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WHY DISABILITY MANAGEMENT? WILLIAM NEMETH MD February 2009

WHY DISABILITY MANAGEMENT? WILLIAM NEMETH MD February 2009. DISABILITY EPIDEMIC!!!!. DISABILITY CO-FACTORS. WORKER’S COMPENSATION- institution ADMINISTRATIVE SYSTEM- slow, cumbersome, ENABLING LEGAL SYSTEM- perverse incentives MEDICAL PROVIDERS- IGNORANCE , medicalization

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WHY DISABILITY MANAGEMENT? WILLIAM NEMETH MD February 2009

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  1. WHY DISABILITY MANAGEMENT? WILLIAM NEMETH MD February 2009

  2. DISABILITY EPIDEMIC!!!!

  3. DISABILITY CO-FACTORS • WORKER’S COMPENSATION- institution • ADMINISTRATIVE SYSTEM- slow, cumbersome, ENABLING • LEGAL SYSTEM- perverse incentives • MEDICAL PROVIDERS-IGNORANCE, medicalization • HEALTHCARE SYSTEM- uninsured /FFS, RE-IMBURSEMENT • EMPLOYERS-JOB, non-accomodating • CLAIMANTS- PSYCHOSOCIAL, constitutional

  4. INJURIES DO NOT CAUSE DISABILITY!

  5. CLAIMANT RISK FACTORS D10 DOI DUTY- Job DOB- Age DOCTOR/ATTY – who? DIAGNOSIS- CHRONIC PAIN DEGENERATIVE DISEASE DIABETES DRUGS – Dependency, Addiction DEPENDENCY- External L.O.C. DEPRESSION - Anxiety

  6. PREVENTDELAYED RECOVERY!“WOUNDED WORKER SYNDROME”

  7. Workers’ CompensationDESIRABLE OUTCOMES • Job Retention-SAW/RTW • Quality Care • Fair Reimbursement • Patient Satisfaction • Manageable System Costs

  8. FREUD • “No other technique for the conduct of life attaches the individual so firmly to reality as laying emphasis on work; • for his work at least gives him a secure place in a portion of reality, in the human community.” • “Love and work are the two things that give life meaning and purpose.” • Sigmund Freud

  9. Work Improves Life Expectancy

  10. “Compensable Injuries and Health Outcomes”www.racp.edu.au/afom/compensable/index.htm • COMPENSABILITY INVERSELY RELATED TO OUTCOME • “Although most people who have compensable injuries recover well, a greater percentage of these people have poorer health outcomes than do those with similar but non-compensable injuries. a complex interaction of factors is responsible for this.”

  11. Age at Retirement and Mortality • Tsai et al.BMJ, doi:10.1136/bmj.38586.448704.E0 (published 21 October 2005) • Study of Shell Oil 3668 employees in Texas 1973-2003 • Mortality of employees who retired at 55 was greater than those who retired at 65 • (RR = 1.37, 95% CI = 1.09-1.73). • Mortality of those who retired at 55, who were still alive at 65, was still increased: • RR = 1.89 (95% CI = 1.58-2.27)

  12. Unemployment and Mortality • Jin et al, CMAJ 1995; 153 (5): 529-540 46 original studies- review article • Most aggregate-level studies and large, census based cohort studies report positive association between unemployment and overall mortality,suicide, and cardiovascular disease. • Workers laid off because of factory closure have more symptoms and illnesses. • Conclusion: “Evaluated on an epidemiologic basis, the evidence suggests a strong, positive association between unemployment and many adverse health outcomes.

  13. UNEMPLOYMENT and DEATHP.T. Martikainen: Finnish men, 1981-1985BMJ 1990; 301 (sep): 407-411 • Total Mortality: • unemployed have a relative risk (RR) of 1.93 (95% CI = 1.82-2.05) • Accidental and violent death: • RR 2.51 (2.28-2.76) • Circulatory Diseases: • RR 1.54 (1.40-1.70)

  14. UNEMPLOYMENT and DEATH • Sundquist et al, Scand J Prim Health Care 1996; 14 (2): 79-85 • Sex standardized mortality ratios computed for all 192 health districts in England and Wales. • “…social deprivation, UNEMPLOYMENT, and overcrowding were related to mortality…”

  15. UNEMPLOYMENT and DEATH • Mansfield et al, Am J Public Health 1999; 89 (6): 893-898 • Multiple regression analysis: premature mortality predicted by • Female headed households • Black race • Low education • American Indian race • Chronic unemployment

  16. UNEMPLOYMENT and DEATH • Scan J Public Health 2002; 30 (3): 216-222 • Standardized mortality ratios • Employed 0.59 men 0.51 women • Disability retirement 2.31 men 1.66 women • “Early” retirement 0.88 men 0.72 women • “…the increasing mortality of the early retirement recipients is consistent with an adverse effect on health of retirement itself…”

  17. Unemployment and Suicide • Caces and Harford J Stud Alcohol 1998; 59 (4): 455-461 1934-1987 alcohol v unemployment as cause • Conclusions: “…unemployment was significantly related to suicide and was shown to confound the relationship between alcohol and suicide.”

