendations suggested. When possible, concrete examples are provided of existing improvement initiatives or of programs that achieve better than average results by using best practices. Adopt a Disability Prevention Model Increase Awareness of How Rarely Disability is Medically Required Only a small fraction of medically excused days off work is medically required, meaning work of any kind is medically contraindicated. The remaining days off work result from a variety of nonmedical factors such as administrative delays of treatment and specialty referral, lack of transitional work, ineffective communications, lax management, and logistic problems. These days off are based on nonmedical decisions and are either discretionary or clearly unnecessary. Participants in the disability benefits system seem largely unaware that so much disability is not medically required. Absence from work is “excused” and benefits are generally awarded based on a physician’s decision confirming that a medical condition exists. This implies that a diagnosis creates disability. However, from a strictly medical point of view, people can generally work at something productive as soon as there is no specific medical condition to keep them from working (see Table 4). The key question is, “What kind of work?” Many obstacles that appear to be medical are really situation-specific. For example, an employee with a cast on the right foot cannot drive a forklift but can perform other tasks until the cast is removed. A person recovering from surgery may not be able to work a full day in the office but could work half days. In fact, people often sit home collecting benefits because their employers do not take advantage of their available work capacity. Today, these decisions generally are misclassified as “medical” and, as such, are not examined.TABLE 4: When is a Disability Medically Required, Medically Discretionary, or Medically Unnecessary?Recommendation. Stop assuming that absence from work is medically required and that only correct medical diagnosis and treatment can reduce disability. Pay attention to the nonmedical causes that underlie discretionary and unnecessary disability. Reduce discretionary disability by increasing the likelihood that employers will provide on-the-job recovery. Reduce unnecessary disability by removing administrative delays and bureaucratic obstacles, strengthening flabby management, and by following other recommendations in this report. Instruct all participants about the nature and extent of preventable disability. Educate employers about their powerful role in determining SAW/RTW results. Current Initiatives/Best Practices. Clinicians, employers, and insurers can now use the following criteria (see Table 4) to determine whether a disability is medically required, discretionary, or unnecessary. If all parties use these definitions, clearer communication and better decision-making will result. In particular, physicians will no longer have to make employment decisions, and employers will stop misclassifying business decisions as medical decisions. Urgency is Required Because Prolonged Time Away From Work is Harmful Unnecessary prolonged work absence work can cause needless but significant harm to a person’s well-being. While on extended disability, many patients lose social relationships with coworkers, self-respect that comes from earning a living, and their major identity component— what they do for a living. Many key players in the SAW/RTW process do not fully realize the potential harm that prolonged medically excused time away from work can cause. Many think that being away from work reduces stress or allows healing and do not consider that the worker’s daily life has been disrupted. With these attitudes, system-induced disability becomes a significant risk. An article by Harris in the Journal of the American Medical Association reconfirmed that workers receiving disability benefits recover less quickly and have poorer clinical outcomes than those with the same medical conditions who do not receive disability benefits. The researchers reported that 175 of the 211 studies meeting their inclusion criteria reported worse surgical outcomes for patients on workers’ compensation or involved in litigation. (Only one study reported better outcomes in compensated patients; 35 studies reported no difference.) Of the 86 studies that excluded patients in litigation, the odds of an unsatisfactory outcome were nearly four times higher for the patients on workers’ compensation than for those not receiving compensation. These findings are similar to those of other studies, including two previous meta-analyses of outcomes studies, one for workers with chronic pain and the other for closed head injuries. Early intervention is the key to preventing disability. Research confirms that people who never lose time from work have better outcomes than people who lose some time from work. Studies have shown that the odds for return to full employment drop to 50/50 after 6 months of absence. Even less encouraging is the finding that the odds of a worker ever returning to work drop 50% by just the 12th week. The current practice of focusing disability management effort on those who are already out of work rarely succeeds. Recommendation. Shift the focus from “managing” disability to “preventing” it and shorten the response time. Revamp disability benefits systems to reflect the reality that resolving disability episodes is an urgent matter given the short window of opportunity to renormalize life. Emphasize preventing or immediately ending unnecessary time away from work, thus preventing development of the disabled mindset, and disseminate an educational campaign supporting this position. Whenever possible, incorporate mechanisms into the SAW/RTW process that prevent or minimize withdrawal from work. On the individual level, the healthcare team should keep patients’ lives as normal as possible during illness and recovery while establishing treatments that allow for the fastest possible return to function and resumption of the fullest possible participation in life. Current Initiatives/Best Practices. Many employers and some insurers now begin return-to-work efforts on the first day of absence or within 72 hours of being notified of a claim. One large workers’ compensation insurer established a group of “preinjury consultants” to help employers prepare to respond from the moment of injury to avert needless lost workdays. Attempts are also underway to detect workers with preexisting risk factors for prolonged disability to manage them more intensively from the onset. Colledge et al developed a Disability Apgar test, which evaluates a situation and assigns a risk score. The State Fund of California recently completed a pilot program that assesses risk factors at claim intake and makes suggestions for claim management. A workers’ compensation insurer in Australia uses an evidence-based assessment questionnaire at claim intake and again at specific intervals to speed detection (and intervention) on claims showing signs of delayed recovery. Address Behavioral and Circumstantial Realities That Create and Prolong Work Disability Acknowledging and Dealing With Normal Human Reactions Injuries and illnesses disrupt lives. Even a minor injury may seem like a major occurrence because it is different. People may fear getting into trouble, the need for surgery, or that the injury may end their career. Frequently, they also must learn to deal with unfamiliar workers’ compensation and/or disability benefits systems and rules. Employers and insurers often neglect to inform injured or ill employees know about how their disability benefit programs work, what to expect, and how to make the process work smoothly. Physicians often fail to tell their patients much about their condition and what they can do to achieve the best possible result. Many injured or ill workers experience