Category Archives: Causes of Poor Outcomes

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!

 

 

 

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August 12, 2015

Who will address working people’s reasonable concerns when illness or injury disrupt their lives?

What do working people wonder and worry about when their lives (and work) have just been disrupted by a new illness, injury, or a change in a chronic condition?

While creating a course to train doctors how to meet their patient’s needs, we realized we had to know what those needs were.  It seemed obvious that patients would want to know what is wrong with them and what kind of medical care they need.  But beyond those things, we came up with a list of predictable and totally reasonable issues:

How long am I going to be laid up (out of commission)?
How long do I have to take it easy?
When I can go back to doing my usual stuff?
In the meanwhile, what can I still do? What shouldn’t I do?
What can I do to speed my recovery?
If I can’t work, how will we pay our bills next month?
When will life be back to normal? …..if ever?
What does this mean about me?   My future?
What is this going to do to my livelihood?  What will this do to us financially?
Who will help me?  Who can I trust?  Who has my best interests at heart?

I often show this list when I am speaking to groups about how to improve outcomes for people with common health conditions like back pain.  It always rings true with the audience.  After one presentation, an influential executive (in a wheelchair with quadriplegia) told me that she had had all of those concerns immediately upon awakening after her accident.

Here’s my question:   How are people getting these questions and concerns answered — when and by whom?  The standard design of a medical visit (memorized by all physicians during our medical training) DOES NOT include a time for doing it.  There is no sub-heading in our report format called:  Patient Education,  Instruction, and Guidance.  If it is happening, it is spotty at best.

So if most doctors are not answering these questions, who is?   Which of the other professionals who are responsible for responding to life & work disruption in working people IS going to address them?   Unless one of these “experts” does so, the people will have to come up with their own answers.  Yet how many are prepared to do that?   They will come up with their own best guesses (which may be wacky) or may turn to their family, friends, co-worker, neighbor, union steward, or a lawyer for answers (who may or may not give them a bum steer).

What does this mean for you?  If you are committed to better service (and/or want to avoid the trouble caused by bad advice), figure out a way to meet people’s totally reasonable needs for information and advice.   If you are a treating clinician, consider making a revision to your standard visit protocol and report templates by adding that missing section:  Patient Education, Instruction & Guidance.

Another simple idea for healthcare providers, employers or insurers is to create a standard operating procedure to mail out or hand out a brochure.  The 60 Summits Project developed a fact sheet for employees whose health conditions have just started to disrupt their work — and a fact sheet for supervisors on how to manage the situation in the workplace..  Feel free to use these sheets as is, or remove the 60 Summits logo and revise them to suit yourself.  But please do SOMETHING!

 

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August 7, 2015

Who should be accountable for NEEDLESS job loss due to medical conditions?

Who do you think should be held accountable when workers needlessly lose their jobs because a newly-acquired or changed health condition or disability?

Right now, none of the professional participants who play front-line roles in the stay-at-work/return-to-work process feels a responsibility to prevent unnecessary job loss.  Doctors, employers, insurance companies, lawyers and so on simply think it’s a shame when it happens — if they are even aware of it.  Unnecessary job loss is being viewed as a private tragedy rather than a sentinel indicator of service and system failure.  A lot more sunshine is needed to illuminate this dark corner.

Gap

Even though OSHA ensures that employers record the number of work-related injuries, lost work-days and deaths, there is no requirement that they record job loss.  Why isn’t it being tracked?   It will almost always be a much worse consequence than the injury itself.   Job loss, especially in someone who was previously healthy but now has some degree of impairment, can be DEVASTATING.   Few people are prepared to deal with this double- barreled challenge.   For the unlucky ones, this means losing their footing in the world of work forever.

We do not even KNOW how many people lose their jobs as the result of work-related injuries much less personal health conditions — and how many fail to find new jobs. I personally don’t think it matters what the cause of the health condition is.

