Monthly Archives: October 2015

October 30, 2015

Turning private tragedies into a public concern: job loss after injury or illness

Do you realize that NO professional feels responsible when a working person loses his or her job because of a health problem — neither the doctor, nor the employer, nor the person handling the claim for healthcare, disability, or workers’ compensation benefits?  At most, the professionals may say “that’s a shame” assuming they are even aware it’s happened.  Job loss is often invisible; the person just drops off the radar.  The government insists that employers track workplace injuries and illnesses, hospitalizations and fatalities — but no-one is tracking job loss.  Among the public purposes of the Americans with Disabilities Act is promoting employment of people with disabilities.  The millions of workers now silently disappearing from the workforce due to newly-acquired disabilities deserve more visibility — and more help.

An estimated 2.5 million people leave the workforce each year for health reasons, most frequently due to things like low back pain and other common musculoskeletal conditions, as well as the most common mood disorders of depression and anxiety.  And none of the professionals who are called on to respond when those individuals start having difficulty are being held accountable for making an active effort to help them keep their jobs. Obviously, some people really can’t continue to work (for example those who have a terminal illness or have suffered an incapacitating injury).  But some of those lost jobs COULD have been averted if any of those three professionals had devoted more of their skill and discretionary effort to finding a better solution.

In my opinion, this hole in our social fabric through which people with newly-acquired disabilities are falling has been invisible until now — and is unacceptable.

To put this in perspective, as Western societies have evolved over the centuries, other kinds of private tragedies have become public concerns.   Do you realize that until roughly the 19th century, no one felt responsible when a pregnant woman died in childbirth, or her newborn infant did — which was very common?  “That’s a shame,” people said.  It was each family’s private tragedy.   Today,  several professions, many hospitals, and whole departments within public health agencies in every single state focus on keeping pregnant women healthy, providing prenatal care, assuring a safe childbirth, and proper care of newborns.  Maternal and infant mortality rates are now considered basic indicators of the health of a country’s entire population  — and the adequacy of its public health / health care systems.  In the developed countries, maternal and infant deaths are 50 to a 100 times lower than the rates in still-developing countries.  Here is data from the CIA’s World Factbook.

Pic of Mat Infant Mortality rates 2015-10-30

Wouldn’t it be interesting to see a comparable table showing job loss rates for the countries?  What do you think it would show?   I bet the developing countries are doing less well by comparison — because their social safety nets tend to be weaker.  And I doubt workers that in the US are a 100-fold better off.   I’ve heard that European countries make it much harder to “throw away” unwanted workers.  It is not only important for workers and their families to stay employed.  Every time a worker loses his or her footing in the world of work, our society takes a DOUBLE hit:  we lose an economic contributor AND at the same time we gain another person dependent on taxpayer funded benefits.

I’ve been part of a two-year effort to start thinking seriously about ways to reduce job loss due to illness and injury among U.S. workers while serving as a member of the US Department of Labor’s Stay-at-Work/Return-to-Work (SAW/RTW) Policy Collaborative. This year three of us (economists (David Stapleton,  Kevin Hollenbeck, and I) were asked to develop policy papers, each on a specific aspect of the issue.

My task was to think about how to establish accountability for job loss among the professionals who have the best opportunity to influence the outcome.  I felt so LUCKY to be PAID to take the time to explore this topic in depth — it was really fun to put my “thinkatorium” into high gear.  Stimulating conversations with more than 30 experts in various fields and sectors of society helped shape my thinking (thank you all — their names are listed in the report).  The final product is three main recommendations and a set of specific suggestions for action — how to accomplish the recommendations.  I hope you will read my paper to see where this line of inquiry leads you.  I bet you will be surprised — because I was.

On October 22, the U.S. Department of Labor’s Office of Disability Employment Policy (ODEP) and Mathematica’s Center for Studying Disability Policy (CSDP) hosted a policy forum to introduce the three policy papers and all of their recommendations. You can view the 90 minute video of the event here.  It includes some very good questions from the audience and subsequent dialogue. All three policy papers are available on Mathematica’s website.

Please consider joining me in transforming these 2.4 million hidden and all-too-private tragedies per year into a public challenge for change.

And before you go — did you notice that the data I cited on maternal and child death rates came from the US Central Intelligence Agency’s INFORMATION WEBSITE???  Who knew?  I just stumbled on it.

Photo announcing policy rec - video of event 2015-10-29

Leave a reply

October 26, 2015

Medical “red herrings” lead to over-treatment & leave patients suffering

When I give a presentation, my goal is to give a gift to the listeners — some new information, perspective, or insight they might not have had before.  I spend time beforehand, imagining how they see the topic now, what they might be thinking, and how I should structure my talk to take them from “here” to “there.”

