How YOU Can Help Doctors Make Better Decisions - Jennifer Christian, MD, MPH President, Webility Corporation - wwdpi
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How YOU Can Help
Doctors Make
Better Decisions
Jennifer Christian, MD, MPH
President, Webility Corporation
Copyright 2018 ©Webility Corporation
3 Opportunities for Improvement
• Employer / insurer skill in
managing non-medical issues
• Physician skill in work disability
prevention and management
• Communications between medical
offices and employers / insurers
Copyright 2018 ©Webility CorporationJennifer Christian, MD, MPH
• Education: Univ of Wash; Board
cert. in occupational medicine. .
• Expertise: Leadership, outcomes
improvement (health & function,
disability), innovation & pilot programs.
• Clients: Employers, healthcare
providers, managed care companies,
disability and workers’ compensation
insurers, government agencies.
• Current:
– New: Praxis Partners Consortium
(multi-stakeholder)
– Webility Corporation – management
consulting & training
– Maze-Masters Program – helping
individuals “lost in the system” get
their lives back on track
– ACOEM - Chair, Work Fitness &
Disability Section
– FREE e-group -- Work Fitness &
Disability Roundtable
Phone: 508-358-5218
Jennifer.Christian@webility.mdPlan for this Session 1. Describe how various parties’ inappropriate expectations of clinicians in the SAW/RTW process create needless work disability and foster job loss and workforce withdrawal. 2. Clarify how unmet needs of key participants in the SAW/RTW make them want to get clinicians involved. 3. Suggest ways to improve the speed and quality of information received from physicians. 4. Suggest when NOT to depend on physicians, and some things to do instead.
5
Problem: Accountability Gap
Medical Offices Workplaces
Delay Delay
Uncertainty Uncertainty
Reactive posture Reactive posture
“Not mine: “Not mine:
NOT a medical issue” This IS medical”
Result: Needless Work Disability,
Job Loss, Withdrawal from Workforce
© 2018 Copyright Webility Corporation –Others Rely on Medical Guidance
• Affected individuals use it as education
• Several parties use it to set expectations
– Short term activities
– Recovery & timeframe
– Forecast evolving changes over time
• Employers / benefits payers use it to:
– Schedule their workforce / Get work done
– Administer absence / attendance programs
– Make benefit eligibility & payment decisions
– Comply with disability-related laws, regs & policiesA Feature of Daily Medical Practice • SAW/RTW considerations are part of everyday practice for all clinicians in outpatient practice. • Activity modification both at work and at home is always a concern whenever a working patient’s functional ability has been altered by a medical condition. • Written notes/forms are frequently requested. – 1 note/day typical outpatient practices – 30 notes/week for ortho / occ med practices • BUT >90% of these cases are trivial and short- lived injuries & illnesses. “Big deals” are rare.
Employers & Insurers Elicit Medical Opinions
to Drive Benefit Programs & Legal Systems
1.† Describe the (basis for your):
• findings and diagnosis
• treatment history and plan
• anticipated duration (prognosis)?
2. Is the cause of the problem work-related?
3. Does it meet our / the law’s definition of disability?
4. What are the restrictions and limitations?
5. Can this person work? When?
6. Has the case reached maximum medical
improvement?
† - The only question most doctors have been trained to answerTypical Medical Training
• An average of 4 hours in four years devoted to the entire
field of occupational medicine – mostly toxic exposures.
• Does not include ANY information on:
– the positive role that work plays in well-being
– the hazards of worklessness
– doctor’s role in preventing work disability
– how to assess risks posed by work
– how to assess work capacity, or formulate
restrictions & limitations.
• Medical schools will not voluntarily change curriculum.Unhappy “Designated Guessers”
• Most doctors aren’t comfortable with this
work and try to avoid it.
– Forced to guess with no framework for decision-
making.
– Scientific foundation of activity guidance is weak
or missing.
– The questions posed are often NOT answerable
with information available at the time.
– Consider these forms “administrivia” -- an
irritant.
