The Next Chapter for Return to Work
During the last recession, many employers opted to fold their return-to-work programs when business slowed and employees were laid off.
Now, the tide is turning, according to Theresa Everett, vice president, director, lead consultant at Aon Risk Solutions in New York.
As employers revitalize their return-to-work programs or launch them for the first time, some companies are adapting RTW initiatives to meet their obligations under the Americans with Disabilities Act Amendments Act (ADAAA).
Not all experts agree with that approach as a way to reasonably accommodate employees, even though the federal government has offered guidance on the use of transitional — and even permanent light duty — programs to accommodate disabled workers.
Nonetheless, the trend may expand even more now that obesity has been included as a qualifying disability under the ADAAA.
Using RTW programs is one way employers may attempt to deal with the country’s “obesity epidemic,” Everett said.
“If an employee gains a great deal of weight after getting a job and they get injured and can no longer do that job, their employer must engage them in the interactive process to see if they can give them a reasonable accommodation through their RTW program — provided they have a position and can do the essential functions of the position,” she said.
But there is an inherent conflict, said J. Bradley Young, a partner at Harris, Dowell, Fisher & Harris LC in Chesterfield, Mo., between workers’ comp and the ADAAA when it comes to return-to-work programs.
Workers’ comp gives a financial incentive to employers to get their employees back to work on light duty. It saves them money. It also enables the worker to recover more quickly by giving them meaningful activities rather than being home alone.
RTW programs under the ADAAA, on the other hand, may be costly for employers, he said.
If a company has already demonstrated that it can accommodate an injured worker in a return-to-work program, then a permanently disabled worker (who was not injured in a work-related incident) may demand light duty as a reasonable accommodation, Young said.
That type of situation could result in a permanent light duty job, as opposed to a temporary situation for employees with workers’ comp injuries.
“Now that courts around the country are starting to recognize obesity as a disability under the ADA, employers in the not-too-distant future may have to start creating permanent light duty jobs for obese employees,” he said.
To mitigate the impact of this, Young advises employers to limit light duty within their return-to-work programs to a specified amount of time, such as no longer than six months.
Video: This lighthearted report on the injury of “Rod Stickman” from the Workers Compensation Board of Nova Scotia offers an employee’s perspective on return-to-work programs.
Then — on a case-by-case basis — the employer can create other ways to accommodate individuals who are permanently disabled due to factors outside of work, leaving RTW light duty to those who were injured on the job.
This could be an opportune time to limit the types of work permitted in RTW programs, he said.
Some employers mistakenly try to accommodate every injured employee through their return-to-work programs, which typically results in some duties that don’t meet the “straight-face” test.
An example would be having someone who is on work restriction sorting paper clips or cleaning desks because the company isn’t able to provide substantial work for them.
Still, for those employers that utilize RTW programs to comply with the ADAAA, formalizing them so that they consistently provide workers with transitional duty can make them more sustainable, said Randi Urkov, a managing director at Marsh Risk Consulting in Chicago.
Many employers have recognized that it is difficult to effectively sustain a program when there is an insufficient structure to offer guidance to managers, she said.
More formalized programs can also help employers to better comply with the ADAAA’s requirements to treat occupational and nonoccupational disabilities similarly, by offering temporary transitional duty regardless of the nature of the disability.
Part of this entails identifying tasks that workers can do within transitional programs that can be deemed as a reasonable accommodation.
Employers also need to establish an escalation process if supervisors can’t or won’t make temporary accommodations, by identifying which manager has the ultimate authority to send the worker home, Urkov said.
“Most employers have various siloes within their organizations that separately manage their primary responsibilities and they don’t always speak to each other.” –Christina Bergman, consultant, Aon Global Risk Consulting risk control, claims and engineering group
Christina Bergman, a consultant with Aon Global Risk Consulting’s risk control, claims and engineering group in Minneapolis, said more coordination is needed.
There are various internal departments, she said, that might be separately managing return-to-work and workers’ comp, as well as compliance requirements under the ADAAA, the Family and Medical Leave Act and the Equal Employment Opportunity Commission.