It’s very gratifying when they send signals that they “got it.”   The funnest [sic] part about public speaking is seeing people’s eyes light up or heads nod as I speak, or having them come up all excited to talk to me afterwards, or when they send an email — or when they write about what they heard.  It’s particularly graifying when the article a reporter writes matches up with what I hoped they would notice.  All those things were true last week when Keith Rosenblum (a senior risk consultant from Lockton), Dr. David Ross (a neurologist and developer of the NP3 diagnostic testing method) and I gave a presentation at the SIIA (Self-Insurance Institute of America) conference last week.  Our audience was a small group of professionals who work for companies (employers) that are self-insured for workers’ compensation.  Our topic was “How Medical Red Herrings Drive Poor Outcomes and Big Losses— and What You Can Do to Stop Them” .

And in particular, here’s a shout-out to reporter Robert Teachout (wow, a rhyme!) for really GETTING what we were trying to get across in our session.   Robert’s article appeared last Friday in HR Compliance Expert.

Dr. Ross taught the audience about the latest definition from pain experts on the essential nature of pain:  it is an EXPERIENCE put together by the brain after it analyzes and interprets many things.  Pain is NOT a sensation in the body.  He also described why and how “objective findings” on MRI often lead doctors to over-diagnose structural spine problems and provide over-aggressive treatments — because the actual source of the pain lies in soft tissues or the brain itself.

My job in the session was to point out this obvious but often overlooked fact:  doing surgery on the wrong problem is not going to make the patient’s pain and distress go away.  And I introduced the audience to the idea that there are other very common causes of prolonged back pain, distress and disability (summarized as biopsychosocioeconomic (BPSE – bipsee) factors) that may mimic or worsen noxious sensations coming from the spine.  Screening for and dealing with easy-to-treat BPSE factors BEFORE resorting to aggressive testing and treatment makes more sense than waiting until AFTER you’ve subjected the patient to those potentially harmful things.  That’s because MRIs, opioids, injections, and surgeries increase the patient’s certainty that their problem is in their spine while at the same time failing to relieve their pain AND causing side-effects and additional problems.    Keith recommended that employers / claim organizations start screening for the presence of a variety of BPSE factors — and get them addressed — BEFORE aggressive, potentially destructive and definitely expensive treatment even begins.  Screening methods can include simple things like questionnaires, or fancy things like the NP3 testing methods.

In addition, even when surgery IS needed, it makes sense to screen for complicating BPSE issues and address them BEFORE surgery as well as during recuperation — because having clear indications for surgery and being a good surgical candidate doesn’t mean a person is free of the kind of BPSE issues that reduce the likelihood of a good recovery.

I sent Robert, the reporter, a compliment via email that read:  “Robert, you did a remarkable job of capturing the salient facts, important implications, and key take home messages from our session.”  I hope you will read his article — and that you’ll send him a note if you found it informative or helpful

Leave a reply

October 22, 2015

Star rankings for doctors who deliver better outcomes in workers’ comp

I was in the audience for a presentation on “outcomes based networks” in workers’ compensation while at the SIIA conference this week (Self-Insurance Institute of America) in Washington DC.   The two presenters were from Sedgwick (which I believe is now by far the largest workers’ comp claims administrator [claims payer] in the country — servicing mostly self-insured employers) and from Multi-Plan (a huge PPO).

The bottom line is that Sedgwick is now putting INDIVIDUAL treating physicians into ranks, from 5 stars (most preferred) all the way down to 1 star (least preferred) .  HOWEVER, many physicians cannot be ranked because the “n” (number of cases for which the payers have data) is too small to analyze with any statistical confidence at all.  The star ratings are NOT generally shared with the physicians — but I bet doctors who know the rankings exist can ask pointed questions about where they stand.

The two speakers have been deeply involved in developing the data sets and metrics to assess physician performance.  They have also been responsible for packaging that information so people who need to know where to send patients can quickly find the best available nearby doctors.  (I am an informed listener on this topic, having developed a physician “report card” myself with less sophisticated data tools in the late 1990’s.)