– No/weak commitment to “enforcing” laws or
rules.Typical Mistakes Doctors Make
• Inattention to function during therapy
• Over-protective – creating fear:
– “You shouldn’t do that.” “Not safe to do that.”
• Over-limitation – underestimating capability:
– “You can’t lift more than 10 pounds.”
• Negative predictions – destroying hope:
– “Don’t even bother applying for a job.” “You’ll
never be able to work again.” “You should apply
for SSDI.”
• Acting as the patient’s secretary: “McDoctor”“Transubstantiation”
• Doctors’ best estimates, which may include wild or
careless guesses and mistakes are transformed
into immutable “true facts” by custom or by law, to
recipients.
• Many disability benefit systems reinforce this
mystery:
– A doctor's opinion is legally accepted as prima
facie evidence, and the treater’s opinion is
given most weight
– Often, no explanation is expected or requiredAll Doctors Are Not the Same • Patients are vulnerable to the large variability in quality, competency, wisdom of doctors. • Medical education / training / specialty • Uneven geographic distribution of HCPs • Local differences in medical practice patterns – 7 to 10-fold variation in rates of procedures, costs • 4 kinds of doctors – WA state: A,B,C,D • Bad/weak apples have a big impact – Hopkins study: Louisiana – 75 out of 1800+ doctors
Can We Realistically Expect More From Doctors in SAW/RTW? • Employers /insurers / legislators want clinicians to do things they don’t think of as “medical,” aren’t trained for & don’t like doing – and do it for free! • Professions define themselves: carpenters work with wood, not metal; electricians don’t do plumbing, artists don’t do accounting. • Private medical practices are businesses and get to choose what services they will provide. • Don’t believe marketing representatives; the systems are not set up to do these things well. • Efforts to change even small things in the bullseye of medical care have required decades of sustained effort to be successful.
Unmet Needs & Naïveté Create Desire to Put Doctors in the Middle • Employees – a sense of urgency and fear of abandonment, distrust of employer/payer; desire to get what they want. • Employers – distrust of workers; false perception that the issue is medical and doctors know everything; lack of preparation for predictable functional disruptions among workforce; desire to shift responsibility. • Unions – distrust of employers; lack of knowledge re: risks of worklessness, and health & other benefits of SAW-RTW, lack of preparation for predictable functional disruptions among members; a ritualized defensive, protective, enabling posture; cynicism.
Other Parties Also Think They
Want Doctors in the Middle
• Lawyers – see clearly that a doctor can usually be found
who will say what you want; value of an “expert” opinion to
the court; belief that money is a good solution for their
client; tradition and personal financial benefits of ritualized
postures and combative behaviors in both defense vs.
applicant/plaintiff bar; enthusiasm for fighting.
• Legislators – lack of confidence in collaboration as an
viable problem-solving process; false perception that the
issue is medical and doctors know everything; lack of
subject matter expertise and get skewed input from
stakeholders with vested interests; focus on looking good to
donors / voters and sensitivity to “poster child” PR issues in
lieu of real systemic improvement.Shift the Emphasis:
Clarify Whether Work
Disability is Medically Required
Copyright 2018 ©Webility CorporationMedical Conditions
Are Not Necessarily Disabling
• Different conditions with different impacts:
– “Temporary” (surgery, wounds, sprains, “the flu”)
– Chronic (diabetes, arthritis, asthma, aging)
– Fixed (blindness, amputation)
• (Natural) loss of function due to age:
– Accelerated by heavy use, deconditioning, genes.
– Delayed by good genes, health habits.
– Most people make adaptations & keep going
Copyright 2018 ©Webility CorporationWork Disability Is
Medically-REQUIRED When . . .
• Attendance is required at place of care
• Recovery requires confinement at home or in
bed
– Acute response to injury
– Risk of contagion - Quarantine
– Need for protected environment
• Work or commute is medically-contraindicated
– Will worsen medical condition or delay recovery
Copyright 2018 ©Webility CorporationWork Disability Is
Medically-Discretionary When . . .
Could do something useful but . . . .
