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Removing Friction from California’s Workers’ Compensation System

The California workers’ compensation system has been buzzing with activity since the passage of AB 1124 in 2015 requiring the Administrative Director of the Division of Workers’ Compensation to establish a drug formulary as part of the state’s Medical Treatment Utilization Schedule (MTUS). The addition of the formulary, in concert with the impending updates to various treatment guidelines (following the new expedited process set forth in SB 1160), in MTUS will improve the system by:

  • increasing the use of evidence based care administered to patients therefore reducing the inappropriate prescription of dangerous drugs and inappropriate medical treatment;
  • reducing system friction by providing a common standard to base medical decisions for injured workers at every step in the care and claim continuum.

California Code of Regulations and Presumptive Weight

Perhaps my day-to-day exposure to regulations and legislative text is what drives my “geeking out” on the code. I have actually heard highly influential people say, “no one pays attention to the labor code”, or “no one cares about what the regs state”. Comments such as these just don’t make any sense.

Admittedly, regulation text can miss the mark if stakeholder input is not considered. Real-world experience and wisdom must inform the process that is expected to turn the gears of the workers’ compensation industry. Absent sound and constructive input from the marketplace, regulations run the risk of being detached from the day-to-day needs of the system and all of its stakeholders.

In California, the Division of Workers Compensation’s Administrative Rules emphasize the state’s commitment to injured workers and their employers by defining what may well be the most critical of expectations – that the best available evidence be used to guide clinical decision-making. The state’s commitment to injured workers and their employers is again emphasized by the thorough analysis that was conducted to inform their selection of the content source that powers the MTUS’ treatment guidelines and drug formulary.

The outcome of the state’s thorough analysis of multiple treatment guidelines and drug formularies lends great weight to the state’s assignment of the MTUS (and the platform that provides the foundation for the MTUS, the ACOEM Practice Guidelines and Drug Formulary) as being the “go-to” source when treating ill or injured workers in the California market:

§ 9792.21 Medical Treatment Utilization Schedule.

(c) The recommended guidelines set forth in the MTUS are presumptively correct on the issue of extent and scope of medical treatment. The MTUS constitutes the standard for the provision of medical care in accordance with Labor Code section 4600 for all injured workers diagnosed with industrial conditions because it provides a framework for the most effective treatment of work-related illness or injury to achieve functional improvement, return-to-work, and disability prevention. The MTUS shall be the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers.

Assigning this weight to the MTUS prioritizes the use of its treatment guidelines and drug formulary above all other sources. In doing so, MTUS becomes California’s primary language of communication for all workers’ compensation system stakeholders. Understanding that on occasion secondary sources may be needed to form a comprehensive foundation for evidence base care, California’s Division of Workers’ Compensation defines a very clear path (through its Medical Evidence Search Sequence) for introducing standards not found in the MTUS. This path should only be taken after the MTUS is considered (see charts below).

More Than Claims and UR Tools

California’s endeavor to establish the tools contained in MTUS as the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers is based in the realization that in order to meaningfully improve the friction in the workers’ compensation system, MTUS must be the guiding source for treatment from day-one.

The treating physician’s initial interaction with the injured worker is paramount to accomplishing favorable health outcomes. The dialog between doctor and patient not only sets appropriate (or inappropriate) medical expectations, it ultimately shapes the trajectory of the claim – smooth going, or friction-filled. This is the point where evidence based care is most effective and necessary.

Retrospective efforts to get a run-a-way claim train back on track are perceived as detrimental to employee benefits by employee advocacy groups. Deviating from or challenging a doctor’s orders, even when informed by the highest-grade of evidence-based medicine, can be an invitation for friction. Disparate standards of care introduced outside of the established path (Medical Evidence Search Sequence) further widens the gap among stakeholders and adds friction to the process.

Opponents of Sound Patient-Centric Medicine

Sound patient-centric medicine will always have opponents – opponents by commission and opponents by omission.

Misaligned interests are present in numerous verticals of the industry. Opponents by commission are identifiable by their persistent off-center messaging in the marketplace. Their message intends to deemphasize what the State has created as a standard; they work to obfuscate what is otherwise a clear path to scientifically based standards for optimal care. Their interest is driven by personal gain, forgetting that a conflict-free, good working system that produces optimal health outcomes benefits everyone.

In some cases, opponents do not see themselves on the opposing side of sound medicine. Opponents by omission are parties that remain neutral when confusion is intentionally sown into the marketplace by the aforementioned. I often question, are opponents of sound patient-centric medicine unware, or are they indifferent to the friction they invite by their lack of action?