“Most employers have various siloes within their organizations that separately manage their primary responsibilities and they don’t always speak to each other,” she said.
“Defined triggers, improved integration and coordination of the overlapping obligations are needed by employers in order to improve outcomes and be successful.”
Next Wave of Scrutiny
Employers also need to determine whether their policies and procedures consistently treat occupational-related return-to-work efforts and nonoccupational accommodations in a similar manner, Bergman said.
“I believe this area will be the next wave of scrutiny and litigation,” she said.
Employers would also be better off if they did not leave all the responsibilities of communication to their third-party workers’ compensation administrators, said Charlie Cartwright, claims control consultant at Lockton Cos. in Kansas City, Mo.
Employers unable to accommodate a light duty job can take advantage of firms that offer transitional duty programs focused on volunteerism.
The sooner employers reach out to injured workers, the more likely they can convince workers to come back to work on modified duty, by communicating that return-to-work programs often expedite the healing process.
And when an employer is unable to accommodate a light duty transitional job, there are firms like ReEmployAbility Inc. in Tampa, Fla., which provides specialty return-to-work and transitional duty programs that focus on volunteerism, said Frances Ford, co-founder.
The firm sets up alternative work at nonprofit organizations within the injured workers’ communities, where workers can perform volunteer duties while recovering from their injuries, Ford said.
Workers are paid by their employers at the same rate as they would be if they were on the job, she said.
The firm charges a flat fee for the placement, which is paid by the carrier or the third-party administrator servicing the claim.
ReEmployAbility’s program has found traction with those employers that do not have an on-site return-to-work initiative or those that need additional options to supplement their on-site programs, she said.
“Transitional employment options are a great solution for employers who have a lot of workers in remote locations such as over-the-road drivers or field technicians,” she said.
Ford mentioned Safelite Auto Glass, which sends workers to client locations to replace windshields, as an example of a company that benefits from the program.
ReEmployAbility’s focus on volunteerism is a popular aspect of the program, said Debra Lingston, the company’s other co-founder.
Especially during the recession, she said, volunteerism gave unemployed workers a way to network to get a new job, learn new skills, and to maintain a regular work routine, she said.
“That trend has not changed, as volunteerism is just getting bigger,” Livingston said.
A volunteerism program “also fits in well with employers’ corporate social responsibility initiatives in addition to their workers’ comp responsibilities,” she said.
VocWorks, a part of York Risk Services Group Inc., also works with nonprofits to provide volunteer placements for employees with temporary job restrictions, said Kimberly Wickert, director of rehabilitation and business development.
Marsh’s Urkov said that employers are becoming more open to using nonprofits for RTW programs.
“Several years ago, many employers didn’t want to do that because they were afraid it would expose them to liability they could not control,” she said.
“But now they realize it can be a very viable option when there is no transitional duty available at the worksite.”
R&I: What was your first job?
Business Unit Safety/Loss Control Manager for Marriott Corporation, Bethesda, Md. I managed a team of safety coordinators throughout the United States and was a road warrior.
R&I: How did you come to work in risk management?
I was working at Marriott Corporation and met a gentleman by the name of Arnie Davenport who was the vice president of risk management. He would stop me in the halls and tell me that I was doing some really good things in safety and loss control for a division that I oversaw. He always encouraged me to get into risk management and learn the insurance side of the business.
R&I: What is the risk management community doing right?
RIMS continues to grow at the grass roots level to attract more members, which is a good thing if you want to learn about insurance. I am also glad to see a lot of diversity of thought in the business.
R&I: What could the risk management community be doing a better job of?
Over my career I have seen a lot of changes in technology, finance and risk. There were points when the risk management community could have done a better job in teaching companies how to prepare for the opportunities that accompany change. I would like to see a more systematic approach (other than ERM) to integrate risk management reforms with companies.
R&I: What’s been the biggest change in the risk management and insurance industry since you’ve been in it?
