Establishing Accountability to Reduce Job Loss AFter Injury or Illness

FINAL REPORT

Establishing Accountability to

Reduce Job Loss After Injury or

Illness

October 2015

Jennifer Christian*

Submitted to:

U.S. Department of Labor

Office of Disability Employment Policy

200 Constitution Ave. NW

Washington, DC 20210

Project Officer: Janet Voight

Contract Number: DOLQ121A21886/DOL-OPS-14-U-0087

Submitted by:

Mathematica Policy Research

1100 1st Street, NE

12th Floor

Washington, DC 20002-4221

Telephone: (202) 484-9220

Facsimile: (202) 863-1763

Project Director: Yonatan Ben-Shalom

Reference Number: 50015.400

*Webility Corporation

Preparation of this item was funded by the Office of Disability Employment Policy, U.S.

Department of Labor, Contract Number DOLQ121A21886/DOL-OPS-14-U-0087. This document

does not necessarily reflect the views or policies of the Office of Disability Employment Policy, U.S.

Department of Labor, nor does the mention of trade names, commercial products, or organizations

imply endorsement by the U.S. government

ACKNOWLEDGMENTS

This report was prepared by Jennifer Christian of Webility Corporation for the Office of

Disability Employment Policy (ODEP), U.S. Department of Labor. A group of subject matter

experts (listed below) offered valuable information, insight, and advice. Although this report has

benefited greatly from their input, they did not review its contents, and the report does not

necessarily reflect their views or imply their endorsement. The author thanks Mathematica’s

Yonatan Ben-Shalom, David Stapleton, and Gina Livermore for their helpful comments on the

report, Effie Metropoulos for editorial support, and Sharon Clark for production support. The

author also thanks Meredith DeDona, Janet Voight, and Michael Reardon of ODEP for their

guidance and support throughout the entire project.

Members of the policy work group

• Ed Corcoran, independent consultant

• Kim Jinnett, Integrated Benefits Institute

• Ann Kuhnen, The Hartford

• Jane Ryan, Mayo Clinic

• William Shaw, Liberty Mutual Research Institute

• Mary Ellen Wright, Kansas Medicaid

Other subject matter experts who were interviewed

• Stephen Bevan, The Work Foundation, Lancaster University; Fit for Work Europe

• Casey Chosewood, NIOSH Total Worker Health

• Marianne Cloeren, Managed Care Advisors

• Peter Dandelides, WorksiteRx

• Aaron Konopasky, Equal Employment Opportunity Commission

• Carolyn Langer, Massachusetts Medicaid

• Pamela Mazerski, independent consultant

• Kathryn Mueller, Colorado Department of Labor and Employment

• Peter Rousmaniere, workers’ compensation consultant

• Steve Serra, Aetna

• Bruce Sherman, National Business Coalition on Health

• Hal Stockbridge, Washington State Department of Labor and Industries

• Sara Tamers, NIOSH Total Worker Health

• Richard Victor, Workers Compensation Research Institute

• Karen Wolfe, MedMetrics

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CONTENTS

ABSTRACT ................................................................................................................................................. VII

I. INTRODUCTION .............................................................................................................................. 1

II. BACKGROUND ............................................................................................................................... 3

A. The affected worker ................................................................................................................... 3

B. Frontline and supporting stakeholders ...................................................................................... 4

III. RECOMMENDATIONS AND A VISION FOR THE FUTURE .......................................................... 7

A. Three recommendations ............................................................................................................ 7

B. A view from the future after a transformational change ............................................................ 8

IV. DETAILED SUGGESTIONS FOR IMPLEMENTING THE RECOMMENDATIONS ...................... 11

A. Capture and consolidate the data necessary to create credible metrics and establish

real accountability .................................................................................................................... 11

B. Provide federal leadership in public health, health care, and social policy ............................. 12

C. Encourage key frontline players to work for positive SAW/RTW outcomes ............................ 14

REFERENCES ............................................................................................................................................ 17

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ABSTRACT

This is one of three policy action papers prepared as part of the Stay-at-Work/Return-to-

Work Policy Collaborative, an initiative funded by the Office of Disability Employment Policy

in the U.S. Department of Labor.

Each year, millions of workers in the United States lose their jobs or leave the workforce

after their ability to work is disrupted by a medical condition. Keeping these workers in the labor

force could help them stay productive, maintain their standard of living, and avoid dependency

on government programs. In this paper, we present actionable policy recommendations for

keeping more people at work by (1) establishing the preservation or restoration of work and full

participation in life as key outcomes and important indicators of the value delivered by medical

care and other health-related services; (2) making three key stakeholders who directly influence

those outcomes more accountable: health care delivery organizations, employers, and insurers;

and (3) designing and implementing an array of strategies to give the accountability real teeth,

disrupt the current status quo, and deliver transformational social change.

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I. INTRODUCTION

Productive engagement and economic self-sufficiency are expected and desirable features of

a full and satisfying adult life. But every year, millions of workers across the nation lose their

jobs or leave the workforce entirely after a medical condition compromises their ability to work.

In many cases, these unfortunate outcomes might have been prevented. Federal policy is

currently focused on helping people get jobs after a long period of disability, but a second area of

focus is needed: helping working-age individuals keep their jobs or promptly find new ones soon

after they develop health problems.

