Achieving a Win..Win Solution in the Return-to-Work Process

…Effective Medical Care Involvement…

Phillip L. Polakoff,M.D.

Commission on Health and Safety and Workers’ Compensation Research Colloquium UCLA Faculty CenterMay 1-2, 2003

A PERFECT STORM Is Coming!

Aging Population

Increased life expectancy

Increased illness and injury burden

Expensive new technology

Double digit health and disability cost inflation (15-20% for next 5-6 years)

• Lost wages from absences

• Unmanaged “claim creep”

• Delayed intervention on disability claims

• Confusion over Health vs. Workers’ Comp

• No aggregate tracking or management

$$ $$ $$ $$

healthcare

STDLTD workers’ comp

The Cost Gaps in Today’s Benefit Model

$$

FMLA

MISSION STATEMENT “health excellence contributes to business excellence”

“The goal is to improve both the work and personal environment, provide quality-based programs and services, manage all health and disability related issues/events and create a healthy environment”

Achieving a Win-Win Solution

Clear health and disability strategy aligned with business, cultural, and organizational needs

Action oriented visionary champion

Engaged and enthusiastic interdisciplinary team

Committed senior management team

Involved business/line operations mangers and labor representatives

Innovative safety, health promotion and disease management programs

Vendor-partner relationships

Key Ingredients

The Focus…

Work/Life

E A

P

Wel

lnes

s

PreventionPrevention

The 3 Critical I’s

Early Identification Early Intervention Early Integration

…continual communications & consumerism …©THAP! 2002

Absenteeism

Presenteeism Presenteeism

Safety &

Health

AbsenteeismAbsenteeism

Health CareHealth Care

Functional ImpairmentNon Chronic resulting in lost time from work

ChronicLoss of Time

General-Routine Care

ChronicNo Loss of Time

Life and Death

Serious/acute

Result: Medically-Unnecessary Disability

delay

no information sharing

non-standard tools & methods

low priority unpaid work

paperwork and phone tag

uncertainty

unhelpful guidance

Medical Offices Workplaces

poor communications flownot a medical issue

weak accountability

The “Medical Care” Process Creates Disability

Acknowledgement: Jennifer Christian, MD, MPH: Webility Corporation

• Inadequate medical care.

• Poor communications between MDs and employers

• Other problems masquerading as medical issues.

• Ponderous management by employers and insurers.

Medically-Unnecessary Disability

Time away from work because:

• Attendance is required at place of care

• Recovery requires confinement to bed or home

• Work is medically contraindicated

Medically-Necessary Disability

1. Communications between medical offices and employers / insurers

2. Employer / insurer skill at managing non-medical issues

3. Physician focus on:• health promotion / disease prevention• chronic disease management• disability prevention (absenteeism &

presenteeism)

Three Opportunities for Improvement

The Doctors’ Viewpoint

• No training in disability & return to work

• No knowledge of your needs & expectations

• No clear accountability for results

• No positive reward for better effort

• Disability is a manual processes

• Networks mean “discounts,” not working relationships

1. * What is the (basis for your): - diagnosis

- treatment plan- prognosis?

2. What date will the employee be released to work?3. What are the limits and restrictions? 4. Is the problem work-related? 5. Has the case reached medical stability?6. Is there any permanent impairment?

The Most Common Questions Treating Doctors Get Asked

* The only question most MD’s have been trained to answer

• Legitimize or “excuse” absence from work

• Trigger wage replacement payments

• Describe appropriate work expectations

• Verify need so others will authorize/pay for services

• Provide “medical clearance” to reduce liability

Doctors’ Notes

MD Decisions in Exam Room: Dx, Tx, Rx, RTW

Patient Medical Chart

Dictation

Test ResultsLab Reports

RTW Questions

ReferralsRx, Tx OrdersPatient InstructionsRTW Slips

The Best Time For The Doctor To Answer Your Questions

Mis-matched Schedules Increase Burden of Communication

Doctor: Patient Visits

Adjuster: Letters, Calls, Faxes

RN Case Manager: Calls, Faxes, Letters

Employer

Day 1 3 5 7 9 11 13 15 17 19

X X X X

X X X

X X X

X X

• Doctors are slow to respond. Delay is the rule.- Delay slows down claims/case management process.

• Non-standardized form and content- Every employer, insurer, and doctor’s office has a version

• Inadequate content affects outcomes. - Unnecessarily prevents or delays return to work- Delay, uncertainty, and disputes lead to need for independent medical exams (IMEs) at $250 - $1200 +.

Doctors’ Notes Are Now A Problem

Why is the value of a physician’s opinion either $0 or $800?

A Basic Question

• On-going disability drives medical services

• Redundancy costs $$$- Each attempt takes time @ $25, $ 60, $ 250 / hour

• Delay costs $$$-Each unnecessary day off work costs $100 - $300 in wage replacement benefits

• Poor quality costs $$$- Creates unnecessary disability and delays RTW- Average lost time case costs thousands of dollars.

Poor Communication Is Expensive

Employers

Treating Physicians are Bottlenecks

DoctorEmployees at w

ork

QUESTIONS ANSWERS

Claims payers

Claims closed

→ →

• Doctors are piece workers

• They choose what to spend their time on

• Why not REWARD THEM for spending time on what YOU WANT them to do?

- physician coordination time- phone calls- fast turnaround- complex and time-consuming forms

• Offering to pay can make a big difference

A New Way of Thinking

• Think: Does the doctor have enough information to make a good decision?

• Think: What information about the job or the employee’s situation can I send to make it easy to make a decision QUICKLY?

• Use a form that looks like it will take less than 1 minute to complete --- 5- 8 items with checkboxes.

Communications Tips

• Identify higher-volume providers (key doctors) and establish an intentional working relationship

• Encourage / require MCOs, PPOs, etc. to provide education to providers about:

- disability management- your company’s regular jobs and

modified duty program / policy / jobs

Bridge the Communications Gap

Faster recovery (fewer inpatient days and reduced overall medical costs)

Improved quality of life (at work and home)

Increased functional status (at-work productivity)

Gains in productivity (less absenteeism)

Decreased impairment at work (at-work productivity)

The End Game !!!