Tag Archives: leadership

May 22, 2018

If you’re interested in RETAIN, let ODEP know today!!

Please be a bumble bee and pass along this pollen information to your contacts at the large healthcare delivery organizations in your area/state that have an outside-facing occupational medicine department. This email is about a strategic opportunity for any occ med program that can also benefit the larger organization in which it sits – as well as hundreds or thousands of newly-injured/ill workers and their employers in their area!  It is a VERY TIME SENSITIVE opportunity, so if you know an organization to whom this might appeal, take action right away.

Any party with a potential interest in some aspect of the RETAIN demonstration projects described below needs to send an email to the Office of Disability Employment Policy (ODEP) in the US Department of Labor. The email address is SAW-RTW@dol.gov, and the phone number is (202) 693-7880. Tell ODEP you want to be put on the mailing list for the RFP (request for proposals) for RETAIN. It is expected to be released in the next week or so, and the deadline for responses will be short — because the money must actually be awarded by the end of September.

There is $67 million dollars in the Federal budget for RETAIN, which will be a five year project. In order for RETAIN to be successful, each state agency that is awarded the money (and will dispense it) will have to contract with – and develop a real working relationship/operational partnership with — one or more entities in the healthcare delivery sector. In Phase 1, the project budget will be roughly $2 million, and in Phase 2, roughly $18 million for each state that participates in the project. The Feds are hoping to award money to EIGHT states for Phase 1, and to FOUR states for Phase 2 – based on their success at getting themselves in position to deliver a successful demonstration.

A healthcare delivery organization you know might be an IDEAL setting for the new organization that will play a central role in the demonstration project. In Washington state, where this model was originally developed, tested, and proved successful, these new organizations are called Centers of Occupational Health & Education or COHEs. The purpose of these demonstration projects is to test a model of COHE-driven early intervention that delivers some simple and proven best practices known to help working people keep their jobs during recovery from an illness or injury that has recently disrupted their ability to work. The ultimate purpose is to reduce the number of rare and unusually poor outcomes: job loss with subsequent entry onto publicly-funded disability programs, especially Social Security Disability Insurance (SSDI). Studies have shown that the COHE program in Washington has improved almost every possible medical, claim, and employment outcome, including reducing inflow onto permanent disability programs by more than 25%.

I hope you will see the opportunity that RETAIN offers a local healthcare delivery system: to establish their organization as a highly visible and forward-thinking leader in occupational health – one that goes beyond delivering effective medical care for work-related injuries by ALSO minimizing some specific adverse secondary consequences of injuries and illnesses that today worsen outcomes and jeopardize too many working people’s lives and livelihoods! …..iIncluding (potentially) working people with non-occupational injuries and illnesses. More employers and workers are likely to choose to use an organization that enhances its services and thus its reputation for practical usefulness in this way.

A very brief description of RETAIN appears on page 6-7 of a Pre-Announcement of Upcoming Competitive Funding Opportunities which forecasts the release of several RFP’s (requests for proposals). I’ve also pasted the text about RETAIN from the Pre-Announcement below.

I’d LOVE to see YOUR state be one of the bidders, be selected, and then execute a resoundingly successful demonstration of this intervention model – because I see the need for it so clearly and trust the solid evidence that underpins it. You may already be aware that, as part of a Capitol Hill initiative to generate ideas for protecting SSDI, I led the development of a policy proposal that served as a source for this project. I was thrilled to tears when I got the phone call telling me it had become a Federal budget item, and have been following its evolution ever since. I am well known among some key players at the Federal level, since I was a member of the Stay-at-Work/Return-to-Work Collaborative sponsored by the Office of Disability Employment Policy (ODEP) at the US Department of Labor. ODEP will be administering/ overseeing the RETAIN demonstration project.