The presentations were fascinating, both because of what the speakers DID say, as well as what they DIDN’T say.  The four most important things they DID say (if I heard correctly) were that:
•    Sedgwick’s clients, claims adjusters, and case managers who are making referrals / recommending physicians to care for work-related injuries now have access to a user-friendly website that automatically lists doctors within certain geographies IN ORDER OF STAR RANKING (though the ranking itself is not displayed).  Reality check:  Some locations simply don’t HAVE any super-top-ranked providers.
•    Employers who are able to get most or all of their employees to 4 or 5 star doctors have DRAMATICALLY BETTER RESULTS in terms of medical/functional outcomes, disability duration and cost, including higher patient satisfaction/lower litigation rates.   These employers are seeing roughly 15-20% improvement in the parameters of interest.  I heard later that these are mostly California results.
•    The highly ranked doctors are happy to get the referrals and have NOT been asking to be compensated better when it has been confirmed that they are the best.  The highly ranked doctors also tend to be the ones who do a lot of work comp — so they are attuned to the critical issues that need to be managed.  Personally, I think those who DO deliver the best results SHOULD thrive and prosper as a result — not just get more patient volume.  MANY doctors already feel maxed out!
•    A nice endorsement for occupational medicine specialists in general.  The speakers consider “occ docs” as “primary treating” providers (along with urgent care, internists and family practitioners) rather than as specialists (e.g. orthopedists, pain management).  In general, occ docs rank high.  The speakers said it was because of our specialty’s philosophy of care that puts high priority on employing evidence-based techniques for medical treatment and preventing needless work disability in order to optimize patient outcomes and control total episode costs. They said it’s not a sure shot — there are SOME duds in our specialty — but both speakers agreed that as a rule, occ med physicians are among the best.  (They only mentioned occ med because I specifically asked the question –and that was because I suspected what the answer would be –and wanted the audience to hear it!)

The three most important things I DIDN’T hear the speakers say were:
•    How OFTEN the employers/adjusters/case managers are ACTUALLY choosing docs based on rankings.
•    What FRACTION of all doctors in any given geography they actually are ABLE to rank.  (In other words, how many cases have Sedgwick’s employer clients actually been SENDING to each doctor.).  I wouldn’t be at all surprised if it’s less than 25% of the doctors.  I suspect the unranked doctors’ names are NOT presented first.
•    How many cases the doctor has to have treated before ranking them makes sense or is fair. Very few payers are going to have the volume of information available that Sedgwick and Multi-Plan do.  Buyer beware:  TPAs and networks that want to keep up with the Joneses may CLAIM to have ranked providers — but it takes a large number of cases AND considerable statistical sophistication to do this ranking stuff accurately and fairly.   One catastrophic injury could make even a great physician look bad without appropriate adjustment.   The speakers both acknowledged that getting accurate data and analyzing it in a fair manner has been a big challenge, and that their capabilities for doing so have improved rapidly over the last 5 years.

This IS the wave of the future.  Physicians who discover they are low ranked should find out why — and do their level best not to be defensive, but rather learn and improve from the experience.  Buyers of /payers for services absolutely do have the right — if not the duty — to select suppliers based on the best information at hand about who will meet their legitimate needs.   And physicians are suppliers in their eyes.

Sedgwick got started building their Outcomes Based Networks after participating in a Cornerstone Conversation co-hosted by the American College of Occupational & Environmental Medicine (ACOEM) and the International Association of Industrial Accident Boards & Commissions (IAIABC).  This was a four-way conversation among a small group of key stakeholders:  ACOEM leaders, large payers, large employers, and state regulators on what needs to happen in order to improve access to high quality healthcare and improve outcomes for injured workers, and to reduce unnecessary costs for employers and payers.  A joint project undertaken by ACOEM and IAIABC as a result of that meeting was the production of a Guide to High Value Physician Services in Workers’ Compensation.  You may find the observations and suggestions made in this succinct document helpful — whether you are a chooser, a recommender, a payer or a physician-supplier of medical care services.

Leave a reply

October 19, 2015

WHY would I want to live to 101?

I am a bit upset and depressed because I just learned my life expectancy is 101 — according to the electronic calculator that analyzed my answers on the Health Age Questionnaire.  I found it on the website of the American College of Lifestyle Medicine.  It seems like a good organization aimed mostly at doctors who prevent chronic disease by prescribing and teaching healthy lifestyles.  However, they had better come up with a better argument for lifestyle change than this:   “Wow, if you do everything we recommend, you get to live until you’re entirely useless, helpless, and bored out of your mind.”

After I got the 101 prediction, I redid the questionnaire, this time shading several answers to the “sad” side instead of the “happy” side — and the darned thing STILL says I’m going to live to 94.  Phooey!  Who the heck WANTS to live that long?  NOT ME!   I can clearly imagine my quality of life is likely to be by then. By the time Americans get over the age of 90-something, the VAST majority are demented, frail, and unable to live independently — and I might add have become totally irrelevant in the eyes of the rest of American society, with a status more similar to pets or babies than adults.

That was my dad’s fate.   He died just a few days before he turned 89 — after refusing medical care for a heart attack because he had been WAITING for a way to die.  Before that day, his medical problems were basically age-related degeneration.