Recent reviews of the evidence have documented how work promotes positive physical,

mental, and social well-being for all individuals—including those with chronic health conditions

(Waddell and Burton 2006)—and how worklessness does the opposite (Waddell and Burton

2006, Strully 2009). Keeping individuals in the workforce protects their health and well-being,

quality of life, and standard of living. It also prolongs their years of productive contribution to

society and helps them avoid dependence on Social Security Disability Insurance (SSDI),

Medicare, and other federal, state, and local disability-related programs.

This paper offers three recommendations for policies that could keep more workers earning

a living after their lives are disrupted by a medical condition. The three recommendations are

supported by detailed suggestions for carrying them out.

The recommendations made in this paper rest on four premises:

• Premise 1. The criteria that define a healthy adult should include participation in human

society and engagement in productive activity, whether paid or unpaid, as long as it is

feasible. These criteria should apply to all adult Americans and be adjusted for each person’s

specific functional abilities as appropriate.

• Premise 2. Maximizing the number of adults who are self-sustaining taxpayers and

contributors to the economy is vital to ensure continued prosperity.

• Premise 3. Today, individuals with a new health-related employment predicament look first

for assistance from three types of frontline professionals. These professionals are in different

disciplines and work in separate places: managers in the affected individual’s own

workplace, practitioners in healthcare delivery organizations, and administrators in the claim

departments of health care, disability, and workers’ compensation programs. None of these

professionals feel responsible for helping affected workers keep their jobs. They are only

held accountable for achieving the limited goals of their own discipline and organization.

They have neither a shared definition of a good outcome, nor a common understanding of

each other’s roles, capabilities and responsibilities, nor a tradition of collaboration with one

another to achieve shared goals.

• Premise 4. The current situation reflects the complex and fragmented nature of the nation’s

health care and welfare systems in both the private and public sectors. Those systems are

also in a state of uneasy equilibrium, balancing the inertia of long-standing traditions and

stakeholders' vested interests with the flux and uncertainty that characterize an era of health

care reform and growing pressure on payers and public benefit programs. Despite expansion

of the civil rights of disabled workers under the Americans with Disabilities Act (ADA), the

I. INTRODUCTION MATHEMATICA POLICY RESEARCH

demand for taxpayer-funded disability benefits continues to grow as the rate of participation

in the workforce steadily declines.

The paper proceeds as follows. In Chapter II, we describe the current environment and the

perspective of key stakeholders. In Chapter III, we present our three main policy

recommendations and our vision for the future. In Chapter IV, we present detailed suggestions

for carrying out the three main recommendations.

See Congressional Budget Office (2012) and U.S. Bureau of Labor Statistics (2015).

II. BACKGROUND

When a person’s ability to work is threatened by a medical condition, there are four main

stakeholders who affect the outcome. The worker is most important, but the outcome will also

depend on the actions and decisions of three types of professionals, each in a different sector:

health care delivery, employment, and insurance. Each of these professionals is directly

responsible for separate and well-defined aspects of the individual’s care and experience. We

discuss these frontline stakeholders here and then describe others that play indirect or supporting

roles.

A. The affected worker

In all but the most extreme cases, the affected person is in the most powerful position to

determine the eventual outcome of his or her situation. A diagnosis that affects the ability to

work can make a person feel powerless, but decisions must be made about how to handle the life

predicament it has caused. Ultimately, the affected person is the only one who can choose how to

respond to the health and employment challenge, how to adapt to his or her new circumstances,

and how hard to work to create a satisfying “new normal” everyday life and future.

How a specific individual responds is partly a function of his or her overall health, strength,

and vitality, but is also affected by personality traits, inherent capabilities, world view, cultural

background, history, and environment. The environment includes families, doctors, employers,

and insurers, as well as the legal, administrative, and economic context. Taken as a whole, these

non-medical dynamics are an integral part of the biopsychosocial model of sickness and

disability (Waddell et al. 2008; Loisel and Anema 2013). We recommend expanding the term to

bio-psycho-socioeconomic (BPSE), given the powerful impact of financial considerations on the

behavior of all stakeholders when a potentially disabling condition becomes manifest.

Some workers’ careers are disrupted by unusual and devastating medical conditions

characterized by sudden, obvious, and irreversible physiological alterations. A much more

frequent scenario is job loss due to conditions with a mixture of symptoms like pain, weakness,

coping difficulties, and the inability to tolerate certain activities due to hidden functional

impairments. These conditions are most often low back, shoulder, and knee musculoskeletal

(MSK) problems, and chronic mood disorders (CMD)—typically depression and anxiety.

Roughly half of the workers now entering the SSDI rolls have MSK and CMD diagnoses.

It is

important to recognize that the overwhelming majority of people diagnosed with these same

conditions every year are able to stay employed —those entering SSDI have had unusually poor

outcomes.

The factors that predict unusually poor outcomes (such as severe impairment and prolonged

work disability) of MSK problems, especially low back pain, are not firmly related to either the

specific diagnosis or the extent of the pathology (Caruso 2013; Franklin et al. 2014; Franklin and

Mueller 2015; Habeck et al. 1998; Harris et al. 2008; Johnson and Fry 2002; Mahmud et al.

