AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 58:245–251 (2015)
Commentary
Workers’ Compensation: Poor Quality Health Care and the Growing Disability Problem in the United States Gary M. Franklin, MD, MPH,1,2,3 Thomas M. Wickizer, PhD, MPH,4 Norma B. Coe, PhD,2 and Deborah Fulton-Kehoe, PhD1
The proportion of working age citizens permanently removed from the workforce has dramatically increased over the past 30 years, straining both Federal and State disability systems designed as a safety net to protect them. Almost one-third of these rapidly emerging disabilities are related to musculoskeletal disorders, and three of the top five diagnoses associated with the longest Years Lived with Disability are back, neck and other musculoskeletal disorders. The failure of Federal and state workers’ compensation systems to provide effective health care to treat non-catastrophic injuries has been largely overlooked as a principal source of permanent disablement and corresponding reduced labor force participation. Innovations in workers’ compensation health care delivery, and in use of evidence-based coverage methods such as prospective utilization review, are effective secondary prevention efforts that, if more widely adopted, could substantially prevent avoidable disability and provide more financial stability for disability safety net programs. Am. J. Ind. Med. 58:245–251, 2015. ß 2014 Wiley Periodicals, Inc. KEY WORDS: fusion; spinal; Insurance; disability; opioids; pain; chronic; syndrome; thoracic outlet; workers’ compensation
INTRODUCTION In 2012, a New York Times editorial addressed a critical problem largely overlooked in the media—the dramatic
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Department of Environmental and Occupational Health Sciences,University of Washington School of Public Health and Community Medicine, Seattle,Washington 2 Department of Health Services,University of Washington School of Public Health and Community Medicine, Seattle,Washington 3 Department of Neurology, University of Washington School of Medicine, Seattle, Washington 4 Division of Health Services Management and Policy, College of Public Health, Ohio State University, Columbus, Ohio Correspondenceto:GaryM.Franklin,MD,MPH,OccupationalEpidemiologyandHealth Outcomes Program, 130 Nickerson, #212, Seattle,WA 98109. E-mail: [email protected] Accepted15 September 2014 DOI10.1002/ajim.22399. Published online 20 October 2014 in Wiley Online Library (wileyonlinelibrary.com).
ß 2014 Wiley Periodicals, Inc.
growth of the population permanently out of the labor market in the US [Leonhardt, 2011]. It pointed out that even in the worst economic times of the 1950s and 1960s, about 9% of men aged 25–54 years were not working; by 2010, that number was 18%. Many of those (including women), normally in the prime of their working lives, are disabled. By 2012, about 8.8 million people were collecting disabled worker (SSDI) benefits totaling $200 billion annually ($120 billion disability cash payments, $80 billion medical benefits), a 75% increase in the number of working-aged people receiving such benefits compared to 2000 [Social Security Administration, 2012; Congressional Budget Office, 2013]. Almost completely overlooked in discussions and analyses of this growing national problem is the functioning of workers’ compensation systems and the health care they pay for and regulate. We believe a major contributing factor to the growth of work disability and the
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reduced labor force participation rate is the failure of workers’ compensation systems to provide effective, timely health care and secondary prevention aimed at reducing long-term disability and at promoting recovery and return to work.
