WHY DO INDUSTRIALIZED SOCIETIES HAVE DISABILITY PROGRAMS?

1. WHY DO INDUSTRIALIZED SOCIETIES HAVE DISABILITY PROGRAMS?

2. HISTORY OF DISABILITY SYSTEMS • Exist in infra-human primate societies • Non-literate societies have similar concepts • Industrial age produced need in Europe • Formal programs started in Bismark's Germany in the late 19th Century

3. TYPES OF DISABILITY SYSTEMS • Workmens Compensation • Need Based • Other Programs

4. NINETEENTH AND TWENTIETH CENTURY DEMOCRACIES BELIEVED THAT DISABLEMENT WAS THE PRODUCT OF SOCIETY AND IT WAS THE RESPONSIBILITY OF SOCIETY TO CARE FOR THOSE WHO COULD NOT CARE FOR THEMSELVES.

5. DETERMINATION OF ELIGIBILITY • Those who cannot work • Those who will not work • Availability of jobs • Permanent or temporary disablement?

6. DETERMINATION OF ELIGIBILITY • Those who cannot work because of a medical condition • Those who cannot work because of lack of job skills, lack of jobs, lack of transportation, lack of language skills etc.

7. In the absence of national health insurance, workers often need to establish the occupational basis for health expenditures. This puts unfair burdens on the worker and the compensation system.

8. It also creates the need for a large bureaucracy and the employment of a vast number of attorneys and claims managers. Money is thereby diverted from both the employers and the employees.

9. MODERN MALADIES ARE SHAPED BY MEDICINE AND COMPENSATION PROGRAMS • Low back pain • Carpal tunnel syndrome • Repetitive strain syndrome • Sick building syndrome

10. THE BIGGEST PROBLEM: IMPAIRMENT AND DISABILITY ASCRIBED TO PAIN

11. TYPES OF INJURIES OVERT SUBTLE

12. CURRENT DISABILITY SYSTEMS CANNOT CONTEND WITH SUBTLE INJURIES PHYSICIAN CONCEPTS ARE PART OF THE PROBLEM

13. Although the prevalence of low back pain is probably not increasing, studies from several countries have shown that the likelihood of submitting a claim for disability has dramatically increased.

14. BIO-MEDICINE AND ORTHOPEDICS HAVE CREATED MUCH OF THE DISABILITY CRISIS. • Symptoms are due to broken parts. • Rest and inactivity are therapeutic and may prevent future symptoms. • Medicalization of suffering is commonplace.

15. THERE IS NOTHING IN A MEDICAL EDUCATION THAT PREPARES ONE TO PERFORM DISABILITY EVALUATIONS.

16. A PHYSICIAN COULD, IF PROPERLY TRAINED, DETERMOINE IMPAIRMENT, ALTHOUGH EVEN THIS IS NOT AS SIMPLE AS IT SOUNDS.

17. PERFORMING A DISABILITY EVALUATION VIOLATES THE DOCTOR-PATIENT RELATIONSHIP.

18. PHYSICIANS ARE CORRUPTED BY THE CURRENT DISABILITY SYSTEMS; INADVERTANTENTLY, THEY CONTRIBUTE TO THE DISABILITY EPIDEMIC.

19. ISSUES FOR PHYSICIANS • Conflict between humanitarian and control functions • Dissent on laws and regulations • Stressed by need to determine disability • Undermining of biomedical model by those who are not cured

20. DISABLEMENT IS A CONTINUUM AND NOT A FORCED BINARY CHOICE.

21. THERE IS NO SYSTEM TO EVALUATE THE IMPAIRMENT DUE TO PAIN.

22. IMPAIRMENT EVALUATION IS HIGHLY VARIABLE AND SUBJECTIVE. IT IS MANIPULATED BY PATIENTS AND EVALUATORS. IT LACKS ANY SCIENTIFIC VALIDATION.

23. In the absence of a meaningful assessment of impairment due to pain, it is meaningless to talk about disability ascribed to pain.

24. PHYSICAL CAPACITIES EXAMINATIONS ARE OF UNKNOWN VALIDITY.

25. HOW SHOULD WE ASSESS DISABILITY ASCRIBED TO PAIN? OR, SHOULD WE JUST DISMISS THE POSSIBILITY AS IN AMA GUIDES PRIOR TO 5TH Ed?

26. IS THE DISABILITY DUE TO PAIN PROBLEM THE SAME IN ALL JURISDICTIONS?

27. THE AMA GUIDES TO THE DETERMINATION OF IMPAIRMENT HAVE NEVER BEEN VALIDATED.

28. DETERMINATION OF BENEFITS • Physician gatekeepers • Standards: social, legal, or educational • Scheduled awards based on diagnosis • Wage-loss system (Florida) • Citizen review boards

29. GOVERNMENTS HAVE DIFFICULTY LIMITING THOSE WHO WISH TO CLAIM BENEFITS • Eligibility criteria • Numbers entitled Absence of incentives to minimize

30. SYMPTOMS COMPARABLE MECHANIC SYMPTOMS COMPARABLE TO THOSE LEADING TO DISABILITY ARE COMMONLY FOUND IN THE COMMUNITY. Mechanic 1992

31. LOOSE LINKAGES BETWEEN INJURY, IMPAIRMENT, DISABILITY AND PAIN

32. CORRELATIONS BETWEEN PAIN, DISABILITY, AND IMPAIRMENT Disability r = 0.31 Pain r = 0.51 r = 0.27 Impairment Waddell 1999

33. DISABILITY PROGRAMS MUST INCORPORATE ENVIRONMENTAL CONTINGENCIES

34. PERILS OF COMPENSATION • Payments for injuries covered by workmen’s compensation average 1.7 times the cost of the same injury covered by health insurance. • Number of days for outpatient services is 4 times greater. • Number of outpatient visits is 2.2 times greater. Durban 1997

35. ALL SOCIAL WELFARE SYSTEMS AND INSURANCE PROGRAMS HAVE A“MORAL HAZARD”PEOPLE WILL MIS-USE THEM FOR THEIR OWN BENEFIT.

36. ANY BENEFIT PROGRAM MUST HAVE A REAL AND VISIBLE COST TO THOSE WHO UTILIZE IT

37. SOCIAL FACTORS ENHANCE OR IMPEDE THE ADAPTATION TO ILLNESS AND DISABILITY WHY NOT DESIGN COMPENSATION SYSTEMS TO ENHANCE THE DESIRED OUTCOMES?

38. DISABILITY PROGRAMS ARE OFTEN DEHUMANIZING. They remove the locus of control from the claimant.

39. MAIN POINTS 1. Social policies always influence health care and disability programs. 2. Disability programs are failing in spite of rapidly increasing costs.

40. MAIN POINTS 3. Disability ascribed to pain is the major problem in all compensation programs. 4. Physicians are trained to give medical care, not adjudicate social issues.

41. MAIN POINTS 5. Linkages between injury, pain, impairment and disability are very loose.

42. DISABILITY SYSTEMS IN THE DEVELOPED WORLD ARE BROKEN