Category Archives: Policy Issues

July 31, 2015

Tell us: Who should be helping workers with health problems keep their jobs?

The US Department of Labor (DOL) wants to engage YOU in dialogue (you employers, insurers, physicians/healthcare providers, managed care companies — and working age individuals whose jobs have been affected by new or changed health conditions.) The dialogue concerns some draft recommendations for Establishing Work and Full Participation in Life as ACCOUNTABLE Health Outcomes.

The recommendations are part of a larger report I have drafted.  It is focused on these questions:
1– How can we reduce the number of working adults who lose their jobs or leave the workforce after their ability to work has been disrupted by a health condition—and conversely, how can we increase the number who get the help they need to stay employed?
2– What will create widely-shared social agreement that preserving/restoring the ability to work and participate fully in life should be seen as KEY OUTCOMES of healthcare for the working age population?
3– Who should be helping working people KEEP THEIR JOBS after acquiring a new or changed disability?    Who should be held accountable when they needlessly LOSE THEIR JOBS?
4– How can that accountability be established—for real?

The DOL’s Office of Disability Employment Policy (ODEP) commissioned this paper.  Many ideas for how to accomplish those things emerged after interviewing about 20 experts in various fields and discussing these issues with a Policy Work Group within ODEP’s SAW/RTW Policy Collaborative.  Because the stay-at-work and return-to-work process is by nature a “team sport”, the reality is that SEVERAL parties will need to be held accountable.

The draft report actually makes more than 20 detailed recommendations, but for now, ODEP would like to get feedback from YOU on the 6 main ones.  This is a reality check, to see if we’re on the right track in your opinion.   I ENCOURAGE you to disagree, make corrections, or suggest things that are missing or would strengthen the proposal.   The purpose of this exercise is to IMPROVE the report – and increase the chances that it actually has a positive impact.  The ultimate goal is to help more people stay in the workforce, remain productive contributors, and enjoy the many benefits of economic self-sufficiency and full social participation.

You can look at the recommendations on ODEP’s “crowdsourcing” website even before you decide whether to vote/comment.  I hope you will.   See the invitation from ODEP below to get started.   Again, FEEL FREE to disagree, to point out mistakes, make additional suggestions, etc. etc.

From: Acting Assistant Secretary of Labor – Office of Disability Employment Policy
Sent: Wednesday, July 29, 2015 3:40 PM
Subject: ODEP’s Latest Online Dialogue Discusses Work as a Health Outcome

 ODEP epolicyworks masthead 2015-07-31

Second Stay-at-Work/Return-to-Work Online Dialogue:
Establishing Work and Full Participation as Accountable Health Outcomes

Do you have ideas on how to reduce the number of working adults who lose their jobs or leave the workforce after their ability to work has been disrupted by a health condition—and conversely, how to increase the number who get the help they need to stay employed? If so, the U.S. Department of Labor’s Office of Disability Employment Policy (ODEP) needs to hear from you!

ODEP is hosting the second in a three-part series of important online dialogues, Establishing Work and Full Participation as Accountable Health Outcomes, to gather input on policy recommendations aimed at establishing work and full participation in life as accountable health outcomes. Through the use of an online crowdsourcing tool, interested stakeholders can provide feedback on these six draft policy recommendations.

Participation is easy. Just review the policy recommendations, register, then share your feedback.

Visit http://WorkAsHealthOutcome.ePolicyWorks.org/ before the dialogue closes on Friday, August 14th. If you have any questions, please contact ePolicyWorks@dol.gov.

Looking forward to your participation,
Jennifer Sheehy
Acting Assistant Secretary of Labor for Disability Employment Policy

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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 7, 2015

#1 of 3 fleeting opportunities to influence policy recommendations

Between now and July 10, you have the first of three time-limited opportunities to preview and maybe influence the recommendations being made in three different policy papers that the Stay-at-Work and Return-to-Work (SAW/RTW) Policy Collaborative is producing this year.  Your input (as an experienced professional in this arena) will make it more likely that their FINAL recommendations are realistic and help accomplish their intended purposes.  Participation is easy.