2000; Nicholas et al. 2011). Although less research has been done on factors that predict poor

In 2013, 35.9 percent of SSDI’s awards to disabled workers went to individuals with “diseases of the

musculoskeletal system and connective tissue” and another 15.6 percent were to workers with “mental disorders”

(SSA 2014).

II. BACKGROUND MATHEMATICA POLICY RESEARCH

outcomes in CMD, and diagnosis does play a more significant role, there are important non-

medical factors (Arends et al. 2014; Cornelius et al. 2011; Loisel and Anema 2013).

Furthermore, MSK and CMD often co-occur.

Some of the factors that predict poor outcomes are preexisting or immutable, such as age,

medical history, work history, and geographic location. But the way a health-related episode

unfolds over time in all dimensions—biological, psychological, social, and economic—can have

a big impact on the outcome. Events 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 the onset of a health problem—and substantially

fewer opportunities later on—but today there are few resources devoted to finding and exercising

these early opportunities.

Examples of negative prognostic factors that are potentially remediable include many non-

medical ones (Waddell et al. 2001; Loisel and Anema 2013), especially elapsed time out of work

(Caruso 2013; McLaren et al. 2010; Loisel and Anema 2013; Wickizer et al. 2011), uncertainty

and distrust due to lack of communication or information (Bowling 2000; Loisel and Anema

2013), uncoordinated or inappropriate medical care and advice (Abásolo et al. 2005; Franklin et

al. 2014), low expectations of recovery (Cornelius et al. 2011; Sullivan et al. 2005), excessive

vigilance, catastrophic thinking, false beliefs, fear of movement, self-limitation, perceived

injustice (Sullivan et al. 2005), and lack of employer support (Cornelius et al. 2011).

Today, the professionals who typically handle these situations do not look for any of the

potentially remediable problems mentioned above and, as a result, do not address them. None of

the professionals have been trained to try to avert job loss (ACOEM 2006), and most will never

even know if it happens. As a result, it is reasonable to presume that some of the workers in this

group have ended up with lost livelihoods and a future on disability benefits, even though their

impairments may have been preventable or reversible, or could have been successfully

accommodated in the workplace.

B. Frontline and supporting stakeholders

Three professionals typically respond when a worker’s life is first disrupted by a medical

condition: a healthcare practitioner, a workplace manager, and a benefits claims administrator.

They each deal directly with the affected worker and have discretionary authority about how to

manage the part of the worker’s care or experience for which they have responsibility. In each

specific case, an affected worker and these three individual professionals are in the strongest

position to influence whether the worker’s predicament eventually achieves an optimal

resolution: the worker keeps working and participating fully in life. If each professional in each

organization takes responsibility for doing his or her part well and is competent, the odds of an

optimal resolution are favorable—unless a problem or uncertainty arises that requires the active

cooperation of another party, such as provision of information or expertise. Today, there is little

interaction among the parties due to professional traditions, social and business conventions, and

organizational and infrastructure barriers.

• Health care professionals. The main reason why physicians and other treating practitioners

interact with affected individuals is to provide healing and relief by making diagnoses and

selecting therapies. They also set future expectations for recovery and work, determine work

II. BACKGROUND MATHEMATICA POLICY RESEARCH

restrictions, and sign disability forms. Typically, practitioners focus only on diagnosis and

treatment, not on functional and SAW/RTW outcomes, which have not traditionally been

within the purview of medicine (ACOEM 2008). They therefore tend to see SAW/RTW

questions and forms as an irrelevant administrative burden. As has been amply documented,

quality and outcomes vary widely from provider to provider. These professionals vary in

their personal qualities, knowledge, skills, and values. They are influenced by the culture,

ethical, and legal obligations of their professional specialty as well as the policies,

procedures, and priorities of the organization in which they work. The average health care

professional derives no economic benefit from helping patients stay at or return to work, and

has no accountability for failing to do so. Physicians may randomly encourage their patients

to work, passively go along with their application for disability benefits, or even tell their

patients they will never work again. Like other helping professionals, physicians tend to earn

more when their patients’ problems continue.

• Employers. The main reason why employers interact with workers who have health-related

work problems is to carry out the organization’s policies and procedures regarding

attendance, performance, and other internal programs, and to comply with applicable laws.

In addition, employers control the availability of work. They decide whether recovering

workers will sit home until they are fully recovered, remain on the job in a reduced capacity

while they recover, or receive timely, reasonable accommodations that permit full

productivity. This means employers can choose whether to support, ignore, or edge out a

worker with a disabling condition. The individuals in management positions who make such

decisions on behalf of a company vary in their personal qualities, capabilities, knowledge

level, and priorities. Their decisions are often influenced by the environment in which their

business operates. For example, small companies (which are exempt from the requirements

of the Family Medical Leave Act and the ADA) typically provide neither paid sick leave nor

private disability insurance. In general, many employers consider employee turnover to be

normal and view their employee benefits packages plus government programs as the best

solution for employees with newly disabling conditions. After a few days or weeks off work,

it is common for supervisors not to ever talk to the worker directly again. Very few

employers—mostly large companies or those employing highly skilled, hard-to-replace

workers—consider the cost of losing an experienced employee and try to avoid that

outcome.