How the actuarial review process is taking over the insurance underwriting process. I spent some time in underwriting and deals were made over dinners and lunch meetings. Now, if I need to make a deal, the underwriter will tell my broker that he needs to discuss it first with the actuarial people and will get back to us. However, I see more underwriters getting out and making sure they have face time with clients. This is good.
R&I: What emerging commercial risk most concerns you?
Bitcoin, the decentralized peer-to-peer digital currency and payment network. Needless to say, this industry in growing and as users grow, so will the risks.
R&I: Are you optimistic about the U.S. economy or pessimistic and why?
Very optimistic about the economy as it will keep getting stronger and better.
R&I: How much business do you do direct versus going through a broker?
We do about 80 percent through a broker and 20 percent direct.
R&I: What insurance carrier do you have the highest opinion of?
Liberty Mutual Insurance. They keep getting better and better in workers’ compensation program development and other areas.
R&I: Is the contingent commission controversy overblown?
That’s a good Monday morning question. The insurance companies took a public relations hit on the topic and should have seen it coming before it got “overblown.” As a client you really want to make sure that the broker has your best interest at heart and the process is transparent.
A gentleman by the name of O.B. Fawley … showed me I could do anything that I wanted to do in life. He told me this every day. Indeed, he was like a father to me and I will always be grateful for that.
R&I: How many emails do you get in a day?
Due to the nature of our business I find myself getting about 100 to 150 a day.
R&I: What is your favorite book or movie?
My favorite book — “They Call Me Coach” by John Wooden. I keep it in my office.
R&I: What have you accomplished that you are proudest of?
I tell everybody this — I married out of my league. My wife is the reason I am where I am today. She made it possible for me to excel in my career by providing a balance in my life with our family. To be able to find a person that understands your career and is willing to support you (all the way) is a big accomplishment. I really lucked out when she decided to married me.
R&I: What was the best location and year for the RIMS conference and why?
For me it was the 2009 Orlando RIMS. I was really fortunate to meet a lot of good people that I continue to have relationships with today.
R&I: What’s the best restaurant you’ve ever eaten at?
I am a pizza nut and the place that has the best pizza is Antico in Atlanta, Ga. This place has authentic Naples-style pizza. Hands down it’s the best pizza in the United States.
R&I: What is your favorite drink?
Root beer floats … from my West Virginia days as a kid.
R&I: What is the most unusual/interesting place you have ever visited?
Willis Reed’s house in upstate New York. It was like stepping back in time with all of the sports memorabilia he had as a basketball player for the New York Knicks.
R&I: If the world has a modern hero, who is it and why?
I would give a shout out to all of the teachers and coaches. I can’t tell you [how many of them] had a profound effect on my life. They have the ability to change people and shape minds.
Medication Monitoring Achieves Better Outcomes
There are approximately three million workplace injuries in any given year. Many, if not the majority, involve the use of prescription medications and a significant portion of these medications is for pain. In fact, prescription medications are so prevalent in workers’ compensation that they account for 70% of total medical spend, with roughly one third being Schedule II opioids (Helios; NCCI; WCRI; et al.). According to the U.S. Drug Enforcement Administration (DEA), between the years of 1997 and 2007, the daily milligram per person use of prescription opioids in the United States rose 402%, increasing from an average of 74 mg to 369 mg. The Centers for Disease Control and Prevention (CDC) reports that, in 2012, health care providers wrote 259 million prescriptions—enough for every American adult to have a bottle of pills—and 46 people die every day from an overdose of prescription painkillers in the US. Suffice to say, the appropriate use of opioid analgesics continues to be a serious issue in the United States.
Stakeholders throughout the workers’ compensation industry are seeking solutions to bend the curve away from misuse and abuse and these concerning statistics. Change is happening: The American College of Occupational and Environmental Medicine (ACOEM) and the Work Loss Data Institute have published updated guidelines to promote more clinically appropriate use of opioids in the treatment of occupational injuries. State legislatures are implementing and enhancing prescription drug monitoring programs (PDMPs). The Food and Drug Association (FDA) is rescheduling medications. Pharmaceutical manufacturers are creating abuse-deterrent formulations. Meanwhile payers, generally in concert with their pharmacy benefit manager (PBM), are expending considerable effort to build global medication management programs that emphasize proactive utilization management to ensure injured workers are receiving the right medication at the right time.