I can send you more detailed information now about the probable design of RETAIN if you’re interested. TIME IS OF THE ESSENCE if there’s ANY chance you or your colleagues or other organizations in your professional network or community might want to play. Send an email to the Office of Disability Employment Policy (ODEP) in the US Department of Labor at SAW-RTW@dol.gov, or call them at (202) 693-7880. Tell ODEP you want to be put on the mailing list for the RFP for the RETAIN demonstration projects.

And of course, if you’d like to toss around some ideas or I can help you in any way, give a shout.

US Department of Labor – Employment and Training Administration (ETA)
Upcoming ETA Competitive Funding Opportunities
Excerpt from pages 6-7

RETAIN Demonstration Projects ~ $63 million
Anticipated Publication: Summer 2018
Awards Made: Fall 2018

The Office of Disability Employment Policy (ODEP), in collaboration with the ETA  [US Dept of Labor’s Employment and Training Administration] and the Social Security Administration plan to award approximately $55,000,000 to $63,000,000 in cooperative agreement funds to plan and conduct pilot demonstration projects called RETAIN – Retaining Employment and Talent after Injury/Illness. RETAIN demonstrations will test the impact of early intervention projects on stay-at-work/return-to-work (SAW/RTW) outcomes. Central to these projects is the early coordination of health care and employment-related supports and services to help injured or ill workers remain in the workforce. To accomplish this, successful applicants will provide services through an integrated network of partners that include close collaboration between state and/or local workforce development entities, health care systems and/or health care provider networks, and other partners as appropriate.

The RETAIN Demonstration will be structured and funded in two phases. The initial period of performance (Phase 1) will be 18 months and will include planning and start-up activities, including the launch of a small pilot demonstration no later than month nine. We expect to provide approximately $2,166,000 each to an estimated six state workforce agencies in the form of cooperative agreements for Phase 1. At the conclusion of the initial period of performance, a subset of up to three Phase 1 awardees will be competitively awarded supplemental funding of up to $18,600,000 to implement the demonstration projects during Phase 2. Awardees will be required to participate in an evaluation, which will be designed in Phase 1 and conducted during Phase 2 by an external, independent contractor.

The following organizations are eligible to apply:
• State Departments of Labor, State Workforce Development Agencies, or an equivalent entity with responsibility for labor, employment, and/or workforce development; and
• Entities described in section 166(c) of WIOA relating to Indian and Native American programs. These entities include Indian tribes, tribal organizations, Alaska Native entities, Indian-controlled organizations serving Indians, or Native Hawaiian organizations. These applicants are not required to partner with Local Workforce Development Boards (LWDBs).

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January 5, 2018

More empathy for suffering improves patient experience

I just ran across the story of Rana Awdish and her sudden, near-fatal medical catastrophe — which put her in the critical care unit and resulted in the death of her near-term unborn baby.  She is a physician and was in specialty training for critical care medicine at the time.  The experience taught her a lot about the nature of suffering.  It also showed her that human caring and empathy is too often missing in hospital care today.  The story appeared on the NPR website yesterday, entitled Brush With Death Leads Doctor to Focus on Patient Perspective. She’s just published a book about the experience and what it taught her.  The title is In Shock.

I found an essay of hers published in the New England Journal of Medicine a year ago entitled “A View from the Edge – Creating a Culture of Caring”. In it, she provides more facts about what happened, especially the way the hospital medical staff and other employees treated her while she was in the hospital.  She clearly had intense emotional suffering at the same time her body systems were failing and she was near death.  Sadly, it is also clear that the people taking care of her did a much better job of attending to her medical problems than her human ones.

In her recounting of the facts, she highlighted specific careless and hurtful remarks that she had overheard or that her physician colleagues had said to her face.  She also highlighted some examples of tender caring others had demonstrated during her hospital stay.  In her new position as Medical Director for Care Experience at the hospital, she has used those specific examples to improve the training for all employees, from physicians to housekeeping staff.

Reading the three paragraphs below transformed the essay for me; it went from worthwhile to sublime.