• Insurers. Health plans, workers’ compensation (WC) companies and private disability

insurance (PDI) companies all interact directly with affected workers or with their doctors or

employers for the purpose of administering benefits claims correctly, usually by telephone

and/or on paper. Health plans define the services they authorize and the amounts that will be

paid for them. WC and PDI companies decide what kind of rehabilitative or SAW/RTW

services to offer and when to offer them. The frontline professionals who make decisions on

behalf of these payers vary in their personal qualities, knowledge, skills, and priorities, and

are influenced by the culture, business rules, priorities, and legal obligations of their

organizations. There is a wide range of subject matter expertise and performance in these

industries, within and across organizations. And although a costly claim for a poor outcome

is undesirable, insurers generally remain profitable by following two principles: (1) focus on

a short time horizon, because the employers may take their business elsewhere next year;

and (2) cover excess losses this year by raising premiums in succeeding years. This means

II. BACKGROUND MATHEMATICA POLICY RESEARCH

that insurance companies typically have limited interest in making systematic efforts to

improve long-term outcomes for individuals.

• Supporting players. Behind the three frontline professionals who deal directly with the

affected worker stands an army of other professionals who play indirect roles—co-workers

and executives in the organizations where the frontline professionals work, as well as civil

and regulatory authorities, government agencies, attorneys and judges, the U.S. Congress,

and state legislatures. Each of these supporting players may influence some aspect of the

cultural, economic, social, and legal environment in which the frontline players operate, thus

affecting their decisions and, indirectly, the outcomes.

Although there are many long-established organizations that promote the employment of

people with long-term disabilities who are not currently working, those organizations are

typically not involved at the outset, when a health condition has just begun to interfere with

working. The factors to be considered in beginning a career or returning to work after a long

absence are quite different from those that confront a person whose ability to stay on the job is

newly challenged by a medical condition. The pace of preparing for and entering the workforce

is often slow, taking months or even years, whereas an existing job can be lost in a matter of

weeks or even a few days.

Of note, there is currently no federal entity specifically designated to take the lead in

preventing job loss among workers who experience a change in their health that creates or

worsens a disability.

III. RECOMMENDATIONS AND A VISION FOR THE FUTURE

Our broad recommendations for policies that would help more workers keep their jobs when

they have medical conditions are based on the four premises laid out in the introduction to this

paper, and take the roles of the frontline players into account. In the next chapter, we present

detailed suggestions for carrying out these recommendations.

Because these recommendations are so comprehensive and varied, implementing them will

require a lead federal agency to drive and coordinate an ongoing, action-oriented, multi-sector

initiative. Doing so successfully means engaging many private sector organizations and various

federal and state agencies in an ongoing collaboration. Natural candidates for this leadership role

include the Department of Labor’s Office of Disability Employment Policy or its Employment

and Training Administration. The Department of Labor cannot be successful on its own,

however. Relevant offices in other federal agencies should be required to cooperate with the

designated lead agency in its efforts. In particular, several units within the Department of Health

& Human Services and the Office of Management and Budget would play instrumental roles in

implementing some of the specific suggestions that follow these recommendations.

A. Three recommendations

Recommendation 1. Add to the list of expected positive outcomes of care for a health-

related episode the preservation or prompt restoration of the affected individual’s full

participation in life—especially a return to paid work among those who have been working.

These outcomes should be considered major indicators of the quality and practical value

delivered by health care services and health-related services, including WC and PDI. Conversely,

avoidable impairment, functional loss, work disability, and job loss should be considered major

negative outcomes because they create an ongoing cascade of consequences that further reduce

quality of life.

Recommendation 2. Develop formal mechanisms to establish and enable accountability for

both positive and negative outcomes among the parties with the most direct influence on them.

Separate mechanisms will be required to make the right things happen more often and the wrong

things happen less often, because the forces that generate them differ in fundamental ways.

Among other things, the mechanisms will need to remove or minimize operational and

administrative obstacles to information sharing and teamwork among the participating

stakeholders’ organizations.

Recommendation 3. Design and implement an array of carefully considered strategies for

how to use accountability to effectively disrupt the forces perpetuating today’s suboptimal

marketplace equilibrium and drive transformational social change. This will require strong

leadership on social and public health policy. As described in the specific suggestions which

follow, the strategies need to include public information and social marketing campaigns,

The scope of this project did not include an evaluation of the fiscal implications of implementing these

recommendations. Some of the recommendations will require significant investment to implement. However, the

expected economic benefits of reduced labor force exit and SSDI entry are likely to be even larger, including

increased growth in employment, personal income, and tax revenues, and reduced rate of growth in federal and state

expenditures. Nevertheless, the potential costs and benefits of each recommendation and the timeline for their

realization should be carefully examined prior to implementation.

III. RECOMMENDATIONS MATHEMATICA POLICY RESEARCH

positive and negative incentives for organizations in both the private and public sectors, new

legal and regulatory mandates, and different priorities for research and development. Reversing

the trends working against change must be accomplished with an acceptable return on

investment of time, energy, and resources.

B. A view from the future after a transformational change

In this section, we ask readers to imagine themselves transported into the future, after the

recommendations made here have been carried out and transformational change has occurred. In

that better future:

The expectation among Americans is that all working-age individuals—including those with

chronic conditions and disabilities—will earn a living (or be otherwise productively engaged)

and participate as fully in society as they can. In addition, Americans are confident that any

employed people who develop a health problem will get the encouragement and help they

need—from their doctor, their employer, and their insurers, all working together—to adapt to

change, restore the rhythms of everyday life, and find a way to stay employed if at all possible.