California’s success in removing friction from its workers’ compensation system hinges on all of the state’s stakeholders committing to work from the same standards and speaking the same language. Anything short of this type of cooperation is both counter-productive and an affront toward the collective effort to produce improved health outcomes for California’s injured workers.

Aides from Dr. Raymond Meister, CA DWC Medical Director

*Complete presentation deck is available at http://ccwcworkcomp.org/ccwc/assets/File/2017%20Conference/PPT%20Presentations/4_1%20Implementation%20of%20SB1160.pdf.

MTUS Online Education

http://www.dir.ca.gov/dwc/CaliforniaDWCCME.htm

The Truth Regarding Outcomes in Texas and the Guideline Never Discussed

The Texas workers’ compensation system is again the center of national discussion. Republican House Representatives in Louisiana are proposing the adoption of the binary drug list that Texas made popular resulting from the material reduction in cost and overall decrease of prescription drugs made available to injured workers in the state. However, employee and patient advocates struggle with correlating lower costs and medication prescriptions to a healthier workforce. Denying medical care, without the support of quality scientific evidence, does not guarantee better care and therefore may not result in overall health outcomes.

Texas Commissioner Ryan Brennan submitted a write up published by WorkCompCentral (subscription is required) encouraging the use of the Texas-model formulary by other jurisdictions. While the success of cost savings and reduced medication prescriptions to injured workers in the state is well documented, Commissioner Brennan’s claim that the drug list is responsible for the state’s improvements in return-to-work may not be as cut and dry. The dual adoption of individual commercial return-to-work and treatment guidelines in the state sets a stage worthy of scientific discourse and dramatic findings of deranged recommendations.

Texas’ Choice for Return-To-Work Standards

Texas’ legislated mandate to use return-to-work guidelines is an element of their workers’ compensation system that is usually discussed out of context, or is all together ignored. Leading up to the passage of House Bill 7, which includes the requirement that the Texas DWC adopt return-to-work guidelines in 2005, the state completed a thorough analysis of both ODG, providers of the Texas treatment guidelines and binary drug list, and Reed Group’s Medical Disability Advisor, now MDGuidelines. The state found the Medical Disability Advisor content to be more reliable and based on actual observed claims data wholly tagged by ICD codes and moved forward with adopting the content source to guide return-to-work decisions for injured workers in the state.

Commemorated in the Division of Workers’ Compensation Biennial Report to the 85th Texas Legislature, signed by Commissioner Brennan, Texas’ return-to-work outcomes are driven by the legislative reforms focusing on returning employees to work such as the return-to-work guidelines, return-to-work reimbursement program for employers, improvements in return-to-work outreach efforts, and other return-to-work specific programs. The report also correlates the rebound in return-to-work rates to the state’s economy in 2012 and 2013.

This information is critically important as state regulators and legislators reference the popular report Impact of a Texas-Like Formulary in other States by the Workers Compensation Research Institute and attempt to replicate outcomes experienced in the Texas system. The improvement in duration of disability and return-to-work is not the product of a binary drug list rather a result of a very comprehensive return-to-work effort mandated through legislative reform.

The following is an excerpt from the biennial report available online:

“Not only has the percentage of injured employees who returned to work and remained employed improved since the 2005 legislative reforms, but the amount of time the average injured employee who received TIBs [Temporary Income Benefits] is off work after an injury also decreased from a median of 28‐29 days in 2004‐2005 to 19 days in 2013. The reduction in the number of days off work per claim not only allows employers to quickly restore productivity levels after a work-related injury, it also allows injured employees to regain their wage-earning capacity quicker, helping them avoid severe economic losses as a result of a work-related injury.”

ODG Recommends Return-To-Work for SIDS & Other Pediatric Conditions

ODG claims to have a comprehensive data consortium undergirding its return-to-work guidelines data set as well. So why did Texas choose the Medical Disability Advisor over ODG? The publisher does not describe established standards for exclusion, fails to provide information about diversity with regard to industry or geographic location, and it cites the use of public databases (i.e., CDC NHIS and OSHA) where ICD codes are likely questionable or unavailable.

ODG also asserts its comprehensive guidelines cover every reportable condition and procedure, including over 10,000 ICD-9 codes, 65,000 ICD-10 codes, and 11,000 CPT procedure codes. Rather than screening these codes and providing information about conditions that affect working-age individuals, ODG’s website provides return-to-work summary guidelines for conditions not relevant to the working population:

  • Sudden Infant Death Syndrome (ICD-9 code 798.0)
  • Instantaneous Death (ICD-9 code 798.1)
  • Fussy Infant/Baby (ICD-9 code 780.91)
  • Infant Botulism (ICD-9 code 040.41).

