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De-medicalizing Disability Management

“Accept and Assist”.

Matthew Burnstein, MD, MCFP, MRO

Chief Medical Officer – Bell Aliant

Feb 13th, 2014

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Objectives

• Understand Total Cost and the Drivers of Disability

• Weakness in the Traditional Approach to Disability Management

• Time for a Paradigm Shift? • A New Model• Study the results• Lessons Learned

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Bell Aliant Regional Communications

• 7000 union and non union members (>60% unionized)• 6 provinces, widely dispersed• Customer care workers, field technicians, engineers, marketing

and sales, finance, support services• TV, internet, home security systems and phones – ever-

changing product mix• Former monopoly • <2% staff turnover• In house team of Health and Wellness (H&W) professionals• Self insured for short term disability- up to 1 yr at full salary• Unlimited incidental absence at 100% pay

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TOTAL COSTS OF DISABILITY

STDINCIDENTAL

WCB

OvertimeBenefitsMorale

Increased stress for colleaguesCustomer Satisfaction

Increased workloadLost Sales Opportunities

Paperwork / ReportingTraining/Retraining

DIRECT COSTS

INDIRECT COSTS(INDIRECT COSTS ARE 2.5-3.5 X DIRECT COSTS)

Cost to Employee and their Family!

Presenteeism- double this

number!

Drug/health costs

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What’s behind the high rates of disability today?

We’ve never been healthier,

never lived as long,

never had such great medical knowledge,

yet, as a society,

we’ve never been so disabled.

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How does an individual end up disabled?

An Individual with a complaint

becomes a

Patient with an illness,

who becomes a

Claimant with a disability.

In most cases, the evolution is driven by the individual, not by the illness or the physician.

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Does the medical model explain disability?

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• “The experience of disability is more related to society’s willingness to accommodate and individual motivation than any underlying impairment or limitation. Our narrow concepts of health and disability limit our potential.

• Over the years, I have been impressed by the relative lack of correlation between impairment and disability….Much of disability results from learned experiences, lack of adaptive skills and reinforcements from physicians, family members, attorneys, employers and others.

• We can no longer accept this societal illness; the costs are too enormous”.

Dr Chris BrighamPresident ABIMEPreface the MDAs

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Only a small fraction of medically excused days off work is medically required – meaning work of any kind is medically contraindicated. The remaining days off work result from a variety of non-medical factors such as administrative delays of treatment and specialty referral, lack of transitional work, ineffective communications, lax management, and logistical problems. These days off are based on non-medical decisions and are either discretionary or clearly unnecessary. Participants in the disability benefits system seem largely unaware that so much disability is not medically required. Absence from work is “excused” and benefits are generally awarded based on a physician’s decision confirming that a medical condition exists. This implies that a diagnosis creates disability.

ACOEM Guideline on Preventing Needless Work Disability by Helping People Stay Employed

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• “Disability is a complicated psychosocial problem that extends beyond the sole question of illness or injury. Many factors contribute to the complexity of the problem.

• They include, but are not limited to an individual’s values and beliefs; the role of illness in the individual’s childhood..; the specific symbolic meaning of illness or injury to the individual; the individual’s relationship with his employer; economic issues; workplace accommodations made available by the employer; and the employer’s policies/practices, culture, and values”.

Dr Presley ReedThe Medical Disability Advisor 4th Ed.

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Disability is not a medical concept

Defined by a contract, usually related to occupation

Therefore, it is a legal rather than a medical concept

Influenced by non medical factors :– Employer, availability of alternate duties– Training, experience, education– Psychosocial factors– Personality

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Doctors are trained to treat illness,

not disability

Reality check:

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Physician’s Perspective On Disability Determination

• 86% of physicians believe that completing disability forms adversely affects the physician-patient relationship

• 62% feel it represents a conflict of interest• 56% are willing to exaggerate clinical data

to assist a deserving patient• Physicians report a lack of confidence in their

ability to determine disability (self rated ability as 4.5/10)

• 80% of physicians feel it would be better for an independent group to determine disability

Journal of General Internal Medicine 1996 11(9)

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Certificate of Disability Canadian Medical Association Policy

• The CMA believes it is the employer’s responsibility to supervise an employee who is absent from work for a short time because of a minor illness. The medical profession objects to being asked to police such absenteeism.