The nation’s workforce development strategy reflects awareness that humans naturally

experience a decline in functional ability over a working lifetime. As a result, there are many

avenues available that allow aging Americans to remain financially and functionally independent

and continue contributing in various ways for as long as possible.

At the front line, all treating physicians and the other health care professionals they

collaborate with to deliver care have been trained to see functional and employment outcomes as

a practical way to gauge the effectiveness of their care and a measure by which their

performance is evaluated. They know how to identify patients at risk for job loss early on and

how to counsel them on realistic goals for treatment and a return to health. Ancillary

professionals with special expertise in functional restoration and the SAW/RTW process are

considered adjunct members of the health care delivery team and are easily accessible, so they

can regularly help treating clinicians achieve the best possible outcomes for their patients. The

health care team routinely coordinates with employers and insurers so patients can resume their

usual responsibilities on a timely basis—as soon as it is medically safe. Patients, employers, and

insurers who want to make an informed choice among possible care providers are routinely

relying on published data about the SAW/RTW services and outcomes delivered by individual

professionals and health care delivery organizations.

Employers know they are obliged to demonstrate that they make an adequate effort to help

all qualified employees who develop disabling medical conditions to keep their jobs or find new

ones—in the employer’s organization or elsewhere. To ensure compliance, employers are

routinely calling on experts to assist them in the SAW/RTW process. Because poor performance

in their SAW/RTW program will invite financial consequences, most employers are trying to

retain affected employees and keep them productive, or try to help them find new jobs

elsewhere.

To assist individuals as well as their employers, health plans and WC and PDI companies

now cover a specified set of SAW/RTW services. Their marketing materials describe how those

services help covered workers stay at or return to work, and help employers meet their

obligations. WC and PDI companies routinely make the services of ancillary professionals with

III. RECOMMENDATIONS MATHEMATICA POLICY RESEARCH

special expertise in functional restoration and the SAW/RTW process available when an affected

individual’s local health care delivery team lacks that capability. Since their program outcomes

are visible to potential customers, insurers have an incentive to provide as much or even more

support to workers from small companies as they do to workers in large ones since the lack of

internal resources in smaller organizations increases the risk of fines.

Organizations in all three sectors—health care delivery organizations, employers, and

insurers—are routinely reporting data on their activities and outcomes to a designated federal

agency, which makes the data publicly available to guide business-to-business purchasing

decisions. The government is using the data to conduct inspections, assess penalties, and take

enforcement actions when appropriate, and to shape its ongoing work in policy, programs, and

research and development.

A lead federal agency has spearheaded the changes that have made all of this a reality, and

has kept track of all these activities. That agency continues to drive and coordinate an ongoing

multi-sector initiative that has successfully engaged many private sector organizations and

various federal and state agencies by employing a public-private partnership approach, among

other techniques. A different federal agency has been given primary responsibility for carrying

out the corresponding research agenda. That research has produced new evidence about more

effective actions the frontline players can take to prevent needless work disability and help

affected individuals stay employed, as well as better tools and methods for them to use in the

process. All federal agencies, in their role as employers, have been leading by example and have

model programs in place. These programs incorporate accountability for keeping people

involved in life and work and employ metrics to guide internal efforts at process and quality

improvement as well as outside purchasing decisions in health care, workers’ compensation, and

disability benefits.

Happily, all of this effort means that fewer working-age people are losing their jobs.

Employers have found creative ways to make good, productive use of employees whose work

capacity has been altered by medical conditions. When employers cannot do so, there are other

jobs available in the community, because the government has made changes in economic and

employment policy that have encouraged development of more jobs that are suitable for workers

in this situation. An array of new service and technology businesses have sprung up to assist

health care delivery organizations, employers, and insurers in carrying out their responsibilities.

The inflow of working-age people onto taxpayer-funded, disability-related income-replacement

programs has been reduced, which has relieved some of the pressure on the nation’s social safety

net. This means that more government resources are available to help people in need of

temporary or long-term supports.

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IV. DETAILED SUGGESTIONS FOR IMPLEMENTING THE RECOMMENDATIONS

A. Capture and consolidate the data needed to create credible metrics and

make accountability real

Today, it is not clear how many workers actually receive SAW/RTW services or lose their

jobs every year because of a medical condition. Relevant statistics are neither kept nor reported

at the front lines (medical offices, workplaces, and insurance companies) where these activities

take place or their outcomes become manifest. Because the facts are hidden, those who might

logically be held accountable cannot be. Visibility has the potential to unleash powerful forces

that may promote positive action—such as professional pride, competitive marketplace

pressures, administrative action, or even litigation.

Real accountability is made possible by credible metrics, which in turn depend on the

availability of accurate data and data systems. Metrics are by definition imperfect representations

of a more complex reality. Metrics inevitably cause technological challenges, howls of protest,

delaying tactics, gaming, and disputes, especially at the outset. These issues can and must be

anticipated and competently managed in a way that keeps the public purpose at the forefront and

harnesses the power of accountability as a force to drive better outcomes.