The dialogue opportunity for the FIRST SET of recommendations will remain open just a few more days — until July 10.   The topic of this first paper is Expanding Access to Evidence-based, Early Intervention SAW/RTW Services and Supports, authored by David Stapleton of Mathematica.  His DRAFT main recommendations have been posted on-line at a “crowdsourcing” website for public review and comment, the National Online Dialogue.

To participate, simply register, read the policy recommendations, give it a thumbs up or down, or go deeper and make a substantive comment.  And please forward this email to any colleagues with an interest in the topic!

The SAW/RTW Policy Collaborative was created to advise the US Dept. of Labor’s Office of Disability Employment Policy (ODEP).   Members are invited by the project contractor, Mathematica, after approval by ODEP.  I have nominated many members all of whom have been accepted (as far as I know).  If you have expertise in this arena and would like to join and actively contribute to the Collaborative, please let me know.

I’m drafting the second policy paper entitled Establishing Work and Participation in Life as Accountable Health Outcomes.  Towards the end of July, my major recommendations will be put into the on-line dialogue.  Y’all come and give my proposals a thumbs up, thumbs down, make a suggestion or leave a comment!   Third in the line-up for dialogue will be the main recommendations from the third paper entitled Job Retention/Creation for Workers Who Experience Productivity Loss by Kevin Hollenbeck from the Upjohn Institute later in the summer.

Before the July 10th deadline, go to this link and provide feedback on Stapleton’s draft policy recommendations:  http://TargetingEarlyIntervention.ePolicyWorks.org/    If you have any questions, please contact ePolicyWorks@dol.gov.   And do remember to let other colleagues know about this SHORT-LIVED opportunity.

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June 5, 2015

Why aren’t we saying and doing THESE THINGS about the ADA?

I’ve been listening to the prevailing conversation about the Americans with Disabilities Act, as amended (ADA), in workers’ comp and disability benefits circles. Most often it has a negative tone: the ADA imposes obligations and creates complicated legal dances that can get us in trouble unless we do things exactly right. I almost never hear ANYONE in these industries (other than disability rights advocates) talking about what we can do to FULFILL the social purposes for which that law was created!

I am also a member of the US Dept of Labor’s Stay-at-Work and Return-to-Work Policy Collaborative, As a result, I met the EEOC‘s Senior Legal Counsel Aaron Konopasky, PhD, JD.  He opened my eyes to the fact that the ADA now applies MUCH EARLIER and MORE FREQUENTLY in health-related employment disruptions (both workers’ compensation and short / long-disability benefits cases) than has traditionally been thought. (See the mini-white paper Aaron and I co-authored on this issue.)

Seems like one of the key purposes of workers’ comp and disability benefits programs SHOULD BE to help workers who get injured or sick or who lose functional ability over time to KEEP THEIR JOBS / LIVELIHOODS and if needed, FIND NEW WAYS TO EARN A LIVING appropriate for their changed capabilities so they can MAINTAIN THEIR ECONOMIC INDEPENDENCE.  If that is so, then it seems like EMPLOYMENT OUTCOMES should be included in the metrics by which effectiveness / success / value of these programs is measured.   (I don’t see this being done now — do you?)

Now let’s look at the flip side:  bad outcomes.  (more…)

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May 31, 2015

Overkill describes the problem PERFECTLY!

Dr. Atul Gawande’s new article called Overkill is a great asset for all of us change agents. The tagline is:  “An avalanche of unnecessary medical care is harming patients physically and financially.  What can we do about it?”   It appeared in the May 4 issue of the New Yorker magazine.  The topic is “no value” healthcare, and he describes both over-diagnosis and over-treatment.  Me and my gang know that those things also create over-impairment and over-disabling — and ruined lives!

Recommendation:  Use this article as a tool to educate yourself – and others!  It is much better than most of the stuff on this general topic in medical journals and august scientific publications  – because he explains things so clearly and in such simple yet vivid language.   There’s a powerful vignette of a guy with two prior spine surgeries whose local doctor recommends a third one – and how the story turns out.    A happy aspect of the Overkill article is that Gawande also describes how the dark forces that are driving these things are being countered by more positive ones.  Things are slowly and spottily changing FOR THE BETTER!