• “No way to get worker to work”
• “Worker is incapable of any substantial work”
• “Effort required to support the worker is more
than makes sense”
• “Can’t figure out how to provide work within
these limitations”
• “Company policy / labor contract prohibits
light duty”
Copyright 2018 ©Webility CorporationWork Disability Is
Medically-Unnecessary When . . .
• Inadequate or delayed medical care (dx and tx)
• “Medical” time lost from work that is really due
to:
– Communications delay / poor information flow
– Employer passivity, ignorance, or resistance
– Administrative / procedural delay
– Other problems masquerading as medical issues
– Flabby management, poor accountability
Copyright 2018 ©Webility CorporationWhere a big opportunity lies:
Benefits Eligible Work Disability
PREVENTABLE
DISABILITY
Copyright 2018 ©Webility CorporationWork Disability Prevention =
Reduce Needless Absence
Medically
REQUIRED Medically
Disability DISCRETIONARY Medically
Disability UNNECESSARY
Disability
Copyright 2018 ©Webility CorporationQUICK BREAK Got a question? Ask it in chat box. Copyright 2018 ©Webility Corporation
Part II
Communicating
With Doctors Re: RTW
Copyright 2018 ©Webility CorporationPractical Realities
in the medical office
on the assembly line of care
Copyright 2018 ©Webility CorporationThe Most Efficient Moment for
SAW/RTW Decision-Making
Exam Room
Patient Appointment: Medical Chart
Dx, Tx, Rx,
RTW Advice
Dictation
Results Rx, Tx Orders
Reports Referrals
Questions Patient Instructions
RTW Slips
Copyright 2018 ©Webility CorporationMis-matched Schedules
Make Communications Harder
Day 1 3 5 7 9 11 13 15 17 19 21 23
Doctor:
Patient Visits x x x x x
Claim handler:
Sends letters / faxes
x x x
Nurse Case Manager:
Phone calls / faxes x x x x x
Employer:
Phone calls / faxes x x
Copyright 2018 ©Webility CorporationConsider This
• Doctors are high-priced piece workers
• They choose what to spend their time on
• Why not REWARD THEM for spending time on
what YOU WANT them to do?
– Improving their skill at managing work disability
– Time and effort spent on preventing it
– Prompt and practical guidance re: work
• Offering to pay sends a very positive message.
Copyright 2018 ©Webility CorporationResearch Shows
Line Management Is Critical
• Workforce with positive work environment &
good management has lower absenteeism
• Employees who like their jobs RTW sooner
• Employees whose questions are answered /
worries are addressed come back sooner
• Employees RTW faster when supervisors
express interest/caring and keep in touch
Copyright 2018 ©Webility CorporationPrevention & Management
Programs Have an Impact
• 1.4% absenteeism with
– RTW policy
– Case management (RTW coordination)
– Supervisor involvement
• 5.3% absenteeism without them
• Programs have saved 20 - 50% on benefit
costs
Copyright 2018 ©Webility CorporationThings Employers
Need to Know
• What you do makes a BIG difference
• Be nice! Use the Golden Platinum Rule
• Take charge on the first day
• Focus on function, not the condition
• Keep in touch with OOW employees
• Have transitional work tasks ready
• Learn how to manage people on TWA
• Educate all parties why TWA is good
• Deal effectively with problem cases
Copyright 2003 ©Webility CorporationBUT
• Very few employers know this now
• A history of letting George (insurers) do it
• Ignorance breeds reluctance
• Unaware of their power
– Passive, resigned, cynical, or naive
Copyright 2018 ©Webility CorporationWhat Employers Can Do
To Reduce Work Disability
Medical Condition
+
Ability / Willingness to Cope
+
External Support
Copyright 2018 ©Webility CorporationFocus On The “Swing” Groups
Bad Outcome Guaranteed
Bad, unless . . .
Good, unless . . . .