Oddly, a search of ODG’s website using the term “infant” returns numerous conditions for which disability duration data does not exist and return-to-work guidelines are all together inappropriate. These recommendations call into question the source(s) of the numbers provided in the summary guidelines tables.

There is no doubt Texas made the right decision to adopt the Medical Disability Advisor, now MDGuidelines, as its standard for return-to-work over the ODG return-to-work content. The outcomes are irrefutable and a clear result of legislative reforms from 2005, not the savings-focused binary drug list made popular by the state.

However, the realization that the same entity that defines treatment standards for injured workers in Texas also publishes outlandish return-to-work guidance for deceased infants, should prompt severe concern for the quality of the science undergirding every recommendation stemming from the ODG library – treatment and return to work guidelines and drug formulary.

This prompts the question: Do the ODG treatment guidelines and drug formulary meet the definition of evidence-based medicine in the Texas Labor Code?

Texas Labor Code, Section 401.011 (18-a)

“Evidence-based medicine” [EBM] means the use of the current best quality scientific and medical evidence formulated from credible scientific studies, including peer reviewed medical literature and other currently scientifically based texts, and treatment and practice guidelines in making decisions about the care of individual patients.”

The labor code specifies “the use of current best quality scientific and medical evidence formulated from credible scientific studies.” While the State’s definition of EBM is not all together complete, the verbiage indicates the need for the content source to incorporate a transparent systematic review process.

Systematic review ensures the use of the “best” scientific evidence from “credible” sources; it is a core element of evidence-based medicine.

Good-working Systematic Review

As an example, the development of guidelines from the American College of Occupational and Environmental Medicine (ACOEM) utilizes Cochrane systematic reviews, in addition to other scientific systematic reviews that meet or exceed the Institute of Medicine’s (now known as the Academy of Medicine) Committee on Standards for Systematic Reviews of Comparative Effectiveness Research. The ACOEM Guidelines rely on systematic reviews conducted in accordance with the highest standards to provide current guidance on the relevant clinical questions.

Here is how it works: The Research Team conducts exhaustive systematic literature reviews for each guideline topic, and/or research question. In order to identify all high- and moderate-quality original research studies, the literature search is broad and comprehensive.

ACOEM searches PubMed, CINAHL, Cochrane Central Registry of Controlled Trials, and Scopus for primary sources of original research. ACOEM also conducts extensive supplementary searches using review articles, systematic reviews, and reference lists of the included and excluded studies. It searches other databases likely to contain references of high quality medical literature, including Google Scholar to identify potential quality, impactful literature that includes the grey literature.

Search strategies and methods are recorded in detail, including specific databases, search terms, number of studies found (e.g., regarding treatment efficacy searches including RCTs and crossover trials). A Search Results section, in paragraph form, is also included as a footnote for each evidence table.

  • The Search Results section includes:
  • Databases searched (that there were no limits on publication dates, limited to English language)
  • Search terms used
  • Number of studies found from all the databases searched
  • Total number of articles screened

– number meeting inclusion and exclusion criteria

– number critically appraised

  • Total number of studies included of high or moderate quality.

Also identified in tables, are studies of low quality.

In formulating the final recommendations, the numbers of studies and the strength of those studies, are all included in summary statements under the “Rationale for Recommendation” section.

The US Agency for Healthcare Research and Quality’s (AHRQ) Verdict on Texas’ Treatment Guidelines

In June of 2016, Mary Nix, AHRQ Health Science Administrator, stated in a WorkCompCentral interview, “Work Loss Data Institute [publisher of the Texas treatment guidelines a.k.a. Official Disability Guidelines/ODG] didn’t fully explain how it selected studies for its evidence-based review, including the number of studies identified, the number of studies evaluated, and a summary of inclusion and exclusion criteria. Another Requirement WLDI didn’t meet was to synthesize evidence from the selected studies in a detailed description or evidence table.”

In a separate interview with Business Insurance during the same month in 2016, Nix stated, “We were not able to … assure that the systematic evidence review was conducted for each of the topics that they cover in the ODGs”.

The following is a list of the types of evidence reviewed by ODG as documented in their methodology document available on line:

STUDIES:

  1. Systematic Review/Meta-Analysis
  2. Controlled Trial – Randomized (RCT) or Controlled
  3. Cohort Study – Prospective or Retrospective
  4. Case Control Series
  5. Unstructured Review

OTHER:

  1. Nationally Recognized Treatment Guideline (from guidelines.gov)
  2. State Treatment Guideline
  3. Other Treatment Guideline
  4. Textbook
  5. Conference Proceedings/Presentation Slides
  6. Case Reports and Descriptions

None of the “Other” materials reviewed and used by ODG meet the selection criteria for inclusion of any methodology literature-scoring model.