“Through the training that was developed, participants learn to articulate their purpose as distinct from their job. Transporters hear how meaningful it was to me when one of their own — having seen me break down when questioned by someone in radiology — took it upon himself to warn the technicians performing various tests not to ask about the baby whose small pink wristband was still in my chart. He asked his colleagues to do the same. In an 800-bed hospital, the transporters had united to form a protective enclosure around one patient.

“Similarly, radiology technicians learn what a kindness it was that they stopped trying to awaken my exhausted husband to move him from my bedside for my portable x-ray, instead throwing a lead cover over him and letting him sleep. The power of these stories shows new employees that they have a purpose and that they are valued.

“In addition, new employees are taught to recognize different forms of suffering: avoidable and unavoidable. Our goal is to find ways to mitigate suffering by responding to the unavoidable kind with empathy and by improving our processes and procedures to avoid inflicting the avoidable kind whenever possible.”

I bet every single employee can find a way to share in a purpose like that.  From top to bottom on the hospital’s / corporation’s / our society’s pecking order of life, we have our humanity in common. We all have hearts and the innate ability to attune ourselves to notice another’s need or distress, and then to find a way to express caring for them.

There is an irony in the essay.  Most of the examples of uncaring comments came from highly trained healthcare professionals.  Most of the examples of compassionate behavior came from employees with more humble backgrounds and jobs.

Here’s another example of that, a YouTube video about Carolyn Collins, the janitor at Tucker High School.  The narrator says Carolyn has found her “true calling” — a purpose she finds deeply meaningful.  She maintains an extra “janitor’s closet” full of necessities for the 20 to 30 homeless students who attend that school.  She came up with the idea herself.  And she spends her own time and money to make sure that closet is fully stocked so those homeless kids always have access to free clothes, school supplies, snacks, and emergency food.

Notice again that this big-hearted person is a janitor.  As you listen to her talk on the video, imagine her own background, her educational level, and the size of her paycheck.  The narrator says Carolyn’s young son was killed in a home invasion.  I think Carolyn believes the person who killed her son was a desperate person.  As soon as she realized there were homeless kids attending Tucker High School, she was inspired to act.  She wants them to have what they need so they can go to school, and don’t need to steal or get in trouble — or kill someone.

I find the goodness of people heart-piercingly beautiful. And I’m the one who feels humble right now.

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September 9, 2016

Pithy 4-min Video & 1-page Manifesto for you to use

Mathematica just released a 4-minute video of me pointing out why the work disability prevention model is important — in plain language.  The video was made at the request of the US Department of Labor’s Office of Disability Employment Policy (ODEP).  The main messages in the video are:

  1. MILLIONS of Americans lose their jobs every year due to injury and illness;
  2. Worklessness and job loss have been shown to harm physical and mental health as well as personal, family, social, and economic well-being;
  3. Worklessness and job loss should therefore be considered poor healthcare outcomes;
  4. Unexpectedly poor outcomes can often be prevented and there is good research evidence about how to do that;
  5. Changes need to be made so that vulnerable people get what they need at the time when they need it — and as a result are able to have the best possible life outcome, stay in the workforce, and keep earning their own living.

In addition, the video also explains WHY and HOW some people have unexpectedly poor outcomes of conditions that do not normally cause significant work disruption and job loss.  Unless you’re in my line of work, it is hard to understand why things turn out badly in some cases and not in others — especially if they looked exactly the same at the beginning.

The video is loosely based on a one-page Work Disability Prevention Manifesto I wrote.  I put a draft of it on this blog last spring and got many useful comments.  After many revision cycles, it is now as succinct and compelling as I know how to make it.  ODEP had no hand in the Manifesto; it’s my independent work.

I’m glad I can now share these two items with you because the WORLD needs to know more about these issues—and most PEOPLE in the world have a very short attention span and no interest in the topic to begin with.   I hope you will pass this stuff along to the people whose thinking you want to change or whose buy in you need. Then maybe THEY will pass it along to others as well.  Social norms ONLY SHIFT when people share powerful mind-opening ideas with one another.