A Harvard College, Harvard Medical School grad, former Director of one of the National Institutes of Health, my dad re-invented himself and his career at least three times.   Originally trained as a pediatrician, he spent most of his career focused on child and maternal health, family planning, and other services to facilitate optimal development and health of the population.  At about age 50, he left the pressure of Washington DC, gave up on a difficult marriage to my mother, and moved to the Eastern Shore of Maryland.  He became a county health officer, developed a wide circle of friends and got involved in community affairs.  He was always a kind, optimistic, creative, and positive person, even though he didn’t have much of a sense of humor.  But his fun-loving second wife put him up to a lot of innocent mischief.  We have a photo of him in Florida wearing a lei on his head, a bra made of coconut shells and a hula skirt — and a HUGE SMILE (while stone sober, I may add).

Around about age 80 he “retired” from medicine.  And then, with some partners, he started a Sylvan Learning Center franchise and founded the Delmarva Education Foundation.  He was still in there pitching, though clearly slowing down.

Shirley, his beloved second wife died in May of 2006, the year he turned 84.   A few days after that, he commented to me “I’ll never be the center of anyone’s life ever again.” His zest for life was gone because she was.  She had cherished him and nurtured him — and vice versa.  He was lonely, sad after that, and grew increasingly bitter.  He had zero interest in finding a new companion or keeping up his social life. Treatment for “depression” had no effect.  My sister who lived nearby did yeoman work to be family and provide companionship to him — and do the practical work required to keep him in the housing complex for independent elders where he lives.   By the time she gave up and moved him to assisted living, there were FOUR part-time workers supporting him — plus her.  However, Daddy was right, of course — he never was the center of anyone’s life again.

He had already given me his healthcare power of attorney.  We had explicitly discussed his wish that I protect him from “the medical juggernaut” in case he was unable to do it himself.  He also did done some exploring of ways to exit gracefully.  I sent him an article from the New England Journal about what dying is like for patients with terminal conditions who refuse food and drink as they near the end of life.  But when my dad in Maryland discussed this with his psychologist, the psychologist pronounced the method both a sin and against the law — so Daddy resigned himself to sticking around.   In February of 2008, almost two years after Shirley’s death, Daddy (who could no longer write because of a worsening tremor) dictated this to his psychologist:

Because of my many disabilities – vision, hearing, etc. – I am happy to take advantage of the first opportunity that the Lord provides to join my wife Shirley in heaven.  My daughter Jennifer holds the medical power of attorney for me.  As a physician, she has the knowledge to determine what conditions are most likely to result in death, or result in disability that I would have to live with.  In the former case, I would like medical care withheld if my condition would ordinarily result in death, and would like for hospice to provide palliative care.  In the latter case, I will just ‘grin and bear it’.   I have made peace with the Lord in this decision, and ask that all my children support the decision that I have made.

As he neared 90, the burdens of age had became even heavier.  He still had no “terminal” conditions other than age.  He was deaf, could no longer read or see the computer screen due to macular degeneration, had a tremor, chronic pain due to joint degeneration, and was very weak.   He had lost all of his curiosity and most of his mental power.  At one point, he was on 14 different medications,  most of them with no discernible effect.  I asked his doctors to stop as many as possible because nothing could reverse the progress of aging.

In the end, Daddy handled his exit firmly and gracefully, by himself, when he developed severe chest pain.  He obviously recognized it for what it was — a potential way out.   He told the ER doctor:  “I’m just here to check and make sure it IS a heart attack.  If so, all I want is morphine, no treatment.”   The ER doctor, luckily, had her wits about her and suggested hospice.  He immediately said yes.  He lived less than a month — long enough to have one last Christmas Dinner with his kids and grandkids.  Then he let go and left this earth.

More than twenty years earlier, Daddy and I had completed a multi-scenario medical decision-making worksheet.  It was designed to make us think about and decide what we wanted our caregivers to do in various medical scenarios if we became unable to express our wishes. Surprisingly, that conversation wasn’t a downer at all.  In fact it was the best conversation I think I EVER had with him because we talked frankly and intimately about what made life worth living for each of us personally — and when it wouldn’t be worth continuing.   At the time, he said he wanted to be kept alive until he couldn’t enjoy the day anymore.   Yet as things turned out, he was forced to live four years after he had stopped being able to enjoy the day.  .

We humans have invented ways that are KEEPING people alive longer, but we haven’t yet invented ways to safely and humanely allow those who HAVE BEEN kept alive past the time when they find quality of life tolerable to say they have “had enough, thank you” and move on to the next realm.

I don’t want to share my Dad’s fate.  The idea of being sidelined, trying to think up “ways to pass the time” because I’ve become too deaf and blind to read or interact with others or do anything useful, beset with the chronic aches and pains of aging bones and joints makes me feel YUCK, or more accurately, DREAD.

