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 !!!
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