Lastly, let’s all stop speaking ABOUT these problems.  It is time for us all to start speaking FOR action and FOR changes.

WORK DISABILITY PREVENTION MANIFESTO
©Jennifer Christian, MD, MPH August 2016

Preventable job loss demands our attention

  • Millions of American workers lose their jobs each year due to injury, illness or a change in a chronic condition.
  • Preserving people’s ability to function and participate fully in everyday human affairs, including work, is a valuable health care outcome, second only to preserving life, limb, and essential bodily functions.
  • A new medical problem that simultaneously threatens one’s ability to earn a living creates a life crisis that must be addressed rapidly and wisely. Most people are unprepared for this double-headed predicament. It can overwhelm their coping abilities.
  • When medical conditions occur or worsen, especially common ones, most people are able to stay at or return to work without difficulty. However, many prolonged work disability cases covered by private- and public-sector benefits programs began as very common health problems (for example, musculoskeletal pain, depression, and anxiety) but had unexpectedly poor outcomes including job loss.
  • Loss of livelihood due to medical problems is a poor health outcome. Worklessness is harmful to people’s health, as well as to their family, social, and economic well-being.

Why do such poor outcomes occur?

  • Medical conditions by themselves rarely require prolonged work absence, but it can look that way. Both treatment and time off work are sometimes considered benefits to be maximized, rather than tools to be used judiciously.
  • Professionals typically involved in these situations (health care providers, employers, and benefits administrators) do not feel responsible for avoiding job loss.
  • Unexpectedly poor outcomes are frequently due to a mix of medical and nonmedical factors. Diagnosed conditions are inappropriately treated; others (especially psychiatric conditions) are unacknowledged and untreated. The employer, medical office, and insurance company (if there is one) operate in isolation, with little incentive to collaborate.
  • Without the support of a team focused on helping them get their lives back on track, people can get lost in the health care and benefits systems. With every passing day away from work, the odds worsen that they will ever return. After a while, they start to redefine themselves as too sick or disabled to work.
  • When people lose their jobs and do not find new ones, they barely get by on disability benefits and are vulnerable to other detrimental effects.

How can we fix this problem?

  • Good scientific evidence exists about how unexpectedly poor outcomes are created, how to avoid them, and how health care and other services can protect jobs.
  • Health-related work disruption should be viewed as a life emergency. Productive activity should be a part of treatment regimens.
  • When work disruption begins, it can be both effective and cost-beneficial to have a coordinator help the individual, treating physician, and employer communicate and focus everyone’s attention on maximizing recovery, restoring function, accommodating irreversible losses, and making plans for how the individual can keep working, return to work, or quickly find a more appropriate job.
  • We must urgently establish accountability for work disability and job loss in our workforce, health care, and disability benefits systems and build nationwide capacity to consistently deliver services—just in time, when needed—that help people stay at work or return to work.
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July 14, 2016

Why we need a 1:1 ratio of healers to lawyers when designing reforms for “comp”

While Linda Rudolph was Medical Director of the California workers’ compensation regulatory agency in the mid-1990’s, she defined workers’ compensation as a medically-driven legal system.  I still use that definition when I give my annual lecture on work comp at the Harvard School of Public Health.   Based on my interpretation of what that succinct and elegant summary really means, I believe that any group setting out to improve the workers’ compensation system should have a roughly equal number of people at the table who were originally trained in a healing art and the law — because of the way their minds were indelibly imprinted by that training.

As you may have heard, I was among 38 workers’ compensation experts of various stripes who participated in the Workers’ Compensation Summit co-hosted by blogger Bob Wilson from workerscompensation.com and blogger Judge David Langham, Deputy Chief Judge of the Florida workers’ compensation system.

I was surprised as we went around the room introducing ourselves.  I was one of only two physicians in the room.  There were no others with healthcare professional training.  There was one person whose original training had been as a vocational counselor.  By far the largest group had had legal training, although many of them were now in other jobs — judges, legal scholars, workers’ compensation system administrators, corporate executives.