Even if I were a “hale and hearty” 90 year old, I can’t think of a PURPOSE that I personally would find exciting enough to make life worth living when I’ve been alive that long.  “Smelling the roses” doesn’t do it for me — because I am already starting to feel like I’ve had my fill of a lot of things.  Been there, done that.  Been THERE and done THAT, too.

For the foreseeable future, my current purpose for living are these:
1)  Devote my energy and talents to leaving the campground of life better than I found it.
2)  Enjoy everyday life with my husband, family, and friends — and the outdoor world.
3)  Seek beauty and truth, especially in music, opera, theatre, dance, the visual arts, and spiritual practice.
4)  Grow in wisdom and kindness.  A VERY COOL thing is that personal growth & development in these two areas are available to all ages, including the very old (ahem, until dementia sets in).

What does this mean for you — if anything?   Maybe you could think about what makes life worth living for you.  It will make you feel STRONG and GOOD to do it.    Fill out a Five Wishes living will from Aging with Dignity that gives your caregivers instructions for how to care for you in case you can’t tell them yourself at a critical moment.   And, do think about what you want the quality of your life to be like and how long you DO want to live.   Do YOU really WANT to live to 101 or to 120?  Why?  What FOR?

1 Reply

October 14, 2015

Let’s stop using words with a “nocebo” effect!

I hereby nominate the first three candidates — the terms “I can’t”,”injured worker,” and “injury”– for elimination from the lexicon of workers’ compensation because they are causing harm.  After having talked with Kristina Phillips again about her trouble with her workers’ compensation claim, I see the negative impact those three terms have had on her life.

Kristina’s had a very rocky course with initial denials of coverage for some parts of her injury, long delays of authorizations for specialty as well as rehabilitation care, unhelpful advice from the state’s ombudsmen, an unresponsive attorney, multiple court hearings, etc — all while she has been living with ongoing pain and limitation of motion.  She’s better, but not ALL better yet — and it’s been 18 months since she was attacked on the subway.

As we talked, she remarked that she finally woke up and realized that in order to get better she HAD to stop using the phrase “I can’t” and replace it “HOW CAN I do this?”   Every time she said “I can’t”, her world got smaller.   She was becoming a hermit.  She had stopped leaving the house whenever it rained or during commuting hours because she was avoiding the New York subway system.  Because they are so crowded, Kristina was concerned about being jostled which causes her pain.   She was unwilling to explain her situation to strangers and ask them not to lean into her or push her, much less ask them to move their stuff so she could sit down.  Shortly after she swore off “I can’t”, she realized she also had to start asking for help.  Once she became comfortable with telling people she has a problem, it has been gratifying to see how kindly most of them respond. The new approach has allowed her to expand the times when she can use the subways — which means she is out and about more frequently now.

That got me to thinking.  I had heard Kristina mention her “injury” several times. She kept talking about it as though her wounds are still present, despite the fact that her injury occurred 18 months ago.  In fact, those injured tissues have probably been healed for more than a year.   What she’s actually dealing with are the consequences of the injury, not the injury itself.

Calling oneself “injured” is similar to calling oneself “sick” — in a vulnerable state with life disrupted, out of commission, off on a sideline away from the regular rhythm of life.  Someone who describes themselves as “recovering” or “dealing with the aftermath” may be struggling, but it’s because they are wending their way back into the mainstream of life.

I suddenly realized that the WORD “injury” has probably been intensifying Kristina’s distress and symptoms, and delaying resolution of this episode in her life.  That is by definition the “nocebo” effect — the evil twin brother of the placebo effect, in which words or beliefs or sugar pills relieve symptoms and allows healing.   So, I recommended that “injury” should be the NEXT term she stops using to describe her current situation.   And on the spot, I educated her about the basic biology of how fast tissues heal.

It depends on the type of tissue.  Generally speaking, the cornea of the eye heals in about 24 hours; a simple skin wound usually takes 7-10 days; bones and muscles often take 6 weeks, sometimes 8 to 9 and occasionally 12 weeks.  Nerves can take months (and sometimes years) to regrow.  But as a rough rule of thumb for most injuries, all the tissues have usually healed by 90 days — no matter what happened.  Additional gains may be made slowly for a year or more, often as the result of rehabilitation and reconditioning.   Function and comfort often continue to improve after healing is complete.

One way to see this clearly is to take the case of a person who suffered a major body burn — a widespread and deep one that went down into the muscle.  The burning itself was over in minutes.  Some areas of skin and underlying tissues were destroyed and other areas were left damaged and weeping.  The tissue healing process was in full swing by 7 days and by the time it was complete, had produced extensive scar.  The skin was as healed as it was going to get, but it left behind stiff and painful scar.  The scar is a CONSEQUENCE of the injury, not a sign that the burn injury is on-going.   Rehabilitation for burn patients focuses on minimizing the impact of scarring on appearance and function.