Recommendations for medical care should not be created based on single studies, or sources. Rather, recommendations should be based on the preponderance of evidence systemically gathered, reviewed, graded, summarized and evaluated. These steps are important to ensure the process is reproducible and the recommendations, when established, are valid and supported by the best quality scientific evidence meeting inclusion criteria from credible scientific studies.

The influence of Texas’ return to work standards on outcomes cannot be more apparent. While the evidence that the content underpinning their treatment standards do not meet their Labor Code’s definition of evidence-based medicine is overwhelming. It is a strange case indeed, when states such as Louisiana are specifically seeking to replicate the adoption of tools proven to have no scientific merit in hopes of achieving outcomes driven by sources and initiatives unique to Texas.

The Problem with Treatment Guidelines and Drug Formularies

Participating in legislative discussions across the country on the efficacy of adopting evidence-based medicine (EBM) treatment guidelines and drug formularies has given me a front row seat into an area of significant concern. The issue to which I’m referring exists among several stakeholder groups and vendor verticals in the workers’ compensation industry – an unclear, off-center understanding of EBM.

This issue is particularly concerning due to the fact that a rudimentary level of understanding exists on the topic, but not enough to provide informed accurate guidance on the health benefits of state-wide adoptions of EBM. The term, “I know enough to be dangerous” is very apropos in this instance.

It is this high-level, broad-brush understanding of EBM that propels sentiments in the marketplace that the content and tools are designed simply for cost containment purposes used as mechanisms to say no to patients for justifiable needed care. The feeling in these circles is that EBM provides no real health benefit to the injured worker.

Admittedly, there are widely used sources that are designed as cost containment tools masquerading as EBM content. These tools are draconian and overly simplistic. Their claims of being evidence-based do not align with trusted public national criteria, such as the National Academy of Medicine (formerly the Institute of Medicine) that have defined Standards for Developing Trustworthy Clinical Practice Guidelines.

During a recent webinar on EBM treatment guidelines a panel comprised of workers’ compensation claims, managed care, medical, and state-agency professionals discussed the obstacles and opportunities of treatment guidelines. While the panelists agreed on the focus of EBM being patient safety, they had various interpretations of what constitutes EBM.

One panelist cited Texas Labor Code, Section 401.011 (18-a):

“Evidence-based medicine” means the use of the current best quality scientific and medical evidence formulated from credible scientific studies, including peer reviewed medical literature and other currently scientifically based texts, and treatment and practice guidelines in making decisions about the care of individual patients.

In a 1996 editorial in the British Medical Journal, David Lawrence Sackett defined EBM as “…the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”(100) It was further noted that the practice “…means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”(100) In 2005, EBM was defined as “… a set of principles and methods intended to ensure that to the greatest extent possible, medical decisions, guidelines, and other types of policies are based on and consistent with good evidence of effectiveness and benefit.”(101) Properly done, the use of EBM is a process which entails the identification of high-quality scientific evidence, as defined by rigorous criteria, and synthesis of the entire body of evidence applicable to a given condition to guide (not dictate) medical practice.

Texas’ definition, while partially correct, is incomplete. Missing from the labor code are cornerstone principles such as the need for a systematic research process, the identification of high-quality scientific evidence through defined rigorous criteria, and a synthesis of the entire body of evidence applicable to the given medical condition.

By nature, the systemic research and development process of EBM addresses the concerns most often raised by opponents of the content:

  • (Concern #1) The studies used in EBM are bias – A high quality EBM development process incorporates comprehensive review and the grading of literature by qualified researchers. This determines if the studies are reliable looking at study design, population sample, results, study sponsorship, and potential conflicts of interest. Additionally, a trustworthy EBM source will not only use literature that has been subject to peer review, as Texas’ definition requires, but their final developed guidelines will also go through an external peer review process conducted by uninterested parties such as a state medical association, or specialty medical society.
  • (Concern #2) EBM is one-size fits all, or cookie-cutter, medicine – The root definition of EMB defines it as the “conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients.” The evolution of the drug formulary concept is a great example of this. Today’s formularies provide drug recommendations appropriate to each patient’s condition and takes into account whether their condition is in the acute or chronic phase. Using the modern formulary concept ensures the right medication is prescribed for the right condition at the right time.
  • (Concern #3) EBM removes the authority to treat a patient from the provider and delegates medical care to a guideline – It is true that some stakeholder groups have used EBM as a blunt instrument. They treat EBM as a definitive authority rather than a guide. As defined by Sackett in 1996, and still applies today, EBM requires the integration of individual clinical expertise from a provider with the best available external clinical evidence for the care of the patient. When clinical expertise is disregarded, the practice is no longer considered EBM. As I’ve stated in previous blogs, the patient/doctor interaction in the clinic will play a key role in eradicating the great drug epidemic that this country is currently grappling with. Providers need high quality content and tools they can trust to educate and keep their patients safe.