Good
Copyright 2018 ©Webility CorporationNormal Human Reactions to
New Injury / Illness / Impairment
• Surprise, disorientation, disruption
• Vulnerability, dependency, incompetent
• Discomfort, pain
• Confused, bewildered, befuddled
• Uncertainty, upset, stress, anxiety
• Meaning, implications, predictions
• Anger, resentment, revenge
• Sadness, grieving the loss
• Alone, isolated, disconnected
Copyright 2018 ©Webility CorporationColledge’s SPICE Model
• Simplicity – Avoid medicalizing normal human
things; do not label (over-diagnose)
• Proximity – Preserve daily routine
• Immediacy – Each day counts; time is the enemy
• CENTRALITY – Keep the focus on the person
and resolving their predicament, not the “policy”,
“process”, “system” or “law”.
• Expectancy – Predict and actively drive situation
towards a positive outcome
Copyright 2018 ©Webility CorporationModifiable Factors that
Predict Work Disability
• Interval away from workplace
• Negative expectations
• Distress, fear-avoidance
• Depression, anxiety
• Maladaptive coping, catastrophizing
• Pain intensity and pain behavior
• Functional disability (self-limiting)
Copyright 2018 ©Webility CorporationReview / Rethink YOUR
Communications with Doctors
Ask: Does the doctor have enough information at
hand to feel comfortable making a decision?
– About your company, your philosophy, your
commitment to honoring restrictions and keeping
workers safe?
– About demands of usual job and work environment?
– About other task options?
– About other task options, your capabilities for
monitoring the worker after RTW?
Copyright 2018 ©Webility CorporationMaximize Simplicity / Brevity of
Information Provided
Think: How can we present the information
so it will LOOK easy and quick for the
doctor to make a good decision?
• Does this form look like it will take
< 1 minute to complete --- e.g.
– One page of info (with backup detail so it’s
available ONLY if doctor wants to bother)
– 5-8 checkboxes?
Copyright 2018 ©Webility CorporationWork disability prevention requires
a team approach, so …….
treat doctors like team members
Copyright 2018 ©Webility CorporationGet to Know One Another
• Identify the doctors who care for your
employees -- and establish a direct working
relationship with them.
• Anticipate and provide information the doctor
will need to make a good decision -- routinely:
every case, every time.
• Expect / ask key doctors to improve skills
– Work disability prevention and RTW communications
– Knowledge of your company’s programs
Copyright 2018 ©Webility CorporationOpportunity Finding Exercise:
See what’s missing and identify specific changes
you can make to work more effectively with your
local medical community
Go to www.Webility.md
Click on Library/Links
Click on “Self-Assessment Tool for Employers / Payers”
http://www.webility.md/pdfs/Exercise%20for%20Employers-Payers--
%20Medical%20Community%20Relationship2014-07-09a.pdf
Copyright 2018 ©Webility CorporationIn Tough Situations… Copyright 2018 ©Webility Corporation
Just-In-Time Access to Trusted
Expertise Meets the Parties’ Needs
When work disability persists or accommodation proves
difficult, any of the key parties need access to trusted
problem-solving expertise at any one’s request
– Facilitation of interdisciplinary and multi-stakeholder
communication / dialogue
– Situational assessment
– Factual input / opinion / advice
– Connection with and coordination of other resources
as needed
– Formulation and execution of resolution strategy
– When necessary, service can be provided remotely.You need a trusted, credible, & expert
intermediary prepared to:
:
1. Assess situation for remediability i.e., identify
needs & unresolved issues of the employer,
employee. and /or treating clinician and any other
significant situational factors at play.
2. Contribute needed information (applicable rights,
respective duties, relevant law) & expertise
(analysis & mediation skills).
3. Facilitate the “interactive process” among the Key
Parties.
4. Bring in needed resources.Summary Recommendations
Re: Doctors
• Leave doctors free to focus on
– health, healing, & prevention of medical harm
– documenting accurate clinical / functional
information
– providing “guidance” on safe level of activity.
• Treat information about activity / capability from
doctors as expert estimates, not “true facts.”
• Defer to well-informed doctors if activity poses a
clear risk of harm (not just subjective symptom
worsening).
• Get doctors off the hot seat whenever possible.QUESTIONS? COMMENTS?
My goal: Reduce inauthenticity and game-playing – by all parties.
Copyright 2018 ©Webility CorporationYou can also read