Training in both law and in medicine shapes a student’s worldview, teaches a precise vocabulary, builds a foundation of factual knowledge as well as rigorous intellectual discipline, and defines how things work in a certain part of human life.  The training also establishes a finite range of things that seem possible, and offers a particular inventory of potential solutions.  A behavioral acculturation process accompanies it, too.  The point here, though, is that the actual shape and content of those worldviews, vocabularies, knowledge bases, intellectual disciplines, possibilities and solutions — and behavioral cultures — differs in most respects between the two professions.

Earlier in life, I spent 20 years as a physician married to a lawyer.  For many reasons, it was kinda like a nice cat being married to a nice dog.  We had a primordial kind of incompatibility.  But I did get to know what made that particular dog tick pretty well.

Lawyers seem to have a predilection for solutions that involve clarifying rights, justice, entitlements, boundaries, and who is responsible to pay for what.  Lawyers are trained to advocate for their clients’ rights and interests.  Most lawyers seem to spend an awful lot of their time and energy anticipating arguments or actually arguing, fighting, and trying to win  — because the everyday grist of their vocational mill is broken promises and disputes.

As I was pondering the difference between the “head set” of medicine and law, I found a quote from an article in the May 31 Boston Globe about a 35 year old man, a published author and poet, now  graduating from Yale Law School — who at age 16 had hijacked a car at gunpoint and served 8 years in prison.   He said “The law is a way to think and argue, and a way to find solutions….. Law is the language of power, and understanding that language is important to understanding power.”  This quote struck me — not because he’s so amazing (which he obviously is) but because he articulated so precisely what I had predicted a lawyer would say.

Physicians and others in the healing professions have a predilection for solutions that reduce peoples’ suffering and restore the integrity of their bodies/minds.  Medicine has nothing to do with winning.  The first precept of medicine is to do no harm.  Physicians are trained to advocate for their patients’ health, to meet their immediate needs today and maximize their future well-being in the future.  The everyday grist of their vocational mill is providing comfort, relief, and reassurance to a stream of patients coming through the door with symptoms, with bodies or minds that aren’t working right, distressed and worried about the meaning of those things for their health and everyday activities (and often secretly fearing death).

In my view, a good “medically-driven legal system” for people injured at work should concern itself primarily with helping injured workers get back on their feet.  That requires paying roughly equal attention to

  1. Helping them manage any life predicament the injury has caused (reducing worry, suffering, and distress, arranging good care promptly that maximizes healing and restores function as quickly as possible, preserving daily routine, minimizing work disability and job loss or providing assistance to find a new job quickly.  The goal is to get everyday life back to normal as soon and as completely as possible.  Time spent in limbo is destructive.
  2. Minimizing their short-term financial stress as well as long-term financial loss, sorting out their rights, and dealing with disputes.

Everyone’s goal should be to expedite the activities in #1 even if there are difficulties in #2, instead of allowing #2 to delay #1 as is common today.

 

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June 14, 2016

Take an important step BEFORE the sausage making starts …….

Do you know the Bible story about wise King Solomon and his response to the two mothers fighting over two babies — a living one and a dead one?   Each claimed the living one was hers and the dead baby belonged to the other.  King Solomon offered to cut the living baby in half and give each mother a fair share. The real mother was revealed when she said she would give up her claim to the baby rather than have it die.

The efforts being made now to “modernize” workers’ compensation and other large scale disability benefits programs may end up dividing the live baby in half by becoming prematurely dominated by the sausage-making and log-rolling among powerful vested interests on all sides.  In particular, past efforts at “reform” in workers’ comp have been feeding frenzies for those who live off system inefficiencies and inequities.  The result is the continuing sacrifice of the metaphorical living baby — the well-being and long-term quality of life of the individuals these systems are intended to protect, and the economic and social health of our society as a whole (as represented by the taxpayers).

