Tag Archives: Federal

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!

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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 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 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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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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