• The association objects to the use of physicians as “truant officers”.

• It is generally accepted that most minor illnesses are self limiting and do not require the intervention of a physician.

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Medical Post 4/5/99

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Gross Absence Rates Agriculture 1.7% Trade & Commerce 2.3% Finance 3.3% Construction 3.4% Manufacturing 4.8% Government 5.3% (Perspectives 1999) USA 3.5% Sweden 6.0% France 8.3% Italy 11.6% Unionized ees 13.2 days/yr vs Non Unionized ees 7.5 days/yr (Stats Can 2011)

If illness was the cause of absenteeism, then absence rates should be similar across communities. But they are not:

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What are the reasons we miss work?

Global/Environment Organization Personal

Region (NS vs AB) Culture Job

Climate Type Gender

Race Size Age

Economy HR policy Schedule

Pension Age Relationships Job Satisfaction

Social Programs Quality of Supervision Transportation

Health Services Sick pay/benefits Family

Epidemics Turnover/Churn Personality

Religion/Culture Working Conditions Individual Health

Health Services Work demands

Leadership Physical workspace

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The primary determinant of work attendance is job satisfaction:

Adding Value Being Valued Sharing Values

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Drivers…

• What makes people come to work?– Opportunity, Desire and Ability– Global / Environment / Organization / Personal

variables can affect those

• Who decides if working is possible?– Decision to work is made by the individual– The decision to offer alternate duties and provide

accommodation is made by employer– Neither is a medical decision

Page 24 But beware the golden handcuffs

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And you want employees to like their work……….

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“It is always more important to know what type of person has a disease than it is to know what type of disease a person has.”

Hippocrates:

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Disability vs Disease• Disability and disease are distinct concepts;

diagnosis does not determine disability• Doctors don’t know disability and are not truant

officers• Disability from work is determined by a multitude

of non medical factors• While supporting the concept of early return to

work, doctors are patient advocates, and ultimately, patients determine their ability to work

• The workplace/workplace policies must encourage employees to remain at work (even in the face of challenges)

• Engagement may reduce absenteeism

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So, if disability is not driven by disease, and doctors don’t know much about

disability or the workplace, what do we do?

How do we determine or manage disability?

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The first paradigm shift

Stop talking to doctors and start

talking to employees.

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Talk to employees

• Doctors talk to their patients - they trust them and advocate for them, but they don’t know the workplace

• Trust your employees – they are telling you the truth* • Treat them as you’d treat a manager or a colleague

or want to be treated yourself• They know their job and what aspects they can do

and can’t do• Allow them flexibility to do the job• It is their motivation which determines outcome – so

what is motivating them to come to work or keep them off?

* Most of the time. Why treat the 99% who are honest to catch the 1%?

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What’s going on?

What you see

What you don’t see

WORKPLACE SYMPTOMSARE ONLY THE

“TIP OF THE ICEBERG”

S p i l l o v e r

Work Issues• Environmental• Interpersonal• Job-Related

KNOWING THE SOURCE OF THE PROBLEM

ALLOWS THE CASE MANAGER TO DETERMINE A

COURSE OF ACTION

Health Issues• Heart Health• Nutrition• Sleeping • Depression

Life Issues• Stress/Emotional• Relationships• Legal/ Financial• Addictions

Lateness

Emotional outbursts

Withdrawal

Mood Swings

S p i l l o v e r

Troubled or Absent Employee

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The Second Paradigm Shift

• Accept them and help them• You cannot rehabilitate someone who is busy proving they are

disabled• Malingerer’s are rare. Anxious and overwhelmed individuals are

common.• Often the claimant is just in the wrong basket – needs family

leave, needs to change jobs, needs to be on administrative leave or re-assigned while workplace conflict is addressed

• Chronic diseases are chronic/recurrent and need to be addressed holistically (is public health up to the task?)