To foster accountability in a way that will change the behavior of the frontline players and

the organizations in which they work, the data need to be multidimensional, including

information about diagnoses, treatment, and the BPSE context; and track services delivered,

processes carried out, and outcomes achieved. These data will need to come from multiple

sources: affected individuals, health care delivery organizations, employers, insurance

companies, government entities, and possibly others. All relevant stakeholders must therefore

possess the means to capture and contribute their own data accurately. Next, data from multiple

sectors must be consolidated to create a complete picture that can be shared with all data

contributors and other interested parties.

Most likely, many organizations will initially resist requirements to capture new kinds of

data, especially if they do not suit their own purposes, citing legal requirements that protect

confidentiality as well as the traditional reluctance to share potentially competitive information

across organizational boundaries. These barriers to the capture, reporting, and sharing of

information will need to be surmounted.

To capture and consolidate the data necessary to create credible metrics and establish real

accountability, we suggest the following actions by the federal government:

1. Designate an agency to expedite the creation and adoption of metrics that will make it

possible for stakeholders to both define and allocate accountability for preventable

impairment, loss of function, and job loss; these metrics will also make it easier for

stakeholders to understand each other and to collaborate with respect to their

responsibilities and contributions. This includes: (1) cataloging and comparing existing

metrics that employers, doctors, health plans, WC and PDI companies, and related public

agencies can use to monitor processes, events, and outcomes that pertain to work and full

participation in life; (2) ensuring that changes are made to federal specifications for

electronic health records as well as to record-keeping by employers, insurers, and agencies,

IV. DETAILED SUGGESTIONS MATHEMATICA POLICY RESEARCH

so they each incorporate data about the portion of the process they actually deliver, manage,

or see. Examples include SAW/RTW services delivered, changes in impairment, medical

restrictions and functional abilities or functional status; and changes in work status, specific

obstacles to SAW/RTW, days away from work, employment status, and receipt of cash

benefits; (3) making it easier for multiple stakeholders to collaborate and exchange data—

including those who carry out and document activities and processes, and those who observe

and document the resulting work absence, benefit receipt, and employment outcomes; and (4)

being at the table when the value of health care is being discussed and potentially relevant

metrics are being developed by industry-specific entities and government agencies.

2. Require that outcome measures in federally funded research include, when applicable,

the test subjects’ ability to participate in important life activities and SAW/RTW. This

includes all health, health systems, public health, and social services research to evaluate the

benefits of various kinds of treatments and interventions for populations that include working

people.

3. Require job losses caused by medical problems to be tracked and reported to the

Department of Labor. This can be done with a log similar to the one that employers are

already keeping for all occupational injuries and illnesses as required by the Occupational

Safety and Health Administration (OSHA). OSHA logs created both visibility and

accountability—and an ongoing stream of data that has made it possible to track industry’s

remarkable progress at improving safety and reducing workplace injuries and fatalities over

the last 40 years.

Logs have also allowed OSHA to identify employers and industries that

perform poorly on these measures and to take corrective action. To apply this idea to

tracking job loss, employers, health plans, and WC and PDI carriers should be required to

keep and report statistics to the government on how many people with health conditions lost

or gained jobs while they were an employee, patient, or beneficiary. Both public- and

private-sector organizations should be expected to log these outcomes.

B. Provide federal leadership in public health, health care, and social policy

To provide the leadership in public health, health care, and social policy that will be required

to disrupt the status quo and deliver transformational social change, we suggest that the federal

government:

1. Modify the nation’s health agenda by redefining “healthy” such that it includes full

participation in work and society. The major indicators of health status for all working-

age adults—including those with chronic conditions and disabilities—should include work

Relevant entities include the National Quality Forum, National Committee for Quality Assurance, Joint

Commission, URAC, Integrated Benefits Institute, Accreditation Council for Graduate Medical Education,

America’s Health Insurance Plans, and National Business Group on Health, among others; and government agencies

such as the Centers for Medicare and Medicaid Services, Social Security Administration, Centers for Disease

Control and Prevention, National Institute for Occupational Safety and Health, and the National Institute for

Disability, Independent Living, Rehabilitation Research, among others.

According to OSHA statistics, workplace injuries and illnesses have decreased from 10.9 incidents per 100

workers in 1972 to 3.3 in 2013, and workplace fatalities have decreased from 38 workers a day in 1970 to 12 a day

in 2013 (OSHA 2015). These trends are in part the result of changes in the type of industries and occupations that

are prevalent today in comparison with the 1970s.

IV. DETAILED SUGGESTIONS MATHEMATICA POLICY RESEARCH

and full participation in life. The nation’s objectives for the public's health are laid out in the

federal government’s Healthy People (HP) initiative (Koh et al. 2014). The current version

is HP 2020, which has 1,200 objectives in 42 topic areas. It does not define what “healthy”

means for people living with chronic conditions and disabilities. In addition, paid work

should be positioned as a major determinant of health status, because employment creates

the means to avoid or compensate for many of the other social determinants of disease.

