2016 Outlook: Disability and Absence Management
The disability and absence management landscape continues to experience rapid change. The driving forces are legal and regulatory and a shift in social attitudes about work-life balance. It can be a challenge to keep up; however, there is also great opportunity for disability and absence management professionals to expand their skills and increase their value.
Here are five trends to watch for in 2016:
Paid Leave: A True National Issue
If paid family and sick leave were issues in 2015, they will be the issues of 2016. More large employers will follow the likes of Netflix, Facebook, Microsoft, Adobe, Apple, Amazon, and other leading companies to implement or expand their own leave policies.
And there will be even more efforts to pass paid leave laws in cities and states, including Washington, D.C. and Maryland. Perhaps as important, the democratic presidential nominee will seek to build on FMLA and make paid federal leave a significant campaign issue.
This means more complex process management, heightened compliance demands, and increased public attention to organizations that come under legal or other scrutiny. 2016 is the year in which large numbers of disability and absence management professionals become leave law experts.
ADA Administration Drives Increased Partnering
As with FMLA, more employees than ever are aware of their rights under the ADA. As a result, growing numbers of employers will look to their current short-term disability (STD), long-term disability (LTD) insurance and FMLA partners to help them manage the ADA process.
There are tools and resources, including automated software systems, to help employers manage the accommodation requests and processes associated with ADA. These tools are increasingly cost effective. We will continue to see an increase in partnering to manage growing employee awareness and the accompanying compliance demands.
Workforce Well-Being Moves Front and Center
The Affordable Care Act has given a large and sustained push to preventing illness. This directly impacts the absence and/or disability that accompanies those illnesses.
From gym memberships as a nice employee benefit to workforce well-being, it has moved to a key tool in controlling health care costs. Disability and absence management professionals are being called on to play a larger role in designing and implementing these programs. That will accelerate in 2016.
In addition, an even larger part of workplace well-being will be an emphasis on behavioral health. More disability and absence management professionals, as well as health practitioners, understand the connection between the mind and body in absence, disability, and overall health.
Depression and other mental health issues are increasingly recognized as topics of major concern when it comes to employee well-being. Attention given to these areas brings lower health-related costs, including those related productivity.
Expanded Professional Opportunities
As leave and health care change, absence and disability professionals are confronted with significant new demands. They need to be aware of laws and regulations and new approaches to minimizing health care costs.
In progressive companies, this translates into organization-wide cooperation that enables disability professionals to collaborate with different departments.
This presents professionals with tremendous opportunities to expand their networks, skills, and credentials. 2016 will see at least one new professional designation.
With it and the continued accumulation of new skills, disability and absence management professionals will add more value to their organizations. The result will be a new level of professional and personal rewards.
Increase in Strategic Enforcement From the EEOC
The EEOC’s interest has shifted from individual violations to more systemic workplace discrimination and this includes pregnancy discrimination. Systemic investigations and cases are effective at addressing workplace discrimination issues on a broad scale in an industry, profession, company, or even a specific geographic area.
The EEOC issued guidance making clear that failing to accommodate pregnant employees may expose employers to Americans with Disabilities Act claims based on temporary disabilities caused by pregnancy.
So what does this mean for you in 2016? Employers will need to ensure they are paying attention to policies, practices, and processes for employees taking leave.
Leave has become a political and social issue. It, along with all forms of absence and disability, have caught the attention of many in the “C suite”. That means we will all hear more about these topics in 2016.
Hospitals are caught between pressure from the Affordable Care Act to discharge patients quickly to their homes and the financial penalties they face if patients are readmitted.
To mitigate the risk, hospitals are focusing on patient education as well as ancillary services such as case and discharge managers to help patients assume greater responsibility for their follow-up care, including medications, nutrition and use of medical equipment.
This requires a coordinated, multidisciplinary effort that starts with a patient’s admission to the hospital, said Terri Nichols, director of risk management, PeaceHealth.
“In a culture of safety, we think ahead about the discharge environment. We think about home assessments,” she said. “We think about grip bars in showers. We think about who will help an elderly relative up the stairs. We think about teaching family members how to inject medications.”
Planning for discharging patients is crucial because inadequate information or preparation, or discharge into unsafe environments significantly increases the chances of readmission.
“Proactive discharge plans have reduced readmission rates significantly,” said Dana Welle, chief medical officer, The Risk Authority, Stanford, Calif.
Most U.S. hospitals are projected to receive lower reimbursements from Medicare in fiscal 2016 because too many patients return within 30 days of discharge, according to “Modern Healthcare.”
Fewer than one-quarter (23 percent) of more than 3,400 hospitals subject to the ACA’s Hospital Readmissions Reduction Program (HRRP) performed well enough in 2015 on the Centers for Medicare and Medicaid Services (CMS) 30-day readmission program to escape penalty.
