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Administrative Delays And Secondary Disability

Following Occupational Low Back Injury

California Commission on Health and Safety and Workers’ CompensationResearch ColloquiumPatricia L. Sinnott, PT, MPH

May 1, 2003

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Introduction Low back pain in the workplace:

5 – 20% of all claims. 30 – 40% of all costs. 20-30% of low back claims produce 60-

80% of low back costs. 2/3 of low back costs are for indemnity

payments. Majority of these costs are produced by

injured workers who are off 3 months or more.

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POPULATION STILL ON DISABILITY

50.00%

30.00%

10.00% 6.00%0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

TIME FROM DOI

PER

CEN

T O

F PO

PULA

TIO

N

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Research to Date Extensive but not conclusive. Requires multifactorial approach. The Holy Grail: to find reasons why

some workers return to work quickly and some do not.

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Healthcare Research That medical diagnosis and treatment

not wholly predictive of outcomes. That patient expectations, perceived

needs and reaction to care play significant part in prediction of good outcomes.

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Workers’ Compensation Research Physical Effects Psychological Effects Workplace Accommodation Early intervention

But no one influence explains all the variation.

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The Individual

Economic and Environmental

Influences

HealthcareSystem

Family and Social Support

EmployerAnd

Payer System

Individual

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Background Claim delay is a necessary procedure

used to determine compensability and liability and to identify fraud.

However: Claim delay may introduce an

adversarial interaction between employer and employee.

Claim delay may hinder access to medical treatment.

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Claim delay may interfere with early intervention, positive reinforcement and workplace accommodation supported in the literature.

Claim delay may increase physiological and psychological stress associated with the original injury.

Claim delay may require repetition and reinforcement of the complaints by the injured.

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Reinforcement of the complaints may slow progress, institutionalize pain behavior, and may promote intentional or unintentional exaggeration of symptoms.

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Hypotheses Individuals injured at work and take any

temporary disability days, who experience delays in claim acceptance are more likely to take more than 91 days off than those who do not experience delays.

Individuals who experience longer delays will have an increased probability of taking 91 days or more of TD.

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The Data California Workers' Compensation

Institute ICIS dataset Contributing carriers represent 70%+ of

the premium in the market All claims from 1993 – 2000 Administrative data

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Case Definition New claim for non specific low back

pain/injury Non traumatic injury No fractures, falls, motor vehicle

crashes, systemic illnesses, neoplasm or pregnancy

At least one day of temporary disability paid

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Key Control Variables Individual characteristics: age, gender,

tenure, wage, full-time status, home zip. Clinical variables: severity classified by

diagnostic complexity. Work and work environment: employer

size, employer industry. Medical care characteristics: days to

first treatment; Provider experience. Time.

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Key Study Variables Delay: days of delay to claim

acceptance calculated as days between the first date of TD and the date of the first check paying TD.

Outcome: 2 possible: takes 91 days or more of TD or not.

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Analysis Logistic model to estimate the

probability of taking 91 days or more of TD.

Then calculate: Conditional probabilities estimated

based on length of delay.

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Descriptive Results 35304 observations: 74.01% male Mean age: 36.8 years Average weekly wage: $472.17 Mean tenure: 4.44 years 87.5% worked full-time 47.27% worked in the agriculture and

mining sector 69.25 % of claims from employers with

<= 50 employees

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78.6% of the TD cases were classified as least severe

60.87% were delayed 14 days or less 5.85% were delayed 91 days or more

Descriptive Results

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Total Days off 50.62% off 30 days or more 38.42% off 60 days or more 32.% off 91 days or more 27.23 off 120 days or more*

Mean TD days off = 109

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Adjusted Odds Ratios Construction OR=1.29 Riverside OR=1.42 Santa Barbara OR=1.50

Moderately severe OR=3.74 Most severe OR =6.85

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DelaysDelays Adjusted odds

ratio15 –28 days 1.402

29 - 42 days 1.507

43 – 56 days 1.493

57 - 70 days 1.469

71 - 90 days 1.710

>= 91 days 2.006

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Conditional Probabilities

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

<= 14 days 15-28 days 29-42 days 43-56 days 57-70 days 71-90 days 91 or moredays

INTERVAL OF DELAY

PRO

BA

BIL

ITY

Male Most Male Mod Male Least Female Most Female Mod Female Least

25%

41%

56%

34%

72%70%

78% 83%

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Summary of Findings Women are slightly more likely than

men to take 91 days or more of TD. The least severe cases have a 25%

probability of taking 91 days or more if the case is delayed less than 14 days

The most severe cases have > = an 80% probability of taking 91 days or more of TD if delayed 71 - 90 days.

The probability of taking 91 days or more of TD increases 30% from day 1 to 56 days

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There is a range of 25 – 70% probability of taking more than 91 days of TD at onset dependent upon severity

But:Severity is not likely known at onset.

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Policy Implications Contributes to understanding of

influence of delay, but not how delay influences.

Identifies a component of the administrative system which the employer and payer can influence.

Potential for cost savings must be balanced with potential for expansion of claim base.

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Acknowledgements California Workers’ Compensation

Institute Foundation for Physical Therapy