Kristina listened hard and seemed to “get it” – but not completely.  She is still in the habit of viewing herself as “hurt” (fragile).  When something happens and she feels pain, she may be interpreting it as a sign she is being damaged or re-injured further – rather than seeing herself as a person who is stuck living with the painful (but harmless) consequences of a previous injury.

So, in my view, the most accurate way to describe Kristina’s situation is that she HAD an injury and is still dealing WITH and recovering FROM its effects.  The injury is in the past.  It is not accurate to say she still HAS an injury.  The choice of words make a real difference.

And lastly, the term “injured worker” has got to go because those words communicate no possibility of either recovery or a positive future.  How can people who’ve had an accident at work ever consider themselves well as long as they are being called by that name?  That term doesn’t even hint at the fact that the vast majority of people who have an injury recover promptly and heal completely.  The unlucky people who don’t end up fully healed are left with things like scars and stiff joints, not unhealed wounds.  The previous term “claimant” was discredited and abandoned because it was too impersonal — but it did not doom the person to a negative and unchanging future.

All along, Kristina has been strongly motivated to get better and get back to earning a good living.   She has been doing everything she can to get herself better and to advocate for herself in the “systems”.  Imagine the “nocebo” impact of these three terms on a person without the inner resources Kristina has brought to bear!

What does this mean for you?   If you are involved with the workers’ compensation system, please abandon the term “injured worker” and “injury” when discussing events longer than 3 months ago.  Talk about “recovery” or “recuperation” instead.  And maybe we should go back to “claimant”, or an even better term.  For now, a few of my colleagues and I have started saying “affected person”.   And if you are a person who had a musculoskeletal work-related injury more than 12 weeks ago, please assume that your tissues are healed.  And, like Kristina start saying “how can I do this” instead of “I can’t.” It is time to start dealing with the consequences of that injury and get the whole thing behind you.   Focus on accepting what you’re stuck with (at least for now), rehabilitate yourself, get back in the best shape you can — and focus on minimizing its impact on the quality of your life and your future!

Leave a reply

October 10, 2015

Some specifics: Our proposal for a Health & Work Service

In our August 2015 proposal to the SSDI Solutions Initiative sponsored by the Committee for a Responsible Federal Budget on Capitol Hill, we recommended that a community-focused Health & Work Service (HWS) be established.  The services to be provided by the HWS are generally not available in our country today, particularly to lower-wage workers and those who work for small firms.This service would be dedicated to responding rapidly to new episodes of health-related work absence among working people in order to help them:

— Minimize life disruption and get things back to normal as quickly as it is medically safe to do so
— Focus attention on treatments and services to restore ability to function at home and at work
— Understand and navigate through the healthcare and benefits programs and systems
— Avoid being abandoned; learn how to be a squeaky wheel and get their needs met
— Communicate with all parties to expedite both medical care and the return to work process, including resolving non-medical obstacles to recovery and return to work, making temporary adjustments or arranging reasonable accommodation when appropriate.
— Keep their jobs or promptly find new ones if that is necessary.

(The material below summarizes our written proposal.  If you’re interested in the scientific research that underlies these ideas, the 30+ pages and 3 appendices of our “real deal” formal report support all key assertions with literature citations and an extensive bibliography.  Along with the 12 other proposals commissioned by the SSDI Solutions Initiative group, it is scheduled to be published electronically in late October, and in print in January 2016.)

The first few days and weeks after onset are an especially critical period during which the likelihood of a good long-term outcome is being influenced, either favorably or unfavorably, by some simple things that either do or do not happen during that interval. It is the optimal window of opportunity to improve outcomes by simultaneously attending to the worker’s basic needs and concerns as well as coordinating the medical, functional restoration, and occupational aspects of the situation in a coordinated fashion.

The best opportunity for basic intervention appears to last about 12 weeks or three months, although some data shows it ending by 6 months.  Many studies have show that a modest set of simple services—that embody an immediate, systematic, pro-active, integrated, and multidimensional approach—can mitigate the potentially destructive impact of common injuries, illnesses, and chronic conditions on quality of life among the working population.

In the USA today, a large and growing fraction of Social Security Disability Insurance (SSDI) awards are being made to people deemed totally unable to work due to conditions that are among the most common health problems in America and the world, but which only rarely cause permanent withdrawal from the workforce. Low back pain and other chronic musculoskeletal conditions (MSK), and common mood disorders (CMD) —particularly depression and anxiety—are the most prominent conditions in this category.