WORK DISABILITY AND SOCIAL SECURITY DISABILITY INSURANCE This rapidly expanding swath of disabled workers has been swelling the ranks of the Social Security Disability Insurance (SSDI) benefits program, whose trust fund is projected to be depleted within a few years. Using national data from the 1992 Health and Retirement Study (HRS), Reville and Schoeni found that 16–17% of respondents aged 51–61 either receiving SSDI or with a substantial disability reported becoming disabled from a work-related injury, illness or accident [Reville and Schoeni, 2003]. Using more recent data from the Survey of Program Participation (SIPP), also used by Reville and Schoeni to validate their HRS findings, [Reville et al., 2001] we find remarkable stability over time; 16.5% of persons aged 51–61 in 2008 also reported becoming disabled from a workplace injury. Thus, the proportion of all Americans self-reporting work-related disability has remained substantial and relatively consistent. The most prevalent conditions associated with disablement in the working age population are musculoskeletal and mental conditions. In 1983, 22% of SSDI applicants had cardiovascular conditions, and 13.4% had musculoskeletal conditions (Table I). In 2012, those proportions were approximately 8.4% cardiovascular and nearly 30% musculoskeletal [Autor and Duggan, 2006; Social Security Administration, 2012]. Similarly, mental disorders nearly doubled between 1983 and 2012 among SSDI awardees. The burden of both musculoskeletal and mental disorders in the US was recently brought into sharp focus: three of the top five conditions accounting for the most Years Lived with Disability (YLD) in the US in 2010 were back (3.18 million
TABLE I. SSDI Insurance Awards by Diagnosis Group, 1983, 2003, 2012; Social Security Disability Insurance Awards (%) by Diagnosis Group Diagnosis group
1983
2003
2012
Heart disease Musculoskeletal disorders (e.g., back pain) Mental disorders Cancer Nervous system Lupus Endocrine system (e.g., diabetes)
21.9 13.4 16.3 11.8 8.4 5.0 4.8
11.4 26.3 25.4 9.4 8.5 3.8 3.1
8.4 29.8 31.8 3.1 9.3 4.1 3.4
Autor and Duggan [2006], Social SecurityAdministration [2012].
YLD), other musculoskeletal (2.6 million YLD), and neck (2.13 YLD) conditions [US Burden of Disease Collaborators, 2013]; mental disorders (anxiety and depression) accounted for the other two of the top five conditions. Much of the policy discussion surrounding the disability burden problem has centered on late stage analysis, after disability has become a fact of life: how to re-employ those already on SSDI, how to incentivize employers to re-employ those already disabled, and the like. Policies targeting these late-stage interventions have shown little effectiveness [Rangarajan et al., 2008; Social Security Administration, 2013]. Earlier interventions may hold more promise [Autor and Duggan, 2010].
Prevention as a Strategic Goal in Workers’ Compensation Systems Occupational safety and health professionals have strategically and appropriately focused on primary prevention, or injury prevention, to reduce the burden of work-related injury. A focus on secondary prevention, or prevention of disability once a worker has been injured, has not been a principal strategic emphasis in the field. Frank et al. may have been the first to differentiate between primary prevention and secondary prevention [Frank et al., 1996a,b] for work related injuries and disability.
Secondary Prevention of Disability in Workers’ Compensation Figure 1 represents the disability “survival” curve for a large statewide sample of workers who received state workers compensation disability benefits in Washington State in 1987–1989 [Cheadle et al., 1994], and in 2010. The data added for 2010 was done using the same methods reported by Cheadle et al. [1994] for the earlier period. In both epochs, the shape of the curve remains essentially unchanged. Half of workers starting out with even a few days of disability leave the disability state quickly and normally return to work. However, by about 3 months of receipt of disability benefits, the chances of still being disabled at one year are already about 50%. For workers on the “flat” side of the curve, the chances of ever returning to full time productive work at anything close to what a worker was making prior to injury is vanishingly low. In a national sample of privately insured low back claims, across multiple years from 1988 to 1996, about 5–10% of all injured workers, those who end up on the flat part of the disability curve, account for up to 90% of disability days and up to 85% of total workers’ compensation expenditures [Hashemi et al., 1998]. Very similarly shaped survival curves have been reported in Canada for neck disorders [Van Eerd et al., 2011], and in the Netherlands [Spierdijk et al., 2009].
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TABLE II. Ultimate SSDI Status for Compensable Cohorts1997^2007 Incident claim years
Percent compensable claims with SSDI by 2012 Percent compensable claims with SSDI or at risk for SSDI by 2012
1997 (%)
2007 (%)
2.1
2.9
5.4
9.2
disability from workers compensation. Thus, the likelihood of “definite” transition from workers compensation to SSDI is on the order of 3% among compensable claims, but the likelihood of “possible” transition among compensable claims may be as high as 9%. Achieving effective secondary prevention of disability in workers compensation will require a focus on (1) improved delivery of occupational health best practices to workers at risk early on after injury, and (2) a reduction in ineffective or harmful health care services through evidence-based coverage policies.