I am ashamed at my petty jealous hatred for this man — because he is handsome, brilliant, insightful, incredibly talented, articulate, frank, and a fabulous writer.    He has been a columnist for the New Yorker since 1998.  Based  on his photograph, he must have been a baby then.   I’ve read several of his articles and books, and recommend them to you.   In particular, if you want to be sickened at how the constant emphasis on money has corrupted the physician culture, read his earlier article entitled The Cost Conundrum – like the White House did.   I’ve just finished his latest book Being Mortal.  It is wonderful — richly informative yet with a very positive tone and personal feeling.    See more about Gawande on the New Yorker’s Contributors webpage or on Gawande’s own website.

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May 9, 2015

Keeping Jenny Weast Employed May Take a Village

Jenny Weast’s predicament appears to be a perfect example of how today’s “system” encourages dependency instead of independence among people with disabilities — and increases the barriers to work rather than reducing them!   Jenny is a popular and energetic high school teacher in California who is quadriplegic.  She needs personal care attendants to help her with her activities of daily living, but Medicaid has decided she doesn’t qualify for coverage — because she earns too much money.    According to Jenny’s Facebook page, Medicaid says her “fair share” of these services would be $2400+ dollars per month, which would leave her with 26% of her paycheck to live on.   There is NO CHARITY and NO FOUNDATION in this country (as far as I know – and I have searched) who sees it as their mission to help people with disabilities STAY EMPLOYED.  Karen Cage who has taken up Jenny’s cause has created a crowd-funding opportunity to help defray the expenses of Jenny’s personal care attendants.  I did make a contribution to help Jenny stay employed – because if the government and existing charities won’t help people in her situation – who will?    It’s NOW that her job is in jeopardy.  Jenny will be on SSDI by the time that Congress acts and/or a foundation’s new initiative gets funded and underway.

Many people with disabilities don’t need personal care attendants – they have much more modest expenses, but can’t afford to pay for them because they earn an even-more-modest-than-that  salary.   Small things often make ALL of the difference.    As the centuries old proverb says:

For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the message was lost.
For want of a message the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail.

From what I read, Jenny is not alone by any means.  MIT economist Professor David Autor wrote in his report The Unsustainable Rise of the Disability Rolls in the United States: Causes, Consequences and Policy Options:  “In its current incarnation, the SSDI program spends too few societal resources helping individuals with disabilities to remain employed and too many resources supporting the long-term dependency of individuals who could be self-sufficient with the appropriate accommodation and supports.”

Perhaps the charity of individuals will support Jenny’s caregivers while we encourage Congress to figure out a way to help ALL people who ARE EARNING A LIVING despite significant disabilities to get help with the EXTRA EXPENSES that make it possible for them to work!   Or maybe, one of the big foundations will notice this opportunity to make a big positive difference and step in.  Obviously, the kinds of impairments that warrant extra services and the definition of services that are covered have to be precise enough to actually accomplish the purpose while avoiding wholesale abuse, but …… doesn’t this just plain old make sense?

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May 9, 2015

2 good signs: Momentum building & mechanisms appearing

You’ll be pleased to hear about two developments that are good signs for the transition away from the fee for service payment model in healthcare and towards payment for outcomes.  Buy-in among healthcare CEOs is clearly growing, and Congress just passed MACRA — a new law will increase the mechanisms available to support value-based healthcare reimbursement, particularly for physicians. See below for more details on these two developments.

But first:  If you believe that a FUNDAMENTAL purpose of healthcare services is to enable people to participate as fully as possible in life –which for most working age people includes earning a living — then ability to function & work should be on the list of accountable health outcomes.  Thus, it is CRITICAL to ensure that SOMEONE is sitting at the table advocating for those outcomes — when the nitty-gritty details of the new mechanisms called for in MACRA are worked out!  As you read on, consider what you can do to increase the likelihood that someone IS sitting there.

First, a recent survey of healthcare CEO’s revealed that the VAST majority of them LIKE the idea of value-based payment – even though a substantial fraction of them predict difficulties and revenue reductions as a result.   Almost 8/10 of them said this statement best reflected their attitude:   “Value-based reimbursement models should play the dominant role in healthcare reimbursement with fee-for-service medicine playing a declining and minor role.” The CEO’s also predict that value-based reimbursement will improve quality of care (93% agree).  Overwhelmingly, they think the pace of change is NOT going too fast (91% agree).  NOTE:  Almost all of the CEO’s think we can’t throw away the existing CPT-based payment system entirely – because physicians need an incentive to work hard, and because the metrics that underlie value-based payment don’t work well when there are statistical challenges (unusual  conditions, rare events, low practice volumes, and other reasons for small numbers and high variability).