These days, more than a HALF of the people entering the Social Security Disability Insurance program are doing so because of adverse secondary consequences of common health conditions like back pain, joint pain, anxiety, and depression.  But notice this:  there are literally MILLIONS of people who keep working DESPITE back pain, joint pain, anxiety and depression.  These conditions should NOT be forcing people into a bleak future of on-going worklessness, especially because unemployment and poverty will WORSEN their health and well-being — and that of their families.

Needless job loss can occur because of decisions that doctors and employers make as well as decisions made by workers, their lawyers, and insurance companies. Anyone who COULD have actively supported a worker in staying at work but DIDN’T plays a part in unnecessary job loss.  Doctors may thoughtlessly select treatments that worsen instead of improve function, or impose work restrictions that “over-limit” someone who COULD actually perform their job.  Employers may refuse to make temporary adjustments that WOULD permit recovery “on the job” — and as a result workers sit home and begin to believe they really are “too disabled to work”.   Employers can refuse to engage in a real problem-solving discussion with workers that WOULD have let them come back to work with a very minor modification.  Employers can neglect to ask for help from a return-to-work expert who COULD have told them about a $200 piece of equipment or work process alteration that WOULD have made it possible for the worker to keep doing her regular job.  Insurers COULD routinely (instead of occasionally) make career counseling and job finding services available to workers who appear headed for job loss or have already been terminated.  Etc. Etc.

So, who DO you think should be held accountable for job loss in those situations?  You and I as taxpayers are going to pay benefits for the rest of these people’s lives if they end up on SSDI because the right things didn’t happen.  Less than 1% of SSDI beneficiaries ever come back off the rolls.

Here’s a place to see and comment on my DRAFT recommendations for what the government can do to create a lot more visibility for unnecessary job loss due to acquired health conditions and disabilities.  You can also contribute your own ideas on this matter at:  http://workashealthoutcome.epolicyworks.org/

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July 20, 2015

My “mini-manifesto” to reduce spine disability

You may be interested in the “mini-manifesto” I delivered this past Saturday 7/18 at the Spine 10×25 Research Summit in Chicago hosted by the North American Spine Foundation.  They have declared a worthy and very ambitious goal:  to reduce spine disability by 10 percent by the year 2025.  Thus the name: Spine 10×25. Pronounce it like you’re buying lumber – “10 by 25”.

(You can see the video and listen to my talk —  or even the ENTIRE 8 hour event because it was live-streamed and recorded.  Click here to do so.  Advance the recording by moving the blue dot along the horizontal line.  My talk starts at 5:31:50 and goes until 5:51:30.)

Do you know of any other medical group that has drawn a bold line in the sand like that?  I don’t.  It had never occurred to me that a professional society would set out to measurably move the needle.  They just don’t take on that type of project.  Most healthcare professional associations content themselves with pontificating:  being experts and telling other people what to do and how to do it.

My own professional society (ACOEM – the American College of Occupational & Environmental Medicine) has made many significant contributions to society.  In particular, our evidence-based treatment guidelines are very well regarded and in use by several states.   ACOEM has produced many other useful publications that have had a positive impact.  In fact, some of them were developed under my leadership.  But, in the end, they all amount to pontification.

In 2006, I told ACOEM I didn’t want one of those documents to just sit on an electronic shelf. We had developed it in order to introduce the work disability prevention paradigm and shift the way all stakeholders think about work disability.  Entitled “Preventing Needless Work Disability By Helping People Stay Employed“, that report needed to go out into the world.  Thus, the 60 Summits Project was born to carry it into the 50 US states and 10 Canadian provinces of North America.  We created groups of volunteer professionals who planned and held 20 multi-stakeholder summit-type conferences in 12 states and 2 provinces.  We invited the attendees to consider ACOEM’s 16 recommendations for improving the stay-at-work and return-to-work process.  We asked them to decide if they liked each recommendation, and if so, to make a plan for how they were going to carry it out in their own business, community, and jurisdiction. (60 Summits eventually ran out of money and was mothballed.)

Then last month, the boldness of the Spine 10x 25 initiative made me realize that even The 60 Summits Project had a pontification angle to it.  Propagating a new way of thinking and discussing a set of recommendations for change is not the same thing as CARRYING them OUT.  I felt compelled to go and check out these NASF people and participate in their Spine 10×25 Research Summit.

