Travel with me to another United States, just for a moment. It's a country where injured workers are channeled to medical provider networks populated with experienced occupational medicine practitioners. You may recognize the place--we visited it briefly in the July issue of Risk & Insurance® ("Pushing a Revolutionary Agenda," page 18).
In this United States, providers treating work injuries fully understand the functional implications of those injuries, and they seek out job descriptions and requirements to assess the impact of injuries on work capability. They treat injured workers with an eye toward return-to-work. Some of them even actively inquire about modified-duty options for their patients. In this new United States, there are far more releases to return to work with restrictions, and they occur early in the life of a typical workers' compensation claim.
This imaginary place could become our reality some day soon, once the recent, sweeping changes in California workers' comp laws begin to influence policy-makers around the country.
This raises the critical question of, Who is responsible for the actual return-to-work? The physician's role is to provide medical care and functional evaluation for the appropriate release to the workplace. If medical providers do indeed begin releasing injured workers to return to work earlier with restrictions, it then falls to the claims handlers and employers to hold up their end of the equation to find appropriate job opportunities in the workplace for these employees. Are we truly ready for this responsibility?
To answer that question, first consider how we are currently performing in terms of return-to-work. It would seem that given our medical and technological advances, along with the rise of more flexible work arrangements, enabling return-to-work for those employees who are injured on the job should be getting easier.
While this is true in less severe cases, the numbers also highlight some troubling trends. Of the 5 million Americans who are injured on the job each year, 1.4 million of them spend time away from work. According to the Bureau of Labor Statistics, 10 percent of the 1.4 million workers out of work are out for prolonged periods of time. Employers and payers spent $55 billion on workers' compensation losses in 2003, of which $29 billion consisted of cash benefits paid to injured workers to compensate for time away from work.
According to the B.L.S., although the frequency of injuries with only one to five days away from work has declined by 30 percent between 1999 and 2003, the frequency of injuries with more than 31 days away from work has actually increased by 6 percent. This trend is especially troubling because previous studies strongly suggest that the longer an injured worker remains off work, the less likely they are to ever return.
THE REAL CHALLENGES
It appears that we are doing a good job with the routine cases (the "low-hanging fruit"), but when the injury is more severe or it is not a routine case, the likelihood that someone will be out for more than a month increases significantly.
Why are we not doing a better job at getting these nonroutine cases back to work?
-Are we actually getting injured workers to the right providers, who have a return-to-work philosophy and release injured workers with restrictions?
-Have we focused so much on the workers' compensation medical cost increases that we have largely ignored the return-to-work aspects and benefits of such?
-Has the spread of disability-duration guidelines created complacency around return-to-work timelines: Are claims managers saying, "The guideline says six to eight weeks of disability, so I don't need to worry about this claim until the seven-and-a-half-week mark."
-Have claims-payers given employers enough assistance to develop return-to-work programs that identify and implement accommodations to current jobs or transitional-duty assignments when there are physical restrictions placed upon the injured workers?
-Are employers serious about return-to-work? Have they actually implemented and enforced return-to-work programs?
-Does every stakeholder in the workers' comp system really understand the financial implications of extended lost time?
Consider an all too common example:
Joe, 30, has been employed as a stock clerk/warehouse worker for a major retailer for five years and was a well-respected, solidly performing company team member, almost ready for a supervisory promotion. One day, Joe tripped in the warehouse and tore the ligaments in his left knee. The injury required surgery (performed one week after the initial injury) to repair the damage, but Joe was fortunate in that he was treated by one of those "right providers" who released Joe to return to work with restrictions a mere two weeks after the surgery. Joe was anxious to return to work as soon as possible as he was a motivated young man who enjoyed the camaraderie of his warehouse colleagues.
Joe's original job entailed constant standing, walking, lifting and carrying, but obviously after his surgery, he was restricted in each of these areas. Warehouses are very busy workplaces, and they are tough environments for return-to-work. For this reason his employer required someone returning to the job to be 100 percent--i.e., released to return to work with no restrictions. Because Joe would remain restricted in terms of standing, walking, lifting and carrying for approximately three months postsurgery, he stayed home and was not able to come back to work.
