1. 1 The Disability Determination Process: DISABILITY RESEARCH INSTITUTE 2004 SYMPOSIUM MARCH 16, 2004 Ronald S. Leopold, MD, MBA, MPH MetLife Group Disability Vice President, National Medical Director The Role of the Health Care Provider Commercial Disability Carrier Perspective

2. 2 Role of the Physician There is a myth that health care providers have the knowledge and motivation to determine how long someone will need to be out of work and when they will be expected to return to work. The reality is, most medical providers have not been trained in making functional interpretations. They are often not accurate in determining what a person can or cannot do as a result of a medical condition or injury. When an extended work disability has occurred (as in short or long term disability), identifying the optimum return- to-work date is considerably. And yet American economy is dependent on the physician’s determination of functional capacity. The economics of the “Doctor’s Note” represents an astounding disconnect between utility and capability.

3. 3 ACOEM* Position Statement  A fundamental purpose of medical care is to restore health, to optimize functional capability, and to minimize the destructive impact of injury or illness on the patient's well being;  Prolonged absence from one's normal roles; including absence from the workplace, is detrimental to a person's mental, physical, and social well being;  A return to all possible functional activities relevant to the patient's life, as soon as possible after an injury or illness, has many beneficial effects;  Physicians positively affect the likelihood and rapidity of healing by setting clear expectations for recovery with patients. Source: *American College of Occupational and Environmental Medicine: The Attending Physician's Role in Helping Patients Return to Work after an Illness or Injury, Consensus Opinion Statements; April 14, 2002

4. 4 The Physician should consider and make recommendations related to the following  Physical and functional limitations or restrictions: The employee's functional capabilities and vulnerabilities should be considered and matched against the demands of the job and working conditions.  Limitations: Any existing constraints in the employee's physical or mental capability to perform tasks. A mild increase in symptoms with increased activity is appropriately viewed as a non-medical issue. Patient self-report may not always be a reliable method of making this determination. Self-imposed limitations may be based on subjective perception or secondary gain. The physician is advised to rely on objectively determinable findings to the maximum extent possible. Source: *American College of Occupational and Environmental Medicine: The Attending Physician's Role in Helping Patients Return to Work after an Illness or Injury, Consensus Opinion Statements; April 14, 2002

5. 5 The Physician should consider and make recommendations related to the following :  Specific restrictions: Any protective measures required to prevent injury or foster recovery. These should be specific e.g. the exact weight and height for lifting restrictions; the amount of time per hour and per shift an activity can take place; postures to be avoided. Duration of restrictions should coincide with the expected increase in endurance associated with the increased activity of a graduated return to work.  Social or environmental limitations or restrictions.  Schedule modifications: Should be noted when return to a normal schedule is medically appropriate.  Medical aids, adaptive equipment, or personal protective equipment. Source: *American College of Occupational and Environmental Medicine: The Attending Physician's Role in Helping Patients Return to Work after an Illness or Injury, Consensus Opinion Statements; April 14, 2002

6. 6 SIX PATIENTS PER HOUR In 60 minutes the average physician must complete the following 10 tasks six times: 1. Read the notes in the patient's chart. 2. Take the patient's statement. 3. Ask the patient questions about the condition. 4. Conduct the physical examination. 5. Consider the facts, make a diagnosis and devise the treatment plan. 6. Explain the diagnosis and plan to the patient. 7. Make plans for the next appointment. 8. Answer all the patient's questions. 9. Fill out forms, lab orders, etc. 10. Dictate notes for the patient's chart. Webility Website 2003: Six Patients Per Hour: www.webility.md

7. 7 THE ISSUE Many stakeholders depend on the health care provider’s disability assessment: –Social Security Administration –Commercial Disability Carriers –Workers Compensation Carriers –American and Industry Employers There is a profound knowledge gap in this group –Technical How do you do an effective disability assessment –Economic How does the system work? What are the ramifications of my decisions and my actions?

8. 8 CALL TO ACTION EDUCATION –What An effective program that remedies the knowledge gap –Who The health care provider community –How Pooled resources of dependent stakeholders –When Now –Why The productivity of the American economy The health and welfare of American citizens

9. 9 CALL TO ACTION THE SYSTEM –SSA disability awards should have a timeframe –SSA income benefits and medical benefits do not have to be “joined at the hip” –Active vocational rehabilitation should be pursued for many SSA awardees –The process should be more efficient