  18. UNEMPLOYMENT and DISEASE • Shortt, Int J Health Serv 1996: 26 (3): 569-589 • Review article • “The most common disorders documented are emotional and cardiopulmonary disease.” • Mathers and Schofield, Med J Aust 1998; 168 (4): 178-182 • Review article • “…longitudinal studies with a range of designs • increasing mortality rates, causing physical and mental ill-health, and greater use of health services.”

  19. Unemployment and Specific Diseases • Lynge, IARC Sci Publ 1997; 343-351 • Unemployment and Cancer: a literature review. • Danish Cancer Society review • “Unemployed men have an excess cancer mortality of close to 25 % compared with that of all men in the labour force.” • it persists long after the start of unemployment and it does not disappearwhen social class, smoking, alcohol intake, and previous sick days arecontrolled for.”

  20. Unemployment and Specific Diseases • Janlert, Scand J Work Environ Health 1997; 23 (supplement 3): 79-83 • Swedish review: Dept of Epidemiology and Public Health, Umeå University, Sweden • “There is a causal link between unemployment and the deterioration in health status…” • “Losing, or gaining, employment has clear effects on psychiatric symptoms and on well being. The death rate is increased among unemployed persons.”

  21. If I return to work too soon I will “REINJURE” myself!False PerceptionsAreCommon

  22. RISK OF RE-INJURYLargest Prospective Study: Backs • Bigos, et. al. (Boeing study) Spine Vol 16, #1, pages 1 - 6, 1991 • Employee’s risk of future WC Back claim: Prior Back Pain 1.7 (1.17 - 2.46) Don’t Enjoy Job 1.7 (1.31 - 2.21) MMPI, scale 3 1.37 (1.11 - 1.68) • n = 3020 follow up 4 years

  23. Boeing study (continued) • Risk of future WC back claim was 1.7 • RISK was the SAME! • Regardless of whether pain was remote or current pain. • Regardless of whether job was sedentary, light, moderate, or heavy

  24. British Columbia Bureau of WCUnpublished Systematic ReviewDonald Krawciw @ DLBC • 1037 articles retrieved • 15 articles apply to physical limitations • 11 articles apply to medical restrictions • “No study contained a description of adverse consequences following return to defined levels of occupationally relevant activities.”

  25. What Makes a Difference?Focus:SAW/RTW MEDICAL QUALITY IMPROVEMENT QUALITY PROVIDER BASE DISABILITY MANAGEMENT

  26. BENCHMARKING•Feedback-Education •Panel Membership •Pay for Performance •Research- Standards

  27. PANEL

  28. Pay for Performance

  29. DISABILITY MANAGEMENT CONCEPTS Managing the High Risk Cases BENCHMARKING “AT RISK” CLAIMS TREATMENT PLANNING FOR “AT RISK” CLAIMS WORK RETENTION STRATEGIES FOR “AT RISK” CLAIMS DISABILITY MANAGEMENT IMPLEMENTATION TOOLS ADOPT TREATMENTGUIDELINES ADOPT TREATMENT PLAN PROTOCOL ADOPT RETURN TO WORK GUIDELINES ADOPT CASE MANAGEMENT RULE(s) OTHER ASSOCIATED RULES Do other rules impact this process? Preauthorization - Designated Doctor- IRO, Other?

  30. Disability Management OV1 MO1 MO 2-3 3 MOS At risk? Guides - Benchmarks YES “Injury” NO YES TD Lost Time > 3 Wks (or) High Risk TREATMENT PLANNING PREAUTH vs VOL CERT CASE MANAGEMENT EARLY INTERVENTION FUNCTIONAL RESTORATION

  31. WHY TREATMENT GUIDELINES? “Because we can’t afford NOT to!!!”

  32. "Doctors are men who prescribe medicine of which they know little to cure diseases of which they know less in human beings of which they know nothing.“ Voltaire

  33. What is Evidence-Based Medicine? • Evidence-based medicine (EBM) is the conscientious, explicit & judicious use of current best evidence in making decisions about the care of individual patients • David L Sackett, William MC Rosenberg, JA Muir Gray, R Brian Haynes, W Scott Richardson, Evidence-Based Medicine: What it is and what it isn't. This article is based on an editorial from the British Medical Journal on 13th January 1996 (BMJ 1996; 312: 71-2)