Joe's employer was responsible for his medical costs and for his wage replacement, in addition to the costs associated with hiring and training a new stock clerk now necessary in order to pick up the slack for the injured experienced employee.
For his part, Joe was now home more than he had ever been before and soon became depressed due to his inability to feel productive or socialize with his work buddies. He was being left out of all the new developments at work, grew isolated and felt increasingly lonely and betrayed. His physical recovery slowed, his fitness declined and he began to see a counselor, creating additional costs to his employer. His return eventually took six months due to the depression and loss of physical conditioning
The lack of an aggressive return-to-work philosophy ultimately cost Joe's employer more than $27,000 plus replacement costs and perhaps worst of all, a significant change in Joe's attitude once he finally did come back.
A BETTER APPROACH
Imagine instead, if we operated in a more enlightened return-to-work paradigm, where the injured employee sees the right medical provider from the outset of the claim and where his employer utilizes a robust return-to-work program complete with formal job analyses and transitional duty. In this scenario, Joe would be treated by a doctor who was experienced in occupational medicine and focused on the functional capabilities of the injured worker, identifying his physical restrictions given his injury.
In addition, Joe's employer would work with this medical provider to make use of their program to facilitate his quick and sustainable return to work. This new paradigm calls for a more enlightened strategy, where an injured employee is only taken off work if there are medical reasons that prohibit him from being in the workplace, where an employer routinely seeks to return injured employees to the workplace while they still may have work, and the out-of-work scenarios are atypical and reserved only for much more serious injuries.
Enlightened return-to-work in this new paradigm would play out differently for both Joe and the employer. The day Joe was injured his employer would refer Joe to the occupational medicine specialist closest to the warehouse. Joe's claims adjuster and nurse case manager would have online access to the employer's detailed job descriptions, which outline the actual requirements of Joe's job, as well as a series of transitional duty jobs available to Joe. Knowing that Joe's injury was to his knee, they would be able to compare his likely restrictions to his job requirements, estimate the probable duration of his disability, and target those transitional jobs/tasks within the retailer (inventory, packaging, hazard inspection, customer service) that would allow Joe to return to work much sooner than waiting for him to be released with no restrictions.
Armed with the beginnings of this plan, the claims team would consult with Joe's employer to obtain its agreement that Joe could perform any of these jobs/tasks that were within his restrictions, as well as helping them train a new stock clerk who could "float" in the warehouse when Joe was ready to return to his full-duty job, covering for others during absences and vacations. Joe's supervisor would also call Joe to see how he was doing and discuss with Joe how the experience with these new transitional tasks would enhance his ability to be promoted within the warehouse to a supervisory position. The claims examiner would send Joe's original job description and a few of the transitional work assignments to the medical provider electronically, asking for identification of the appropriate immediate return-to-work positions and an immediate release to return-to-work in that capacity.
Joe would return in three weeks with a great attitude, saving the employer at least 18 weeks of temporary total disability, while also assisting in the training of a permanent floater for vacations, sick time and injuries, and better preparing Joe for a supervisory role within the warehouse. Joe would not be home long enough to become depressed, thus no need for a therapist. And going to work each day, gradually increasing his physical activities according to doctor's orders, Joe would stay more fit and be ready to return to full duty in a shorter period of time.
The cost to the employer for this ability to return Joe to the workplace would be only $9,500; a greater than 50 percent savings ($17,500) to the retail employer for this one claim while providing several benefits to all of the stakeholders.