The problem with treatment guidelines and drug formularies is not related to content as each content provider has clearly defined their methodologies, for better or worse. The problem is a lack of understanding on the subject by individuals who are tasked with making decisions that ultimately impact an injured workers’ wellbeing. The standards for developing trustworthy EBM are not subjective. Content that is labeled as EBM should be measured meticulously to the appropriate standards.

The webinar I referenced earlier concluded with one of the moderators politely criticizing education that has previously been disseminated, intended to parse fact from fiction, about EBM. The comments assumed that all guidelines are created equal and that there is no room for accountability in workers’ compensation. I politely disagree.

If there is a platform where accountability is needed, its workers’ compensation. Our organizations deal with human beings when many of them are in their most vulnerable state – emotionally, physiologically, and financially. We, who understand the complexities of the system and our respective industries, have a duty to be their advocates.

100.Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. Br Med J. 1996;312(7023):71-2.

101.Eddy DM. Evidence-based medicine: a unified approach. Health Aff 2005;24(1):9-17.

WorkComp’s Unsung Hero

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

Weekend Read: Catching Feelings

Being an emotional person by nature (as many are) and knowing this about myself, I consciously work to keep my personal feelers (my 3 year-old daughter’s word for feelings) and views from being the only filter I see the business world through. A college mentor once made a very strong and lasting impression on me when explaining her view about how to show you care in a business context:  Showing you care in your business life is not as different as you might think [as in your personal life].

A big overlap in both settings that I’ve experienced is that verbal affirmation is not enough. In other words, don’t just speak about it; be about it.

Speaking the words “I care” must be followed by action and commitment. In my day-to-day business life, honesty, trustworthiness, reliability have all been great staples of ways to show my colleagues that I care about them and their contributions to the business community. It has only recently become very real to me that QUALITY and ACCOUNTABILITY are such great, tangible ways to say, “I care” to my internal and external customers.

QUALITY

It is easy to let a corporate marketing department do all of the talking about the quality offered by your firm. Most large organizations have very robust marketing operations to reach the masses at multiple levels; massive marketing efforts don’t just happen at the mainstream level, some of the best marketing happens at the grass roots level (individual email/phone campaigns, etc.).

When you “get down to nitty-gritty” (in my best Nacho Libre voice), does the service or product your offer measure-up to clearly defined quality measures? Can someone who is an expert in your line of work look “under the hood” of your vehicle and see the time (and financial) investment you’ve made to provide a best in class value/experience?

If you answered these questions with a resounding YES, invite deep dives and thorough analysis of your process and final product. Meeting and exceeding your industry’s highest quality measures is a great way of saying, “I care” to internal and external clients alike. Passing the test of quality is truly speaking with your actions and not just your words.

ACCOUNTABILITY

Being subject to the test of quality also says, “I care” through accountability.

Even in an industry founded in the spirit of fairness and cooperation like Workers’ Compensation, the industry’s evolution has given birth to a host of interests that routinely clash due to misaligning goals/incentives (or the perception of misaligned goals/incentives). Communication is as valuable as an oil gusher spewing crude richness hundreds of feet in the air from a Texan well and as scarce as volcanic lightning. Accountability is the great equalizer desperately needed to create balance among system vendors, whose inception (some may say) can be attributed to the apparent chaos and disconnect, to ensure the wellbeing and recovery of injured workers remains the epicenter of their efforts.

Can an industry say, “I care” any better way than to keep its shareholders and stakeholders honest and focused on the participants it was designed to protect through accountability?

Accepting accountability is the actionable way of saying, “If I can do it a better way, I want to do it better way.” Settling for the status quo or resisting growth and progress is detrimental to the success of the industry as a whole and a major obstacle for accomplishing its primary objective(s).

Please hear what I’m saying, I’m not opposed to growing profits or implementing efficiencies wherever possible. When profits and efficiencies come at the cost of quality, it is not worth the effort and could derail already established success.

Investment in quality and being open to accountability are ideal tangible ways to say, “I care” in business terms. People in the business world may not always care how you feel, but they will always respect and appreciate the quality you offer and your openness to accountability.