Statistics about hospital readmissions are confusing and contradictory. — Pamela Popp, executive vice president and chief risk officer, Western Litigation
HRRP targets higher-than-average readmissions for heart attacks, heart failure and pneumonia, and it stepped up penalties from 1 percent in 2013 for to 2 percent in 2014 to 3 percent in 2015.
The problem, however, is especially intractable among the homeless, Nichols said.
Seven in 10 homeless individuals who were discharged were readmitted, visited the emergency room or returned for an observation stay, according to the National Center for Biotechnology Information.
Interpreting the Numbers
Statistics about hospital readmissions are confusing and contradictory, said Pamela Popp, executive vice president and chief risk officer, Western Litigation.
While the proportion of hospitals receiving a penalty increased to 78 percent in 2015 — up from 66 percent in 2014, according to The Henry J. Kaiser Family Foundation – penalties remain below 1 percent, although the maximum cap rose in 2015 to 3 percent.
It’s unclear what those numbers say about hospitals’ efforts to control readmission because of some changes in the regulations, said Popp.
CMS added two more diagnoses — chronic obstructive pulmonary disease, and hip and knee replacements — to its performance criteria in 2015, significantly raising the potential universe of tracked readmissions.
And the ACA requires more reporting about readmissions than in the past, forcing hospitals to acknowledge that admissions that wouldn’t have been counted in the past – often for sepsis – are related to a prior admission.
About half of the sepsis infections are preventable, and they accounted for roughly the same percentage of hospital readmissions in California as heart attacks and congestive heart failure in 2015, according to UCLA research.
Preventing avoidable readmissions depends on unbroken communications between patients, care providers and care managers, said Popp.
“Make sure patients and families know what normal healing looks like as opposed to an acute condition,” she said.
Often, she said, patients and caregivers fail to comply with follow-up instructions, either because they don’t understand what is necessary or are not able to.
“They can’t afford their meds, or they can’t afford to stay home from work. Then they put a recovering child back in day care, and the providers miss symptoms until there’s another crisis,” Popp said.
An increasing number of hospitals phone patients immediately after discharge to check on their condition and later to remind them of follow-up visits, Welle said. Some send doctors or nurses within 24 hours of discharge to re-evaluate patients.
Some contract with rehabilitation and home health services to provide follow-up care.
Hospitals will also engage their quality control and risk management departments to monitor and implement the new interventions, she said.
“It’s not enough to simply put interventions in place. There must also be a way to measure if they’re helping,” she said.
To prevent misallocation of time, attention and resources, it’s important for the risk management community to understand that “most of the factors leading to a readmission have nothing to do with the quality of clinical care,” Popp said.
“It’s a communications issue.”
Readmissions should be reported all the way up to the board of directors, Welle said, because senior-level involvement may increase funding for external resources such as additional discharge nurses or contracts with rehabilitation and home health services.
The insurance industry also can play a role in reducing readmissions, Popp said, by ensuring that hospitals track and learn from readmissions.
Investigation into its readmission rate should be part of the underwriting process, she said, especially for those related to sepsis.
“Look for adequate discharge instructions and follow-through,” she said.
The Doctor as Partner
Professionals helping employees return to work after being on disability or a leave of absence face many challenges. After all, there is a personal story behind each case and each case is unique.
In the end, the best outcome is an employee who returns to the job healthy and feeling well taken care of, while at the same time managing the associated claim costs.
Learn what most employers want from their group disability and life benefits program.
While many carriers and claims managers work toward these goals, in the end they often tend to focus on minimizing costs by aggressively managing claims to get the worker back on the job, or they “fast track” claims, approving everything and paying little attention to case management.
Aggressively managed claims can leave many employees and their doctors feeling defensive and ill-at-ease, creating an adversarial relationship that ultimately hinders return to work and results in higher direct and indirect employee benefit costs for the employer. Fast track or non-managed claims can lead to increased durations, costs and workforce productivity issues for employers.
Is it possible to provide a positive employee benefit experience while at the same time effectively managing disability and lowering an employer’s overall benefit costs?
A Unique Approach
Liberty Mutual Insurance’s approach to managing disability and absence management focuses on building consensus among all stakeholders – the disabled employee, treating physician, employer and insurer. And a key component of this process is a large team of consulting physician specialists, leading practitioners from a variety of specialties, highly regarded experts affiliated with leading medical universities across the country.
“About 16 years ago, our national medical director, Dr. Ed Crouch, proposed that if we worked with a core group of external consulting medical specialists – rather than sending most claims for Independent Medical Evaluations – we could do a better job making disabled employees and their attending physicians comfortable, and therefore true partners in producing better disability management outcomes and employee benefit experiences,” said Tim Kastrinelis, senior vice president, Distribution Partnerships at Liberty Mutual Benefits.
“In this way, our consulting physician and the attending physician are able to work with the disability case manager, the employee and the employer to deliver a coordinated, collaborative approach that facilitates a productive lifestyle and return to work.”