Near-immediate assistance from a community-focused Health & Work Service will allow people with these kinds of common conditions to avoid the kind of adverse secondary consequences they too often experience today. Those consequences are usually not obvious until months or years later, after unfortunate things have happened. The unlucky ones have received sub-optimal health care, been left with under-treated or iatrogenic impairment,  become dependent on opioids, found themselves socially isolated, lost their jobs, withdrawn from the workforce, lost economic independence, and ended up on long-term disability benefits programs or SSDI in order to survive. Anticipatory programs that ensure the right things happen from the start and include early identification of those needing extra support are the simplest and most effective way to prevent later adverse secondary consequences of these conditions.

As we envision it, the HWS will build strong collaborative relationships with referral sources in local communities: treating physicians, employers, and benefits payers. Service delivery in individual cases can be largely telephonic and internet-based because these technologies are proving to be as or more effective than face-to-face care delivery. The quadruple goal is to maximize service quality, optimize outcomes, minimize logistical challenges, and control costs. The HWS service will:

(a) — get its referrals from affected individuals, local treating physicians, employers, benefits payers and others when work absence has lasted or is expected to last more than four weeks;

(b) — champion the stay-at-work and return-to-work (SAW/RTW) process from the time of referral through the end of the immediate response period (usually 12 weeks post onset);

(c) —  quickly evaluate the individual’s situation, screen for known risks for poor outcomes, help them make a SAW/RTW plan and support them in carrying it out;

(d) —  facilitate communications among all involved parties as needed to get everyone on the same page and driving towards the best possible outcome.;

(e) — expedite and coordinate external medical, rehabilitative and other kinds of helping services, including referrals for specialized services as needed to address remediable obstacles in a variety of life domains;

(f) — take a problem-solving approach in collaboration with affected individuals, their treating physicians, employers, and payers.

Of course, developing the HWS will first require a commitment to funding, either by the government or by a foundation that is committed to system change. Once that has been obtained, the initiative will unfold in a series of steps including design, prototyping, development, and field-testing in different geographies, followed by a large randomized controlled trial.  After that, the HWS can gradually roll out across large geographic areas.

What does this mean for you?   First, if you like the idea of working people getting the kind of support they need and deserve — and when it is most likely to make a difference,  please support this idea in whatever way you can.  Why not call or email your Congressman?  Second, if you are a professional with the expertise and passion required to help people get “right back on the horse” — and are now stymied and frustrated by the current system’s inadequacies / dysfunctions, you have probably realized that the HWS service might create a lot of fulfilling and satisfying jobs for specialists like you.  If so…. that’s another reason to call or email your Congressman!

1 Reply

October 9, 2015

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

 

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

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

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

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

Remediable or Avoidable Reasons for Poor Outcomes

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

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

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

The first few days and weeks after onset are an especially critical period during which the likelihood of a good long-term outcome is being influenced, either favorably or unfavorably, by some simple things that either do or do not happen during that interval. It is the optimal window of opportunity to improve outcomes by simultaneously attending to the worker’s basic needs and concerns as well as coordinating the medical, functional restoration, and occupational aspects of the situation in a coordinated fashion.

The best opportunity for basic intervention appears to last about 12 weeks or three months, although some data shows it ending by 6 months.  Many studies have show that a modest set of simple services—that embody an immediate, systematic, pro-active, integrated, and multidimensional approach—can mitigate the potentially destructive impact of common injuries, illnesses, and chronic conditions on quality of life among the working population.

In summary, the way a health-related episode that disrupts work unfolds over time in all dimensions—biological, psychological, social, and economic—can have a big impact on the outcome. Events that occur can either mitigate or aggravate existing risk factors in the situation, leading to better or worse outcomes. There are usually many opportunities to actively influence the course of events immediately after onset of a health problem (and many fewer opportunities later on), but today there are few resources devoted to finding and exercising these opportunities. Most of the current attempts to steer situations to a better outcome are made long after the best opportunities have passed by.

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

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

 

 

 

Leave a reply

October 8, 2015

Dan Siegel says I can use my mind to reshape my brain — or YOURS!

I’m in the middle of taking an on-line course by Daniel Siegel, MD.  I hope you do, too.   It’s called “Practicing Mindsight” — 6 hours consisting of 32 video mini-lectures delivered live to an audience of about 240 mental health professionals, physicians, educators, as well as organizational behavior and social policy wonks.   (I’ve also  heard a great TED talk by this guy).  He’s a famous psychiatrist, trained at Harvard Medical School and UCLA, now clinical professor of psychiatry at UCLA, an award-winning educator – and expert researcher in the emerging field of “interpersonal neurobiology”.