By their nature in a pluralistic and democratic society, legislative and regulatory reform ARE sausage-making and log-rolling activities.  As a regulator commented at last month’s Workers’ Comp Summit, good government must “account for the multiplicity of interests”.  That said, we have a better shot at creating a more satisfactory system IF we give the sausage-makers a North Star to guide their efforts.   As they write legislative language, they need to be using a written “spec sheet” of requirements that the solution must meet — a list of the major design principles or performance specifications that a twenty-first century replacement would need to satisfy.  A credible group needs to come up with a draft System Design and Performance Specifications document which could then be circulated for comment and revision in community meetings and industry groups all around the country.

The people invited to create the spec sheet should be well suited for this kind of socially responsible foundation-laying project:  thoughtful, expert in the matters at hand, with real world and front line experience, each respected in their own sector, able to see things from a broad perspective — and preferably NOT elected officers or designated representatives of organizations.  The participants must feel completely free to advocate for what they think is best for the two parties most vulnerable to system dysfunction (the affected individuals and society as a whole).  The people sitting at the table must not allow themselves to be swayed by the vested interests of their own livelihood, profession, enterprise, trade association, or industry — but should be worldly wise enough to acknowledge the power that those interests have to distort and defeat naive solutions.

As an example of the KIND of document that might result, see this preliminary draft for a set of design principles for the nation’s healthcare system.  This list was developed in the late 2000’s — before Obamacare was passed and signed into law.   It expands and refines an initial set of ideas that bubbled up from a small group of people in different walks of life in my “social set.”

As citizens and taxpayers, we were uncomfortable at the country’s lack of a core document articulating widely-accepted values, principles or expected outcomes against which to judge the merit of various details in the legislative proposals.  We also felt that a document with core principles like these could later be used to determine whether a law is creating the desired changes, and to guide later amendments and regulatory changes.   After creating this document, I envisioned groups around the country holding community meetings, to either consider and modify it or come up with their own versions.

Widespread engagement in dialogue at the community level — a “from the ground up” development of the US population’s vision of what a well-functioning health system would look like — would have given the USA a coherent values-based and outcomes-based population health policy at long last.  The results being produced by the ACA today could be compared with that vision/policy in order to judge whether Obamacare has moved us towards or away from that vision, and to identify places where changes need to be made.  (And you do realize that the US still doesn’t have a population heatlh policy, right?)

Similarly, while there is wide acknowledgement that modernization of our nation’s workers’ compensation system is needed, why don’t we take this tack and start building a vision of how a good system SHOULD operate, and the results it SHOULD produce?

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May 18, 2016

It’s time to establish accountability for job loss

My report on Establishing Accountability to Reduce Job Loss After Injury or Illness (commissioned by the US Department of Labor’s Office of Disability Employment Policy) was originally conceived as a simple effort to lay out the rationale for adding work and participation in life to the list of positive health outcomes.  (I suspect that I was asked to write it because they thought a physician like me would focus on medical practitioners and the healthcare delivery system.)

Almost immediately, it became obvious to me that in order to make a solid contribution to the on-going public dialogue about health outcomes, the paper would have to explore the meaty issues of explicit expectations, accountability, metrics, credible data, rewards for best practices, and incentives for both participation and performance.

Soon after that, the absurdity of discussing expectations and accountability for the healthcare system alone became obvious —because organizations in other sectors of society play a role in the SAW/RTW process, each of which has enough discretionary power to support or thwart it.

Thus, over time, the purpose of the paper shifted to answering this question:  What has to happen in order to engage the professionals at the front-line  — the ones who work directly with affected individuals and make discretionary decisions about how much effort to make and for what purpose — so they start making a real effort to help people stay employed?

Who are those front-line professionals?

(1) Healthcare professionals.  Most of us view our purpose as making accurate diagnoses and providing appropriate treatment.   We are generally not trained to assess work capacity and prevent work disability.  Yet our opinions about work have considerable weight under law, regulations, insurance policies and traditional business practices.  We generally don’t spend much time and energy thinking about issues outside the exam room.