The result of Dr. Crouch’s initiative has produced positive results for the clients of Liberty Mutual Insurance. This consensus building approach to managing disability with consulting physician expertise has helped achieve industry leading client retention results over the past decade. In fact, 96 percent of Liberty Mutual’s group disability and group life clients renew their programs.
“By getting all stakeholders on the same page and investing heavily in consulting physician specialists, we have been able to lower claim costs and shortened claim duration for our group disability policyholders. …In the end, it’s a win-win for all.”
–Tim Kastrinelis, Senior Vice President, Distribution Partnerships, Liberty Mutual Benefits
A Collaborative Approach
In the case of complex disability medical health situations, Liberty Mutual’s disability case managers play a vital role in seeking additional expertise—an area where the industry’s standard has been to outsource the claimant for independent medical examinations.
However, Liberty Mutual empowers its disability case managers with the ultimate responsibility for the outcome of each claim. The claimant and the case manager stay together throughout the life of the claim. This relationship is the foundation for a collaborative approach that delivers a better employee benefit experience and enables the claimant to return to work sooner; which more effectively controls total disability claim and absence costs.
Sending a disabled employee with complex medical needs to an external specialist may sound like a cost-effective path, but it often comes at the cost of sacrificing the relationship and trust built between the employee and case manager. The disabled employee must explain their medical history to a new clinician, which he or she is often reluctant to do. The attending physician may be uncooperative as this move can appear to question his or her treatment plan for the employee.
As a result, the entire claims process takes on an adversarial atmosphere, building major roadblocks to the ultimate goal of helping the claimant return to a productive lifestyle.
Liberty Mutual takes a different approach. Nearly 100 physicians representing more than 30 medical specialties are available to consult with its medical and claims professionals, working side-by-side with case managers.
More than 95 percent of these consulting physicians are in active practice, and therefore up-to-date on the latest clinical best practices, treatment guidelines, therapies, medications, and programs. Most of these physicians are affiliated with leading medical universities across the country. “We recruit specialists from around the country, getting the best from such prestigious institutions as Harvard, Yale, and Duke,” said Kastrinelis.
These highly-credentialed physicians help case managers focus on providing the support needed for the disabled employee to successfully return to work as quickly as appropriate. Their collaborative work with the attending physicians provides the behind-the-scenes foundation that leads to a positive claimant experience, results in a better outcome for the claimant, and more effectively reduces total claim costs.
Coordinated Care Plan
When one of these consulting physicians reaches out to an attending physician, there’s an immediate degree of respect and high regard for his or her opinion. This helps pave the way to working together in the best interest of the employee, improving treatment plans and return to work results.
In this process, the claimant is not sent to yet another doctor; instead, the consulting specialist works with the attending physician to help fill in the gaps of knowledge or provide information that only a specialist would have. Although not an opportunity to direct care, these peer-to-peer discussions can help optimize care with the goal of helping the employee return to work.
The attending physician may have no knowledge of the challenges the employee faces in order to return to work. A return to work plan created in concert with the specialist, disability case manager, employer, and attending physician can set expectations and provide the framework for a proactive and effective return to a productive lifestyle.
“Our consulting physicians bring sophisticated medical expertise to the discussion, and help build consensus around a return-to-work plan, helping us more effectively impact a claim’s outcome and costs, and at the same time provide a better claimant experience,” said Kastrinelis.
“We can work more collaboratively with the attending physician, manage expectations, and shepherd the employee through the process much more effectively and in a much more high-touch, caring, and compassionate manner. Overall, we’re able to produce better outcomes as a result of this consensus building approach.”
“Our approach – including the use of consulting medical experts – helped us significantly reduce disability costs over two years for one large health service company,” notes Kastrinelis. “We cut average short-term disability claim durations by 4.2 days in that time, while increasing employee satisfaction with our unique disability management model and collaborative, partnership approach.
How did Liberty Mutual’s unique approach lower claim costs, reduce disability duration and improve the benefit experience for one customer?
“By getting all stakeholders on the same page and investing heavily in consulting physician specialists, we have been able to lower claim costs and shortened claim duration for our group disability policyholders,” said Kastrinelis.
“Plus, we, the employee, and the employer also get the bonus of creating a better employee benefit experience. This model has shaped our disability and absence management program to more aptly reflect our core mission of helping people live safer, more secure lives. In the end, it’s a win-win for all.”
How does Liberty Mutual provide a superior employee benefit experience?
Tim Kastrinelis can be reached at firstname.lastname@example.org. More information on Liberty Mutual’s group disability and absence management offerings can be seen at https://www.libertymutualgroup.com/business-insurance/business-insurance-coverages/employee-benefits.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Liberty Mutual Insurance. The editorial staff of Risk & Insurance had no role in its preparation.