Today’s workers’ compensation regulatory landscape is populated by requests to standardize the use of prescription drug monitoring technology, evidence-based medicine treatment guidelines, drug formularies, and other modern approaches to Occupational Medicine. All is geared toward minimizing the over-utilization of treatment and the eradication of inappropriate prescriptions of highly addictive pain medications. The key to addressing these grave healthcare concerns is not flashy, sophisticated, or modern…it is expressed in one word – WORK.
Return-to-work is mostly referenced as a retrospective outcomes metric that indicates a program’s success and often viewed as the end-game, or the goal. In workers’ compensation, the effectiveness of evidence-based medicine treatment guidelines and drug formularies is measured by their impact on drug spend and return-to-work rates, when quality data is available.
The State of Texas has been widely used as an example for their success in reducing the amount of non-preferred, non-formulary drugs prescribed to injured workers and overall drug spend by pundits in workers’ compensation. Receiving less headlines, however, is the fact that the success of the Texas formulary is strongly driven by Title 28 of Texas’ Administrative Code §137.10:
(a) Insurance carriers, health care providers, and employers shall use the disability duration values in the current edition of The Medical Disability Advisor [now known as MDGuidelines®], Workplace Guidelines for Disability Duration, excluding all sections and tables relating to rehabilitation, (MDA), published by the Reed Group, Ltd. (Division return to work guidelines), as guidelines for the evaluation of expected or average return to work time frames.
DC Campbell, research director of the Workers’ Compensation Research and Evaluation Group at the Texas Department of Insurance has stated that lost-time claims have dropped from 165,000 in 2000 to less than 90,000 in 2014.(1) The state’s diligent effort to keep workers employed while recovering from a work-related injury or illness is preventing the pathogenic effects of lob loss such as, decreased physical and mental health and higher treatment utilization, and thus driving down medication consumption.
Gordon Waddell (pronounced WAD-uhl) and A Kim Burton explored the positive influence of work on a sick, or disabled person’s overall health and well-being in their book Is Work Good for Your Health and Well-being. Their findings state that when a person’s health condition permits, remaining in or re-entering work as soon as possible will be therapeutic, help promote recovery and rehabilitation, lead to better health outcomes, reduce risk of long-term incapacity, and improve quality of life and well-being.(2)
Conversely, Waddell and Burton document a strong association between job loss and poorer general health, poorer mental health, higher medical consultation, higher medication consumption, higher hospital admission rates, and higher mortality.(2)
If these findings are valid, why are return-to-work guidelines not as frequently considered for standardization by state workers’ compensation agencies compared to their content counterparts, treatment guidelines and drug formularies?
Is it due to the perception that return-to-work will sort itself out with strong compliance to treatment and pharmaceutical standards?
According to Dr. Jennifer Christian’s Work Disability Prevention Manifesto, health care providers, employers, and benefits administrators typically involved in return-to-work situations do not feel responsible for avoiding job loss, or absences.(3)
Similar to the education process that should occur in the clinic between the treating provider and the patient when considering the use of narcotics, the benefits of return-to-work and the risks of worklessness should be discussed in comprehensive detail. Creating appropriate expectations about return-to-work, or stay-at-work, at the point of care should be the highest priority understanding the impact it will have on the overall recovery and treatment and medication consumption by the patient.
The AMA Guides to Evaluation of Work Ability and Return to Work 2nd Editionprovides the following guidance:
Physicians are familiar with prescribing medications for patients. If a physician looked up a drug in the Physician’s Desk Reference and found a “black box” warning required by the Food and Drug Administration (FDA) like this one:
would physicians prescribe that medication?
Physicians should have the same mind-set when filling out return-to-work forms as when about to prescribe a medication with the above black box warning.(4)
Addressing possible solutions to the problem of job loss, Dr. Christian writes, “Health-related work disruption should be viewed as a life emergency. Productive activity should be a part of treatment regimens.” (3)
Perhaps the best model to follow when considering an injured worker’s readiness for return-to-work involves the consideration of Risk, Capacity, and Tolerance.(5)
Risk is a basis for physician-imposed activity restrictions. Most return-to-work forms sent to physicians have a line on which the physician can state restrictions that may pose a risk to the individual or to others (e.g. co-workers, the general motoring public, etc.). Risk, in this context, means the person should not do something, even though they may actually be capable of doing the activity. For example, individuals with uncontrolled seizure disorders are not permitted to work as commercial airline pilots or bus drivers based on risk.
Capacity is the basis for physician described activity limitations, and means the individual is not yet physically capable of an activity. Many of the aforementioned forms have a line on which the physician can state limitations based on capacity evaluation. For example, after a wound into the biceps muscle mass of the arm, an individual may not yet have the strength to permit lifting a certain amount of weight; or after a fracture of the shoulder, an individual may not yet have enough shoulder motion for his/her hand to reach the overhead control on a factory press.
Tolerance is the issue with which doctors, employers, employees, and insurers struggle. It is the ability to put up with the symptoms, such as pain or fatigue, that accompany doing work tasks, that the individual can clearly do, in order to gain the rewards of work (e.g., income, self-esteem, health benefits of work, etc.). Tolerance is not a scientific concept, and is not scientifically measurable. Patients consider factors like income and finances, job satisfaction, need for employer provided health insurance benefits, availability of disability or workers’ compensation insurance to maintain income, ability to switch to physically easier careers, etc. when deciding whether the rewards of working are to them worth the “cost” of working.
This model, which effectively brings into consideration the main factors that involve job loss, works well in conjunction with the MDA disability duration tables’ Minimum, Optimum, and Maximum timeframes for physiological recovery, adopted by the State of Texas.
Return-to-work is a potent ally in preventing medical scenarios from becoming unnecessarily complex and causing long-term disability while fostering over-utilization and over-consumption of treatment and medications. It can, and should, be used proactively as part of treatment regimens to ensure injured workers profit from the therapeutic benefits of the workplace.
Dr. Richard Pimentel, a passionate disability rights activist, once stated, “You do not get injured workers well to get them back to work. You get them back to work to get them well.”
1. Foster, JTodd. “State Touts Workers’ Compensation System as ‘Model’ for the Nation.” WorkComp Central, September 2016. Web. 01 November. 2016. https://www.workcompcentral.com/news/story/id/a8f3b13bdbbc471ce6b81a036649c0e836863559
2. Waddell GA, Burton AK. Is Work Good for Your Health and Well Being? The Stationery Office, London, 2006
3. Christian, J. (2016, August). Work Disability Prevention Manifesto [Web log post]. Retrieved from http://www.jenniferchristian.com/tag/work-disability/
4. Talmage JB, Melhorn JM. Hyman, M. AMA Guides to the Evaluation of Work Ability and Return to Work 2nd Edition. AMA Press, Chicago, 2011. P.3-4
5. Talmage JB, Melhorn JM. A Physician’s Guide to Return to Work. AMA Press, Chicago, 2005