(2) Workplace supervisors or HR professionals.  Their focus is the business of the organization, producing its goods or delivering its services,as well as abiding by company policies and applicable laws. They can decide how much effort to make to help the employee stay at work and keep their job.  With rare exceptions, they are neither aware of the preventable nature of most work disability, nor are they trained how to negotiate and arrange stay at work or return to work plans, identify alternative temporary tasks or reasonable accommodations.  And they are not incentivized to do so.

(3) Claims/benefits administrators.  Their focus is administering the benefit programs correctly, establishing eligibility, compensability, meeting deadlines, making payments, and other requirements. In between these duties, they decide how much effort to make to help the beneficiary/claimant. Like the workplace professionals, with only rare exceptions, they are neither aware of the preventable nature of most work disability, nor are they trained how to negotiate and arrange stay at work or return to work plans, identify alternative temporary tasks or reasonable accommodations.  And they are not incentivized to do so.

Job loss is the third worst outcome of an injury or illness

As I thought about these players and those who influence their behavior, the biggest realization dawned more slowly:  job loss is a potentially devastating secondary consequence of a health-related employment disruption or a failed SAW/RTW process — because it often leads to permanent withdrawal from the workforce.  In fact it is the third worst outcome of a health condition, the other two being death and loss of limb or core functions like sight and hearing.

Yet we have not seen it that way.  Unlike death and serious injury, job loss is generally not noticed.  It’s actually a hidden outcome.  The frequency with which it occurs can only be estimated indirectly — because it is untracked and thus invisible.  When someone loses their job due to long-lasting illness or injury, they often end up leaving leave the workforce permanently, becoming dependent on public benefits programs like SSDI.

Some years ago, a senior Social Security Administration official commented to me that SSDI is the largest insurance fund IN THE WORLD and yet it has no risk management program, no loss prevention program.  Private sector insurance companies view these as core functions of their organizations.  They know they must identify and take steps to reduce risks and mitigate losses in order to meet their responsibilities and stay solvent.

In my view, government should be likewise obligated to take steps to protect SSDI (and the taxpayers who fund it) from the economic consequences of the dysfunctions, inadequacies and gaps in the upstream social structures and programs — because their failures end up on public benefit programs.

Government will make a major contribution to reducing demand on SSDI by:
(1) establishing policy that job loss/withdrawal from the workforce is a very unfortunate outcome of a health problem and should be avoided whenever possible,
(2) enabling all parties to see more clearly when it happens by requiring reporting of these events; and
(3) establishing consequences of some sort when involved organizations are non-responsive (negative incentives such as financial penalties, loss of privileges, or public exposure) or do take appropriate action (positive incentives such as credits, privileges, or favorable publicity).

This combination of outcomes visibility and accountability should then start to shift how parties in the private marketplace choose vendors and suppliers.

How will things look different when there IS real accountability for job loss?  

Implementing the broad range of actions recommended in the Establishing Accountability report will require a significant long-term effort because of their comprehensive, complex, and varied nature.  Taken as a whole, these actions have the potential to create truly transformational change.

Success will mean that more workers living with adult-onset chronic conditions and impairments (acquired disabilities) will be able to stay fully and productively engaged in their own personal, family, and community life; protect their household’s standard of living; remain economically self-sufficient contributors to their local area economy; and avoid dependency on government programs—which will in turn protect their future health and well-being and improve their children’s future prospects.  At the national level, success has the potential to stem the tide of declining labor force participation, lighten taxpayer burdens, and bolster the nation’s social fabric and the vitality of the economy.  All in all, the initiatives proposed make good use of limited government resources.

The ultimate success of the initiative will hinge on the ability of Federal policy leaders and supporters to create and sustain real multi-stakeholder buy-in and enthusiasm for achieving the future vision described in the paper.   A good next step is for the federal and state governments to decide whether and where to start.  It will take time and effort to achieve consensus among key stakeholders that this kind of initiative is necessary, timely, and deserves priority for person-power and funding.  Once that preliminary groundwork is laid, more detailed planning work can get underway.