stress because coping with these uncertainties can be difficult. The amount of stress a specific individual experiences in a specific situation will vary widely based on factors such as the magnitude of the medical problem, the personal and family situation at the time, and the job situation. According to medical anthropologists, patients take on the “sick role” and the “dependent patient role” after becoming ill or injured. To recover, they must relinquish these roles. The sick role exempts people from their normal responsibilities while giving them the right to receive care from others and be free of fault. Those who have trouble coping with their circumstances are likely to resist relinquishing those roles, using them instead to feel good about themselves and ensure their future security. The ability to function and deal with life’s problems varies from individual to individual. When people are under stress, they function less well and are more susceptible to illness or injury. If the demands of a situation exceed an individual’s ability to cope and no assistance is provided, the personal adjustment process will stall and recovery and return to work will be delayed. Experience shows that the current processes do not acknowledge these emotional realities. Workers are typically left alone to cope regardless of their situation and their coping effort has been to and other of up in stress that they cannot alone are not identified. Even when SAW/RTW process participants emotional assistance is not Because benefit programs do not medical treatment for that will help disability patients recover and return to work is not In workers’ compensation, claims are to acknowledge these and health that doing so will lead to claim for a illness and claim However, most of these sick or injured people do not need need the minor and that a family social or employee assistance program can physicians could much and stress by clearly out the functional of medical and of treatment, thus people to cope on their Recommendation. all participants to their SAW/RTW to of the normal emotional that temporary disability to prevent it becoming to to provide these or for them. Current Initiatives/Best Practices. U.S. employers are between their disability benefit programs compensation, and long-term their employee assistance and/or their management programs to that employees know they can into existing A makes after a injury occurs, that injured workers feel for and their questions are and Address Social and Realities Research shows that an individual’s social to the the occurrence of injury and illness as well as the outcome of the SAW/RTW process. the worker like his or her job? How much and decision does the employee have at work? the worker with his These of factors can a major role in a person’s to return to work, when with the emotional adjustment Job has been shown to be one of the of disability. may also problems for the worker the SAW/RTW process. The worker may be to resolve such problems by disability benefits. Although many players in the SAW/RTW process acknowledge the of these little has been done to them. Employers and workers often use the disability benefit system to difficult that are to them but not to these parties a significant effort to the to the are When key parties to the SAW/RTW process do not know what is actually because they lack any effort on SAW/RTW may be or and a of resources and time. Recommendation. The SAW/RTW process should into and of and social better communication between SAW/RTW develop and disseminate that and social for and conduct pilot programs to the of Current Initiatives/Best Practices. An program that is now being used by employers and in a between the employee and the Each focuses on part of job can do other parties become resources and for the two key participants as they work to resolve the situation. in both employee and with the these situations are and the total of the SAW/RTW process are this benefits. a to Address Conditions When a person with illness a potentially physical illness or the risk of permanent disability the problem is A significant becomes during a of medical illness in more than 50% of cases, those with a of a major Many more workers also are to their first of or when sick or injured. In these cases, the physical illness or injury the health treatment is required for these because the condition his or her to the to medical treatment, the of its impact on function, and functional recovery from the physical factors can to permanent disability treatment is and However, the current SAW/RTW process often or does not detect or The of physicians to make a diagnosis comes from lack of and often do not these Even when a diagnosis is made, treatment is often or benefits coverage and of health often that treatment is Although all healthcare the need to and role functioning in personal they often the of role functioning at work. with a patient who describes stress due to at work, work is often as the in diagnosis and treatment have during the Although some employers know that treatments are potentially they also have on that many health do not focus on functional recovery but with treatments that no have not and on to current treatment with other chronic may require treatment of episodes as well as long-term, treatment to prevent Recommendation. Adopt to acknowledge and SAW/RTW participants about the of and physical problems and better prepare them to deal with these perform of people with and make for treatment on treatments of Current Initiatives/Best Practices. The State of and an program that provides to injured The all workers’ compensation claims and all benefits for the The with the medical to for up to days of treatment an to a physical injury if the initial treatment and report a between the diagnosis and specific to working is as is a between the treatment and of those as is for up to days. Reduce of the Medical Process by In disability cases, the medical treatment process is often by nonmedical factors with patients often or treatments to or benefits. also occurs when employers or benefits claims physicians questions and that becomes the for or employment One cause is the complex and of for and benefit in the disability benefit programs. With of disability benefit few physicians can determine the impact their actions may have on a given benefit or hidden may Physicians are uncomfortable when they patients, employers, or of making based on hidden often practice in such situations, they will not be paid for time Recommendation. ways and best practices for with these Instruct on how to respond when they hidden Educate about that could the process. to ensure of medical should not keep the it and in the about the actual factors at work. participation by physicians may be For example, an occupational medicine to brief the When possible, reduce the between benefit programs that create to Employers are in a better to do this than other Current Initiatives/Best Practices. Many employers their benefit programs to determine whether they create for employees to in a For example, some employers have up paid time off in of sick to and the of employee absence. have their short-term disability program benefits to more the workers’ compensation benefit and An increasing number of employers are their workers’ compensation return-to-work programs to conditions as Acknowledge the of on and to Pay Physicians for Disability Prevention Work to Increase Their Physicians receive compensation for their time and effort in the disability prevention and management of the SAW/RTW process. a they may those they have no In more complex situations that could benefit from the or the by lack of often the from quickly or making the often SAW/RTW. Because most physicians do not consider disability prevention their their does not a to out their Although employers and insurers may

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