2. Convene a multi-stakeholder panel of experts to develop a strategic plan that clearly

specifies how to effectively disrupt the status quo and deliver transformational social

change. A good plan will need to be preceded by a realistic assessment of the forces

perpetuating the current equilibrium and those that might alter it. An essential ingredient

will be sustained, expert, and committed leadership in public health, medical, and social

policy, along with interagency coordination. This kind of leadership is required because an

effective initiative will involve specific strategies and tactics on many fronts over a period of

several years. Examples include professional education, public information, and social

marketing campaigns; positive and negative incentives for the private sector marketplace

and public sector agencies; a legislative agenda for new legal and regulatory mandates

including reporting requirements; changed priorities for funding of research and

development efforts; and expansion of some existing programs and reductions of others.

3. Develop a set of key documents to serve as a persuasive and easy-to-read, evidence-

informed foundation for effective action. The United States has not yet made it a national

research priority to study the benefits of work or the best ways to ensure that adults who

develop health problems are able to stay at work. Perhaps this is because it has seemed

obvious that working is a necessary part of adult life. However, we are now in an era of

evidence-based policy-making. Decades of research and education about occupational health

hazards funded by the National Institute of Occupational Safety & Health and similar

organizations have created an imbalance between the public’s awareness of the science

concerning the benefits of work versus its risks and harms. Although it is true that research

studies on the positive impact of preventing needless work disability and the hazards of

worklessness have been rapidly accumulating in the last decade or so, that literature has not

yet been comprehensively collated, catalogued, analyzed and digested in documents written

for professionals in relevant fields, much less for the general public. (An example entitled Is

Work Good for Your Health & Well-Being? was published in the UK in 2006 by Waddell and

Burton. It had limited scope and needs updating.) Therefore, the U.S. government should

commission a series of comprehensive reviews of existing literature, written in plain

language, on key issues that are central to keeping workers employed after a challenge to

their health. The reviews, to be widely disseminated, should summarize what is known about

the issues and what the findings imply for real-world action, and point out knowledge gaps

that need to be filled.

Although the government is now developing a new area of emphasis for HP—health-related quality of life and

well-being —to recognize the many social determinants of health, employment is just one in a long list of many new

measures the government is evaluating in this area.

Examples of key topics that need to be reviewed include (1) the consequences of unemployment on the well-being

of Americans, including its impact on morbidity, mortality, and mental health, and on family, social, and economic

well-being; (2) the extent to which functional impairment, limitations on activity, and inability to work because of a

IV. DETAILED SUGGESTIONS MATHEMATICA POLICY RESEARCH

4. Launch a strategic campaign that informs and shifts the beliefs of stakeholders who

are in a position to influence the implementation of these recommendations as well as

those who influence outcomes for individuals. Social change usually occurs as the result

of widespread changes in beliefs, which in turn influence behavior and then outcomes. The

success of a public health campaign largely depends on whether it presents the facts

persuasively to different stakeholders. Examples in the U.S. include campaigns against

tobacco, drunk driving, and domestic violence, as well as campaigns promoting safe sex,

immunizations, and the use of seatbelts and car seats. In this case, the messages should be

evidence-informed and tailored to specific target audiences. For example, key messages

suitable for educating politicians and policy-makers will be different from those aimed at

health care professionals or the population at large. Social marketing techniques to consider

include: (1) creating a series of short documents addressed to various stakeholders,

summarizing the findings of the evidence reviews; (2) using evidence-based techniques for

spreading ideas and influencing individual behavior to construct and disseminate short and

effective public education messages customized to various stakeholders; and (3) reaching

out to targeted groups of stakeholders with the new information and ideas.

5. Revise federal research and funding priorities in order to bridge the critical gaps in

our understanding of how to consistently achieve better functional and work outcomes.

Agencies that could potentially fund this research include the Department of Health and

Human Services, the Centers for Medicare and Medicaid Services, the National Institutes of

Health, the Centers for Disease Control, and the Department of Labor. Suggested priorities

include (1) conducting clinical research into the development of services (including

educational, instructional and treatment methods, techniques, tools and programs) that

optimize functional recovery, avoid medically-induced harm, pseudo-impairment, and over-

limitation, and prevent work disability and social withdrawal for health reasons; (2)

conducting practical research to understand marketplace dynamics and the operational,

financial, and competitive barriers to implementation, and then developing, testing, and

deploying real-world techniques that facilitate widespread adoption and routine use of tools,

techniques, methods, and service and payment innovations that facilitate or support

functional restoration, SAW/RTW and full participation in life; and (3) conducting public

health and health systems research to develop population health strategies and programs for

optimizing the health, well-being, sustained social participation and productive contribution

of the working age population.

C. Encourage key stakeholders to work toward positive SAW/RTW outcomes

Below are a variety of suggestions for incentives and models that could promote positive

SAW/RTW outcomes:

health condition (that is, work disability) can be avoided, eliminated, remediated, or accommodated; and (3) the

relationship between health care costs and work disability (which engages the health care sector).

For certain groups, this will require more than providing written materials—it also means engaging them in

dialogue by inviting them to conferences, going to the conferences they hold themselves, and meeting with them in

person.

IV. DETAILED SUGGESTIONS MATHEMATICA POLICY RESEARCH

1. Pay or otherwise reward physicians and other health care providers for specific efforts

they make to restore their patients’ ability to function in everyday life and for the time

and expertise they devote to forwarding the SAW/RTW process. Certain health care

services that are known to improve SAW/RTW outcomes are currently available only

sporadically to a limited number of individuals. In large part, this is because there is no good

way for providers to document their own activities, order services for delivery by others

with confidence they will be authorized, or be confident that payment will be made for

them.

