Balancing Employee Health and Safety with Company Goals Michael Erdil MD, FACOEM Occupational and Environmental Health Network Johnson Occupational Medicine Center

Potential Challenges In Workers Compensation n Conflicting goals and multiple parties u Worker u Employer, supervisor u Treating providers (Primary WC and specialty MD/DO, DC, PT/OT, PCP, other) u Insurer / TPA, adjuster, case manager, utilization review u Attorneys

Potential Challenges In Workers Compensation n Adversarial relationship among entities n Non evidence based care with suboptimal outcomes and excessive cost n Delayed recovery and associated indemnity and replacement costs n Communication breakdowns and poorly coordinated care and RTW n Lack of effective efforts regarding prevention

Costs of Musculoskeletal Disorders n LBP estimate $ billion annually u 5-10% = 80-90% of costs n Upper extremity MSDs u 25% = 89% total costs n Indirect costs perhaps up to 4x direct cost n Non-monetary considerations n Impact of comorbidities

Organizational Commitment to Safety n Establish and communicate goals n Active health and safety committee n Effective reporting of injuries, etc. n Consider injuries, non-acute MSDs, near misses as opportunity for improvement

Align Goals and Educate n Timely evaluation and effective treatment n RTW goals n Communication standards n Facilitate payment to workers and health care providers n Track outcomes

New Employee Orientation n Lifestyle issues: weight, smoking, etc. n Safety goals and prevention n Understanding timely injury reporting and WC system n How to obtain care n Most conditions respond to conservative care

New Employee Orientation n Home exercise and PT / OT n Early imaging not needed in the absence of red flags n Prolonged opioids and side effects, delayed recovery u CDC Risk Mitigation Strategies n Excessive lumbar spine surgery u 2/3 patients with lumbar fusion disabled at 2 years u Opioid dose often increases post-op u Opioids and post-op mortality

Death from Drug Overdoses

* Per 100,000 population. † Coded according to the International Classification of Diseases, Ninth Revision, during and according to the Tenth Revision during Additional information regarding classification of deaths according to intent and mechanism is available at Age-Adjusted Death Rates* for Leading Causes of Injury Death, † by Year - United States,

Opioid Deaths vs Daily Dose n Bonhert JAMA 2011

New Employee Orientation n Early RTW at modified duty often not harmful and can improve outcomes u Support from ACOEM, ODG, AAOS, AMA, other

Low Back Pain at Work - Principal Recommendations n Carter JT, Birrell LN (Editors) n “Epidemiological and clinical follow-up studies show that early return to work (or continuing to work) with some persisting symptoms does not increase the risk of 're-injury' but actually reduces recurrences and sickness absence over the following year”

Meet With Primary Occupational Health Providers n Need for facilitated initial medical evaluation and follow-up n Clear description of treatment plan and appts u Evidence based medicine guides n Describe work capabilities and estimated full duty RTW target u Evidence based LOD targets n Real time communications n Outcomes

Employer Expectations for WC Providers n Rousmaniere 1999 J. Work Comp n Ability to define and document work restrictions n Responsiveness n Appropriateness of referrals to specialists n Timeliness of reports from initial care providers n Quality of clinicians

Patient Satisfaction and Provider Communication re: LBP n Shaw et al 2005, Dasinger et al 2001 n n Took problem seriously n n Explained condition clearly n n Tried to understand my job n n Advised ways to prevent re-injury n n Discussed my behavior that might influence recovery n n Discussed my readiness for RTW

Provider Factors and Increased Length of Disability n Not knowing modified duty available n Provider unwillingness to cooperate with case management and RTW n PCP concerns re: offending patients n Difference of opinion on RTW among providers

Worker Factors and Increased Length of Disability n Short job tenure n Lower job satisfaction n Poor expectation on RTW n Coping issues n High pain levels and fear avoidance n Reporting delays

Worker Factors and Increased Duration of Disability n Perceived lack of coworker support n Perceived lack of supervisor understanding and assistance on RTW

Work Factors and Increased Duration of Disability n No modified duty n No RTW coordinator n Higher physical demand levels n Supervisor support

Employer Opportunities n Train supervisors on responding to injured workers u Inform workers of efforts to improve safety u Improve opportunity for worker injury reporting u Express concern for reported symptoms u Minimize blame and stigma

Employer Opportunities n Provide information to worker on obtaining treatment n Develop temporary alternative work options u May require communication with other departments n Involve worker in problem solving to address barriers to RTW at same job, modified job, other jobs n Overcoming fear of RTW and reinjury with graded RTW and monitoring

Employer Opportunities n Monitor worker during RTW transition n Coping issues n Dealing with heavy work demands with alternative solutions n Provider communication, ergonomic evaluations, assistance with PT / OT if questions regarding work demands and worker abilities

Worker with Prolonged LOD n Discuss RTW abilities/goals with worker, supervisor, provider, insurer n Encourage active worker participation n Return to own vs. any job n Use of FCE and IME n Barriers of collective bargaining agreements, employer policies