• Whatever the barrier or reason for being off work, the outcome is better, and total cost reduced, if you support the employee and work through the issues

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The Third Paradigm Shift: think long term

• Employees are there for the long term, so you need to think long-term

• An injured/ill employee who could be at work, but chooses not to rtw, generates a greater loss to the organization over the long term than the “extra” few weeks of sick leave. They are disengaged.

• Presenteeism costs more than absenteeism• Forcing an employee to rtw when they feel

they are “unfit” will cost the employer money every day

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Tools to Assist the Shift: Health Assessment

A complement to, not a replacement for, a discussion between manager and employee.

Health Assessment Type When to use

Health Status •Proactive•Accommodation Issues

Attendance •Medical issues impacting attendance•Level 3-Attendance Support

Ergonomic •Persistent Ergonomic Issues

Return to Work •Assess fitness to return to work from LTD, Administrative Leaves, etc. (used infrequently)

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Train Managers to Identify Employees at Risk

• How to help employees stay at work– Identify employees who is having difficulties, as early as

possible.

• Absence is a predictable event– How to predict absences?

• Know the workplace / know the people and know when action is necessary

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Tools to Assist Shift: Attendance/Performance Improvement

Program

• Triggered when there is a demonstrated history of being over the average for the department for absence or not meeting performance targets

• Absence is absence –– it’s not why you missed work, it’s that you missed work (assumed innocent).

• The reasons for the absences/poor performance determine the help needed.

• Early identification is key.

• No fault, no blame but the absences/performance is an issue –What can you do? What can we do?

• Non-disciplinary

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Transitional Return to Work

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Transitional Return To Work

• Focus on ability not inability• Manager and employee (+/- health services)• Part of corporate culture - it should be expected

(and employer should be prepared with options)

• Time limited – it’s a transition not a move• Progressive (but flexible)• Must be safe (for ee, co-workers, public)• Goal is rehabilitation – it cannot be punitive• Work must have meaning• Workplace must be welcoming

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Bell Aliant is Committed to Early and Safe RTW (as is the Union!)

• 28.12 It is agreed that the rehabilitation of sick and injured employees is a priority. The Company and the Council will participate in programs that will enable early and safe return to work…The rehabilitation plan will be based on the employee’s functional capability, input from the employee’s existing health care providers, and other health care professionals as deemed necessary by the company.

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Manager and Employee can decide on

modified duties – LRA 2008-04.

• If the employee’s restrictions are expected to last 30 days or less and the employee can be accommodated under the terms of the collective agreement, no action is required other than proceeding with the accommodation request. If however, the employee cannot be accommodated under the terms of the collective agreement, then medical documentation may be required. At any time, the manager can seek input from Health and Wellness. The manager must inform the local shop steward of the details of the accommodation and the duration.

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Mental Health Initiative

• 1/3rd of claims, last 50-100% longer• MH issues start young and recur• Often months of presenteeism before absence

(opportunity to intervene)• There are often workplace drivers and workplace

solutions! (another opportunity to intervene)• Mental health awareness training for Leaders of

people• Educational sessions, communications• Focus on early recognition, highlight resources

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Results of this Approach

• Gross Absence Rate* 4.5%>4.3%>4.1%>3.6%>3.6% (2013)

• SDB as % salary` 1.36%>1.28%> 1.24% >0.97% >0.99%• Denials < 1% - usually wrong basket• Grievances on denials – rare • Relationship with Union - positive• # of Health Assessments – increased (some referred by

Union)• # of IMEs for SDB adjudication – rare• # of IMEs for HA’s and SDB mgmnt - frequent

* Cdn GAR: Company >500 ee =4.4%;Unionized Workplace 5.3% (stats can 2011)

`SDB % of Income Cdn average 1.5% (Towers Watson)

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Lessons Learned• Accept and Assist trumps Deny and Defend• Think Total Cost and think long term• Talk to employees, not doctors• Engage HR/LR/Ops in program development – make them

stakeholders/ambassadors; train mgrs/union• Don’t under estimate cultural resistance• Become health navigators – focus on Chronic Disease• Orient new employees/managers• Address presenteeism- its your next SDB claim, offer help• Performance = Attendance improvement• EE who can, but won’t participate in TRTW, is likely

disengaged and a problem beyond their SDB claim

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THANK YOU ……….Questions?