Nearly all physicians, physical therapists, occupational therapists and other health

care providers involved in the SAW/RTW process are required to use a defined set of

numeric CPT codes to describe and bill for the specific services they provide.

The current list of codes, however, does not include SAW/RTW services. One way to get

such services included is to direct the Centers for Medicare and Medicaid Services to

collaborate with the American Medical Association, the American College of Occupational

and Environmental Medicine, and other relevant medical societies to (1) create new CPT

codes or modify existing ones, (2) assign relative value units to them, (3) revise fee

schedules, and (4) mandate reimbursement for them if specific criteria are met. All four

steps are essential. Clinicians could then document, bill, and get paid for a defined set of

services that facilitate functional restoration and SAW/RTW, and/or increase their patients'

engagement in work and other activities of life.

An additional strategy is to expand the list of billable activities that can be delivered by non-

physician staff under codes for chronic care coordination, case management, patient

education and the like in order to include best practices such as two-way communications

with employers and payers about SAW/RTW issues. A third and long-overdue strategy is to

make professionals in the field of disability management and vocational counselors with

specified credentials and expertise part of the health care team. When they carry out

physicians’ orders, they should be allowed to bill using CPT codes for specific SAW/RTW

services.

The billing codes used in Washington State’s Centers for Occupational Health & Education

program can serve as an excellent model. Research has shown that when doctors and health

care coordinators perform, bill, and are paid for well-defined best practices, both short-term

and long-term outcomes improve (Wickizer et al 2011).

The process of creating and modifying CPT codes usually specifies the circumstances under

which each code can be used, as well as the training and expertise of professionals eligible

to provide the various kinds and levels of service.

2. Explore the possibility of funding SAW/RTW services for workers who lack access to

them by fining employers who do not attempt to retain employees with medical

challenges or to assist them in finding new jobs. Whenever the EEOC investigates an

Two examples of activities that physicians could take on are (1) educating patients about the implications of their

health condition for work and then counseling them on why they should try to stay at work and how they can cope

with the disruption to their life, and (2) carefully considering and then providing explicit guidance to workers (and to

their families, employers, and/ or insurers) on what they can still do safely—including advice on whether certain

tasks are within a worker’s capability and suggestions for possible job modifications, whether temporary or

permanent. Although CPT codes already exist for patient education, case management, and care coordination, they

are new, very limited in the specific topics covered and parties involved, and not yet widely used by physicians or

reimbursed by payers.

IV. DETAILED SUGGESTIONS MATHEMATICA POLICY RESEARCH

employer or a government agency awards disability benefits, they should evaluate whether

the current or immediate past employer made an adequate effort to keep the worker in the

workforce. Criteria must be established for what constitutes an adequate effort to help avoid

job loss or help the worker find another job (which at a minimum should include

involvement by professionals with relevant expertise). Penalty fees should be put in a fund

that pays for services delivered to workers who lack access to SAW/RTW services due to

prior job loss and/or lack of benefits coverage.

3. Create a positive certification program for employers that is analogous to OSHA’s

Voluntary Protection Program (VPP). The VPP program showcases effective occupational

safety and health programs. Employers apply for the program. Based on a set of

performance-based criteria, OSHA conducts a verification process to ensure that applicants

meet those criteria. Typically, employers’ performance improves during the certification

process (OSHA 2015). A similar program could be created to publicly recognize employers

and insurers whose SAW/RTW programs are exemplary.

4. Design a model for a health plan that includes SAW/RTW services. The model would

incorporate existing evidence and current best practices for health plan design, health care

delivery, managed care, patient education and care coordination services, and their

interactions. Suggested features would include a specified set of SAW/RTW services for

mental and/or physical conditions; utilization criteria; criteria for exemption from utilization

review, deductibles and co-pays; defined credentials of specialists to deliver the services;

and so on. The model plan would be disseminated to employers, industry groups, and health

plans. Education about the financial impact of preventable impairment and work disability on

total health care costs and other employer costs will need to be created along with the model

itself. Likewise, incentives or mandates will be necessary for states and private exchanges

that might otherwise be reluctant to offer these models due to competitive concerns about

raising premiums to cover expected increases in the cost of health care.

5. Create model curricula for physicians in training, along with incentives for educators

to use the curricula. Medical educators should teach physicians how to help minimize the

impact of injury and illness on working and quality of life and work, and physicians should

understand the benefits of this to patients and its value to society. These concepts should be

introduced in medical school and picked up again in residency when new physicians are first

being exposed to the realities of medical practice. Because medical education programs are

already pressed for enough time to cover all the material they focus on now, schools will

have to be given a mandate or significant incentives to adopt the model curricula.

6. Create an interagency collaborative whose mission is to improve outcomes for federal

workers. This collaborative would make it easier for personnel at different agencies to

coordinate and strengthen their own efforts to actively prevent needless work disability and

minimize both lost productivity and workforce withdrawal due to disabling medical

conditions—among both civil service and contract employees. Among its activities, this

collaborative should jointly develop and disseminate a model SAW/RTW program in order

to create more harmony and consistency of approach among the various agencies.

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