In another development, while repealing the dreaded Medicare fee cuts called for under the SGR legislation (Sustainable Growth Rate), Congress opened the door to some (potentially) HUGE changes in physician payment.   MACRA – the Medicare Access and CHIP Reauthorization Act of 2015 – lays out a general plan for changes in CMS’ physician reimbursement methods.   MACRA replaces the uncertainty about SGR and its draconian 21 percent cut to physician fees this year with tiny but predictable payment increases for the next four-and-a-half years. Then, starting in
2019, MACRA removes some irritating and burdensome penalties and gives physicians two ways to earn performance based incentive payments, either by participating in a new Merit-based Incentive Payment System or an Alternative Payment Model, like a Patient-Centered Medical Home.

Here’s how the White House blog portrayed this legislative achievement.  And here is a brief summary of the key features from the point of view of the American College of Physicians (the ACP) which also provided a more detailed discussion of the law’s provisions concerning physician payment   And here is a one page handout summarizing these provisions of MACRA prepared by ACP for its member physicians.

Lots more to come on this!

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April 27, 2015

Why no physician leadership in disability at the Federal level?

I just returned from a trip to England, Ireland, Scotland and Wales studying their new national work disability prevention program, the Fit for Work Service and the events that led up to its creation.  It was a professional dream trip, and there are stories to tell.  But the MAIN THING I want to tell you today is a realization that dawned as I was on the plane back home.   I suddenly noticed that virtually all of the people I had met who have been persistently, solidly, visibly, and credibly leading or supporting the change efforts in the UK and Ireland are CLINICIANS, and nearly all of them are PHYSICIANS.   I met with Sir Mansel Aylward, Dr. Debbie Cohen, Dr. Kim Burton, Dame Carol Black, Dr. Bill Gunnyeon, Dr. Rob Hampton, Dr. Ewan MacDonald, and Dr. Clem Leech.    It was quite a shock once I noticed it, because I realized that there are few or no physicians playing equivalent roles in the US.   I wonder why not, and whether this should change.

I’m not talking about the political leaders.  I’m talking about the subject matter experts who analyzed the problems (made a diagnosis)  and came up with the ideas for what could improve it (treatment plan), and then patiently championed the cause, speaking on behalf of specific ideas for what needed to be done in order to provide more effective HELP to people to reduce the impact of injury, illness, age and congenital conditions on their lives – and then designed the initiatives and run the pilot programs, etc.

I have spent more than 30 years in the private sector, and only in the last couple of years have entered the Federal disability “marketplace of ideas”.   I’ve been rather steadily introducing the work disability prevention approach and the CLINICAL implications of the biopsychosocioeconomic (BPSE) model for the TREATMENT of sickness and disability into their world.   The strange thing is:  as a physician, I am nearly alone here.  There is a dearth of physician input much less actual leadership here.

The biggest message that physicians can bring:  some people on SSDI today have been over-disabled by the care they got in today’s inadequate and inequitable medical and disability benefits systems.   The right care could let them be less impaired and more functional — or even “un-disabled”.  This is particularly true of people disabled by common everyday conditions that DON’T disable most people.  The impairments they have today might have been avoided or minimized and their work disability could have been prevented by APPROPRIATE treatment in a RESTORATIVE system of care.  Today’s systems OVER-emphasize bodily anatomy and physiology (and over-aggressive treatments such as opioids, injections, and surgeries that often actually worsen outcomes).  Today’s systems UNDER-acknowledge the influence of the individual’s brain (memories, knowledge, thoughts, beliefs, reasonable concerns, fears, expectations and intentions) on their response to the predicaments that arise when symptoms appear that interfere with daily life and work .   As a result, treatments that have been shown to effectively address these things are NOT AVAILABLE.  Chronic pain is the poster child for this failure.   It really DOES MATTER whether the reason a person cannot perform a function is because of (a) paralysis or a fused bony joints  or (b) protective self-limitation and deconditioning.    Sometimes BOTH impairment and work disability are preventable – or remediable.

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