My assigned topic was “Precedents and Prospects for Success” in a 15 minute time slot that got expanded to 20.  It seemed important to speak straight and share my ideas about what needs to be true in order for their goal to be realized.  I offered the audience a (draft) conceptual foundation to use as a context for change, as well a summary-level vision of the way things will look in the future WHEN things have ACTUALLY changed and spine disability is BEING REDUCED by 10%.  View it here. Remember to advance the recording to 5:31:50.

I may expand a bit on some of the main points of that mini-manifesto in later posts.  I developed all of those slides at the conference in order to take into account what the speakers said who had gone before me!  Luckily, I also had some time at lunch.  The tight time limit meant a few big ideas got short shrift.

 

 

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July 6, 2015

Why Put People Who Don’t Care in Charge of Timing?

I just realized that there are two short little sentences that are causing BIG PROBLEMS.   They are:

1.   “We can’t start looking for transitional duty for him  (or, we can’t start the reasonable accommodation process) until we get specific work restrictions from the doctor,” says the employer.

2.   “She will be eligible for job training only after her condition is declared to be medically stable (at MMI or P&S) and permanent work restrictions for all body parts are known,” says the benefits administrator.

These two sentences reveal that the speaker is in a REACTIVE posture, refusing to make an effort to get out ahead of the ball.  They are passively waiting for a PHYSICIAN or the POLICY/LAW to determine the timing of an important event  — an event which could have a huge impact on the outcome.   The problem is:  neither the physician nor the insurance policy/law are watching time slip away.

I hear these two sentences frequently during the part of my week when I serve as a physician adviser to a multi-disciplinary care management team.  Since many of the standard techniques to manage claims have previously been tried, I often suggest non-standard things.  I tend to hear those sentences AFTER  I suggest doing something pro-active in a case that’s stalled out and headed towards a predictably poor outcome.  For example, I may recommend that INSTEAD OF WAITING, we approach the doctor with an proposal for a return to work plan and some potential transitional tasks.  Or I may recommend that we acknowledge the obvious handwriting on the wall — which says the person is never going to go back to the original employer — and offer the worker some psychological or vocational counseling to help them start focusing on the future and figure out what kind of work they want to do and how to find a new job.

The PHYSICIAN doesn’t know that the longer employed people are absent from work due to a health condition, the more likely it is that they will lose their jobs, never get another one, and end up on as a long-term disability claimant.    And with a conventional medical education, the doctor doesn’t feel responsible for helping patients stay employed.

So WHY is the employer WAITING for the doctor?   WHY can’t the employer ANTICIPATE the general nature of the limits/restrictions?   If the shoulder has been affected, it’s obvious the restrictions will involve lifting and reaching!   If it’s the right foot, it’s obvious there will be limitations on walking and standing!   If you’re uncertain what workers can do, ASK them!  (The Americans with Disabilities Act expects you to do so.)   If the employer and the employee propose a plan to the doctor that they both agree on — what are the odds the doctor will say no?  VERY LOW!

The POLICY or LAW describes outer limits, not the best path.  The law usually dictates the earliest or the latest date when something must occur —  not the optimal timing of it.  So WHY is the benefits handler WAITING for the formal declaration of MMI / P&S?  This too is not part of conventional medical training.  Most doctors don’t see it as a milestone and are unaware they’re supposed to make a formal statement.  I suspect that benefits handlers are so worried about violating rules and regulations that they think they HAVE to wait to start helping a person move on and find a new job until the LAW MANDATES it.  Why can’ t that benefit handler VOLUNTARILY make a move earlier?

Seems to me that determining the OPTIMAL timing for events, and deciding whether to offer BETTER assistance than the minimum specified in the law lies within the discretionary authority of the benefits handler.  In fact, aren’t we supposed to be paying them to use their judgement?

[CAVEAT: This has been true where I have worked, but maybe in some jurisdictions or policies, I’m wrong.  If you are more expert on these matters than me, please tell me why I’m incorrect.]

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