It’s on a website called www.Udemy.com.  I’ve listened to the first 9 mini-lectures so far.  He began by asking how many of the professionals in the audience think the mind is important in everyday affairs — and in their practices/organizations.  All hands went up.  Then he asked how many had any instruction on what the mind is?   Five percent raised their hands.   He says that the proportion has been similar in 85,000 professionals he has asked.   He  says the purpose of the course is:  How to see the mind and make it stronger.    I say the course is focused on STRATEGIES for changing the STRUCTURE of the brain (one’s own and that of one’s patients/clients) by using the mind.   Think of that:  USING the mind as a tool to INTENTIONALLY remodel circuits in the brain.

Here are three big points I have heard in his lectures so far:

(a) Key definition:   The mind is a PROCESS not a thing.  It REGULATES (monitors and directs) the flow of energy and information both within an individual and between people.  (Energy is roughly defined as stuff that makes things happen.  Information is both data and meaning or story.)  As part of his grant-funded work, he had put together a group of 40 researchers in a wide variety of fields who were all (eventually) able to agree on this definition.

(b) “Attention” – which is where the mind focuses, what it is paying attention to  – is what CREATES new neural pathways, and STRENGTHENS either existing or new ones by reinforcing the pathway.  As the saying goes: “neurons that fire together wire together”.  For example, the more we pay attention to our pain (assessing it, worrying about it, “fighting” it), the deeper we are carving that channel.  Common sense, grandmothers, and “New Agers” have been telling us for years to focus on what we DO want instead of what we DON’T want  — and now science is confirming it.

(c) Humans are genetically programmed to AUTOMATICALLY create internal experiences and capabilities that mirror or incorporate things they see or feel during interactions with others.  As we watch someone else raise a glass of water to his lips, the cells in our brains that move our own arms light up.  We sense his intention to drink, we may experience thirst, or the sensation of water or of refreshment.  We feel sad when someone cries, and are happy at their joy.  Others’ brains shape what goes on in ours —  what circuits are firing and being reinforced — and vice versa.  Simultaneous mutual (interpersonal) experience is a KEY part of the “social” in our “social species”.

So I got this:  The techniques we use to SHIFT our attention (or another person’s attention) away from bad stuff and towards more productive ways of thinking are actually MODULATING neural circuitry in the brain (which is neuroplasticity in action).  This has now been confirmed by rigorous research on techniques such as mindfulness, CBT, etc.   (I personally remember reading a study which showed that SIMILAR changes in the brain can be observed after either medication OR “talk therapy”.  In that TED talk by Siegel that I watched, he asserts that much of the circuitry in our frontal lobe is created and shaped by everyday INTERPERSONAL INTERACTIONS which DEVELOP it – and of course it is our frontal lobes which make us uniquely human.)

The takeaway for us as physicians in tangible organ-system-focused specialties is there is POWER TO HEAL in our words —  and in the human quality of our interpersonal interactions.  We have an opportunity to INTENTIONALLY HARNESS that power and explicitly add it to our therapeutic armamentarium.

Although the mental health professions already are aware of the power of words and relationships, physicians are on the front-line dealing with patients with PHYSICAL complaints and distress.  We are in the best position to use the power of words and relationships to start relieving those symptoms and easing that distress — even if all we do is alert the patient to the healing power of the mind and persuade them to accept help from a mental health professional.  Apparently, the only specialty these days that requires training in patient communication is family practice.  Thus, this appears to be a neglected skill area in all of the other medical specialties.

Those of us who have accepted the idea that sickness and disability are the COMBINED product of bio-psycho-socio-economic factors, and who are setting out to reduce the disruptive/destructive impact of injury/illness on quality of the patient’s everyday life and future – especially in at risk cases and “heartsink patients” — MUST master this stuff.  We need to practice the SCIENTIFIC ART of empathic therapeutic interaction.  We must learn how to effectively redirect the patient’s attention into more appropriate channels so they develop their own capability to adapt to / cope effectively with their own situations.

The tuition for the Siegel Practicing Mindsight course is usually $137, but if you follow the directions below, you may be able to get a $39 special rate.  It supposedly ends TODAY — although it supposedly ended yesterday, too.  Some people don’t seem to be able to find the $39 offer.  There’s probably a glitch of some kind that is making it show up only when you wend your way through the electrons a particular way.

Here’s how I found it again just now:  I use Firefox.  I entered  “daniel siegel mindsight” in the search box, then I clicked on the link for an Udemy ADVERTISEMENT that appeared in the top left corner of the search results.  The website that appears says the rate is $39 again today (coupon valid until October 8).   But when I went STRAIGHT to the udemy site, the cost is $137.

Go for it — fool around, and then REGISTER!   But bring your brain AND appreciation for quirkiness with you.   This is  fascinating material taught by a deep and independent thinker, serious expert and experienced researcher.  And, Siegel is a character with really colorful personal stories:  so far we’ve heard tales of misfittery in medical school, salmon fishery, dance, nudity in Greece, etc.

1 Reply