Whoever you are, I hope you read the Establishing Accountability paper and agree that change and action is needed.  If my suggested recommendations spur you on to creative thinking, you do NOT need to wait for the government to act.  You can start factoring these issues into your decisions about who to collaborate with now.

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March 7, 2016

Manifesto – Preventing Needless Work Disability (DRAFT)

I’ve tried to squeeze all the main ideas of the work disability prevention (WDP) model into one page (see below). The model has matured over the last several years as key dynamics have become more apparent.  I’m curious to hear your reaction to this new version.

After promoting the WDP model in the private sector for a long time, I started introducing it to the Federal / State disability sector in 2011.  Now seems like the right time to get a compelling and very succinct document circulating so it gets in front of many more eyes  – for example, lots of eyes on Capitol Hill and in regulation-creating / law-making (sausage making) circles.

The members of the Work Fitness & Disability Roundtable are also helping me craft a 3 or 4 bullet “sound bite.”  However, in my view it will take more than that to get influencers and decision-makers to decide to explore these issues further. They need a quick summary of WHAT the problem is, WHY things look the way they do, and WHAT might be possible instead — but just a bit.  Thus, this one-pager.

I’m not yet clear what to do with this draft – other than to post it here and solicit your comments.   Am also hoping to get your ideas for the best organization to issue and disseminate a manifesto like this — so it has the maximum impact.  What are the chances of it going viral?  Please leave a comment below or email me your ideas and suggested revisions.

Work Disability Prevention Manifesto (DRAFT)

  • Preserving people’s ability to function and participate fully in everyday human affairs, including work, is a valuable health care outcome, second only to avoiding loss of life, limb, and essential bodily functions.
  • Loss of livelihood due to medical problems is a poor health outcome because worklessness is harmful to people’s health as well as their personal, family, social, and economic well-being.
  • A new medical problem that threatens the ability to continue earning a living is a big challenge – a life crisis that must be addressed. Most people are unprepared, never having faced this double-headed predicament before. It can overwhelm their coping abilities.
  • When medical conditions occur or worsen, especially common health problems, most people are able to stay at or return to work without difficulty because the right things tend to happen during the first few days or weeks.
  • However, many of the prolonged work disability cases in both private and public sector sickness programs, disability benefits, and workers’ compensation programs began as very common health problems (for example musculo-skeletal pain, depression, and anxiety) but had unusually poor outcomes.
  • Unusually poor outcomes are frequently due to the interplay of sub-optimal health care and non-medical factors. Without a team focused on helping them get their lives back on track, people can get lost in the healthcare and benefits systems. Remediable issues in the situation are overlooked and not addressed. Incentive alignment among the involved parties is poor.
  • Medical conditions by themselves rarely require prolonged work absence, but it can look that way. And with every passing day away from work, the odds are worsening that people will ever return to work. After a while, they start to see themselves as too disabled to work.
  • Unlucky people lose their job and do not find a new one. They leave the workforce and eke by on disability benefits, in poverty, and vulnerable to its detrimental effects.
  • Today, most professionals typically involved in these situations (healthcare professionals, employers, and benefits handlers) do not feel responsible for avoiding job loss.
  • Good scientific evidence exists about how unusually poor outcomes are created, how to avoid them, and the health care and other services that can optimize function and protect jobs.
  • When work disruption begins, it is both effective and cost-beneficial to have a coordinator assist the individual, their treating physician, and their employer with communications, as well as focus everyone’s attention on restoring function, accommodating irrevocable losses, and making plans for how to keep working, return to work, or quickly find a more appropriate job.
  • Urgent priority should be given to establishing accountability for work disability and job loss as well as building nationwide capacity to consistently deliver services that help people stay at work or return to work – just in time, when needed.
  • Helping more people with medical problems to keep their jobs or find new ones in a timely manner will benefit them and their families, and will benefit our society as a whole.

March 7, 2016

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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

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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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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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