A variety of factors can still influence the outcome of a workers’ compensation claim. Some are long-recognized for their affect on a claim; for example, body part, nature of injury, state of jurisdiction, and regulatory policy. In contrast, prescribing practices and physician demographics are perhaps a bit unexpected given the more contemporary data analysis showing their influence on outcomes. Such is the case for medication monitoring. Medication monitoring tools promote patient safety, confirm adherence, and identify potential high-risk, high-cost claims. Three of the more common medication monitoring tools include:
- Urine Drug Testing (UDT) is an analysis of the injured worker’s urine that detects the presence or absence of a specified drug. Although it is not a diagnosis, UDT results are generally a reliable indicator of what is present (and what is not) in the injured body worker’s system. The knowledge gained through the testing helps to minimize risks for undesired consequences including misuse, abuse, and diversion of opioids. With this information in hand, adjustments to the medication therapy regimen or other intervention activities can occur. UDT can also be an agent of positive change, as monitoring often leads to behavior modification, whether in direct response to an unexpected testing result or from the sentinel effect of knowing that medication use is being monitored.
- Medication Agreements or “Pain Contracts” signed by the injured worker and their prescribing doctor serve as a detailed and well-documented informed consent describing the risks and benefits associated with the use of prescription pain medications. Medication agreements help the prescribing doctor set expectations regarding the patient’s adherence to the prescribed medication therapy regimen. They serve as a means to facilitate care and provide for a way to document mutual understanding by clearly delineating the roles, responsibilities, and expectations of each party. Research also suggests that medication agreements promote safety and education as injured workers learn more about their therapy regimen, its risks, and benefits.
- Pill Counts quantify adherence by comparing the number of doses remaining in a pill bottle with the number of doses that should remain based on prescription instructions. Most often, physicians request pill counts at random intervals or the physician may ask the injured worker to bring their medication to all appointments. As a monitoring tool, pill counts can be useful in confirming proper use, or conversely, diversion activities.
On a stand-alone basis, these tools rank high on individual merit. When used together as part of a consolidated medication management approach, their impact escalates quite favorably. The collective use of UDT, Medication Agreements, and pill counts enhance decision-making, eliminating gaps in understanding. Their use raises awareness of potential high-risk, high-cost situations. Moreover, when used in concert with a collaborative effort on the part of the payer, PBM, physician, and injured worker, they can improve communication and align objectives to mitigate misuse or abuse situations throughout the life of a claim.
Medication monitoring can achieve better outcomes
The vast majority of injured workers use medications as directed. Unfortunately, situations of misuse and abuse are far too common. Studies show a growing trend of discrepancies between the medication prescription and actual medication-regimen adherence when it comes to claimants on opioid therapy (Health Trends: Prescription Drug Monitoring Report, 2012). In response, payers, working alongside with their PBM and other stakeholders, are deploying medication monitoring tools with greater frequency to verify the injured worker is appropriately using their medications, particularly opioid analgesics. The good news is these efforts are working. Forty-five percent of patients with previously demonstrated aberrant drug-related behaviors were able to adhere to their medication regimens after management with drug testing or in combination with signed treatment agreements and multispecialty care (Laffer Associates and Millennium Research Institute, October 2011).
In our own studies, we have similarly found that clinical interventions performed in conjunction with medication monitoring tools such as UDT reduces utilization of high-risk medications in injured workers on chronic opioid therapy. Results showed there was a decrease in all measures of utilization, driven primarily by opioids (32% decrease) and benzodiazepines (51% decrease), as well as a 26% reduction in total utilization of all medications, regardless of drug class. This is proof positive that medication monitoring can be useful in achieving better outcomes.