  34. What is Evidence-Based Medicine? • EBM is healthcare based on clinical studies of what works best and what does not • EBM is NOT healthcare based on opinion, personal observation or tradition • Treatment guidelines put EBM into action (in the hands of treating doctors and payors) • Highest quality care at lowest possible cost

  35. Why Adopt EBM Treatment Guidelines? • “The only way to achieve real and lasting cost-savings in workers’ comp is through the delivery of quality and timely care” -Charles W. Kennedy, MD, Senior Medical Editor, ODG Treatment in Workers’ Comp • This is best achieved by adopting evidence based treatment guidelines

  36. Why Adopt EBM Treatment Guidelines? • EBM Guidelines benefit all stakeholders: Employee, Employer and Provider • Providers practicing in-line with EBM Guidelines are insured of timely payment • Injured workers' receive early access to quality care, therefore health & wellness are restored • Employee returns to work, and so the drain on the business community is contained

  37. What States Have Adopted EBM Treatment Guidelines? • California: ACOEM (2003), ODG (2008) for pain, etc. • Ohio: ODG (2003) • North Dakota: ODG (2005) • Texas: ODG (2007) • Kansas: ODG (December 2007) • Other AHRQ, State Funds, etc

  38. What States Considering Adopting EBM Treatment Guidelines? • Alaska, Arizona, Delaware, Illinois, Kentucky, Maryland, Michigan, Minnesota, Nebraska, New York, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Washington, Wisconsin, Wyoming

  39. Outcomes Data: Ohio ODG adopted statewide in Ohio by BWC in November 2003 Pilot study by CompManagement, Inc. (a leading MCO) Medical costs reduced 64%, lost days reduced 69% Treatment delay reduced 77% Ohio BWC Official Disability Guidelines Diagnosis Related Authorization Pilot. Average Lost Days and Average Medical Costs per Diagnosis (CompManagement, Inc. 07/22/05) 40

  40. Rand Study: Evaluating Medical Treatment Guideline Sets for Injured Workers in CA (11/04) Technical Quality Evaluation—AGREE *McKesson WC Guidelines have been discontinued by McKesson What to look for in EBM Guidelines 41

  41. What to look for in EBM Guidelines Evidence-Based with Explicit Links Ongoing Updates, Annual Editions Independent, Multi-Disciplinary Comprehensive Clear and Unambiguous Designed for UR and Clinical Practice Integrated Treatment and Duration Guidelines Proven Results 42

  42. Provider Issues: “Cookbook Medicine?” • EBM Guidelines are not “cookbook” medicine • The guidelines identify many different approaches to therapy, noting which ones work and which do not • No single approach is right for every patient • Providers can make decisions using own judgment enhanced by access to the latest scientific studies • Solution: Education, Outreach and Training 43

  43. Provider Issues: Specialty Bias Each medical specialty has their own guidelines Each specialty represents the interest of their members (i.e. hand surgeons recommend hand surgery) Orthopedic Surgeons don’t want to follow guidelines from the Occupational Doctors (and vice versa) Solution: Don’t adopt the treatment guidelines from a medical specialty society Independence and multidisciplinary approach crucial 44

  44. Labor Issues: Denial of Care? • The primary beneficiaries of evidence-based guidelines are injured workers • The scientific studies are focused on one thing: what is most successful in getting the patient better • Many therapies are proven to be harmful to patients, and guidelines can minimize these • Prolonged unnecessary treatment in and of itself, along with delayed return to activity, has also been proven to be harmful • Injured workers should get faster care, which can happen if guidelines reduce uncertainty

  45. IMPLEMENTATION KEYS • STATUTE • LEADERSHIP • STAKEHOLDER BUY-IN • PRODUCT QUALITY • USEABILITY

  46. REFORM -REBALANCE- ACCESS and COSTS (Utilization) Governance-Laws-Rule Provider Base Behavior

  47. DISABILITY MANAGEMENTID “AT RISK” and CO-MANAGEMEDICAL/VOCATIONAL REHABILITATION

  48. WHAT DOES WORK?EARLY INTERVENTIONDISABILITY MANAGEMENT and TREATMENT PLANNING • OUTSIDE GUIDELINES or 60 DAYS • “PEER TO PEER” NEGOTIATION (Preauthvs Voluntary Certification) • EVIDENCE BASED- MDA-ACOEM-ODG • FUNCTIONAL RESTORATION

  49. EARLY FUNCTIONAL RESTORATION • Risk Assessment • Early Intervention • Cognitive Behavioral Therapy • Exercise • Adjunctive Care • SAW-RTW • Continuance

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