Clearly, there is a need for best-practice enlightened return-to-work models among claims-payers and employers. The key components of a best practice return-to-work model should include:
As with other programs, one of the keys to success for a return-to-work program is communication. All employees should understand what to do in case of an injury, as well as the company's return-to-work philosophy, policy and procedures. Building communication about safety, injury procedures and return-to-work into the employee orientation program is the best way to weave a return-to-work philosophy into the company's value system. All supervisors and managers should understand their role in the process and consider themselves responsible for the return of their own team's employees, even if someone else within the company is identified to coordinate the program. Once an employee is injured, maintaining contact with the injured employee is an extremely important component of a successful return-to-work program. Keeping the people who work with the injured employee informed about the situation is also critical so they understand the adjustments that might be necessary for the injured employee to return to the workplace. In addition, there is the critical communication with the medical providers regarding the employer's program and job descriptions for regular and modified-duty positions.
Having detailed job descriptions for all jobs that include the specific job tasks (essential functions), along with the physical, sensory and environmental requirements, is an important first step for a return-to-work program.
If completing all of the jobs is an overwhelming challenge, then identify the key jobs in which the lost-time injuries occur most frequently and start with those. As you identify those jobs with injury frequency, consider adjustments to these jobs that might make them safer while you develop the job descriptions. You can consider requesting vocational rehabilitation assistance in order to obtain accurate job descriptions for your organization.
Identify all the tasks within each department that could be considered light duty, meaning they could be performed by someone who has physical restrictions. This should include current jobs that could be modified slightly to enable someone who has been injured to perform them with or without assistance. This is another area where you might obtain vocational rehabilitation assistance from knowledgeable organizations.
Obviously, merely having a definition of a best-practice model is not enough. Claims-payers and employers alike need tools that will allow them to implement these best practices across their entire organizations. Knowing that a chain is only as strong as its weakest link, employers' and claims-payers' return-to-work efforts will only succeed if all of their involved parties use the best practices consistently.
The good news is that there are emerging technologies that facilitate institutionalizing these return-to-work best practices and help to identify those challenging claims earlier and more consistently.
As noted above, as an industry, we are doing a better job of returning the routine cases to work, but when there are factors that prohibit an injured worker from quickly returning to their same job, the claim is at increased risk for an extended period of disability.
One emerging approach to identifying these at-risk claims is to apply smarter scripting tools to the initial three-point contact to ensure that adjusters are consistently gathering the key information that will help flag problematic claims. While the best adjusters intuitively conduct this type of open-ended, probing interview, automated interview tools, such as the one recently introduced by startup e-Triage, combine the results of recent academic research with intelligent branching interview scripts to ensure that all of a payer's examiners are asking the critical questions that will help predict problematic claims right from the outset.
In addition to improving the information gathered from medical providers, there are tools emerging that help improve the flow of information to treating medical providers. One of the most common complaints from employers and claims organizations is that the injured worker gives his treating doctor or nurse an inaccurate description of the physical requirements of his job. With this embellished view of what the worker's job requirements are, the treating doctor is much less likely to release that injured worker to return to work.
One way employers and payers can combat this phenomenon is to implement an electronic database of objective, detailed job descriptions/job analyses that can be quickly e-mailed or faxed to treating providers at the outset of the claim.
If the injured worker is truly not able to return to his original job due to the physical restrictions identified by the treating doctor, employers and payers can use the more advanced features of these electronic "job banks" to supply the provider with transitional-duty ideas. The more sophisticated return-to-work database tools also store transitional-duty tasks that can be matched to an injured worker's restrictions to create a customized return-to-work plan that is consistent with an injured worker's current capabilities. This plan can be transmitted electronically to a treating provider in order to obtain an immediate release with restrictions.
By using a database-driven approach, employers will also be able to leverage the best practices for transitional duty identified in one location across their entire organization.
Our return-to-work revolution must include improvements in our focus, resource investments and technological enhancements in returning injured employees to the workplace as productive individuals. Let us not forget that this was in fact the original intent and essence of our workers' compensation system from its beginnings.
president of Chicago-based Maddy Bowling & Associates Consulting Inc., has been in the industry for 26 years and is a frequent speaker and journal contributor.
DAVE HUTH is a senior associate at Maddy Bowling & Associates Consulting Inc., specializing in insurance analytics, systems and strategy.
November 1, 2005
Copyright 2005© LRP Publications