Improving Health Care Delivery for Injured Workers to Achieve Secondary Prevention
FIGURE 1. Survival curves of incident compensable claims from 1987 to 1989 and 2010.
The data reported for 2010 in Figure 1 demonstrates worsening of the likelihood of long term disability over the past 20 years. In 1987–1989, approximately 11% of all compensable claims accumulated 1 year of disability. For the 2010 cohort, approximately 19% of compensable claims developed 1 year of disability. Additional data were obtained from the Washington State Department of Labor and Industries actuaries regarding the proportions of workers whose claims were initiated during the 1997–2007 decade and who had follow-up through 2012 (Table II). The likelihood of receipt of SSDI increased nearly 50%, and the likelihood of increased risk of receipt of SSDI nearly doubled, during this decade. We used four criteria to define a broader range of potential risk of SSDI, including (1) receiving Social Security offset, (2) having received disability cash benefits for at least 5 years, (3) having received a permanent partial disability award 50% impairment, or (4) receiving total permanent
The most consistently reported early predictors of persistent disability after onset of low back pain are a high degree of pain interference with ability to work, important psychosocial variables, such as high fear avoidance and catastrophizing, low expectations of return to work, and employer factors, including no offer of work accommodation [Turner et al., 2008; Chou and Shekelle, 2010]. The Washington State Department of Labor and Industries (DLI), in collaboration with business and labor leaders, has been pilot testing for over a decade a community-based health care delivery innovation (Centers of Occupational Health and Education, COHEs) with a principal goal of preventing disability. The key component of the pilot has included both financial and non-financial incentives to deliver occupational health best practices within the first weeks after injury [Wickizer et al., 2004]. Direct payment for these best practices and for care coordination within the health care delivery system are elements similar to those called for in the Institute of Medicine report regarding improving healthcare in the US [Institute of Medicine, 2001], and embodied in the accountable care organization concept of the Affordable Care Act [Crosson, 2011]. With 25% of workers in WA participating, we have demonstrated a reduction in long-term (1 year) disability by about 30% for low back injuries [Wickizer et al., 2011]. We have completed preliminary analysis of the
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FIGURE 2. Reduction in risk of transitioning to Social Security Disability Insurance, 8 years of follow-up from 2002 to 2010 for original COHE cohort.
the summary odds ratio of 3.79 suggested far worse recovery in the injured workers for nearly every procedure [Harris et al., 2005]. None of this explains why an injured worker may be worse off, and these studies do not take into account in any substantial way the indications, desirability, or appropriateness of the surgical procedures performed. Three specific examples of potentially inappropriate medical care are presented to support our view of work disability and workers’ compensation as a public health problem: (1) chronic opioid therapy, which until recently most physicians did not know was contributing to long term disability; (2) lumbar fusion surgery, which most spine surgeons still do not recognize as potentially harmful; and (3) thoracic outlet surgery for disputed neurogenic thoracic outlet syndrome, a procedure infrequently conducted by a very small percentage of surgeons in each state.
Opioids impact of the COHEs on receipt of SSDI; Figure 2 demonstrates a 26% reduction in the proportion of compensable claimants receiving SSDI benefits 8 years after injury associated with COHE care. Thus, effective secondary prevention efforts through incenting occupational best practices and greater integration of care can reduce both long-term disability and subsequent transition of the long-term disabled to SSDI. The WA legislature, with nearly unanimous support from business and labor leaders, passed legislation in March 2011 expanding the quality improvement (COHE) effort to 100% of WA workers by 2015 [Washington State Legislature, 2011]. Recruitment of additional COHEs has resulted in what is expected to be near universal access to occupational health best practices for workers statewide. Further testing of promising structured interventions, such as activity coaching, that specifically address some of the psychosocial barriers to return to work, are now underway [Sullivan et al., 2005]. Development of additional health services coordination functions within the health care delivery model are also planned; these include potentially promising primary care/ surgery “hand-off” coordinators, and behavioral health coordinators [Unutzer et al., 2002].
IMPROVED SECONDARY PREVENTION BY USING EVIDENCE-BASED COVERAGE POLICIES TO IMPROVE OUTCOME AND PREVENT HARM Much less research has been conducted on the medical factors which may be at the heart of the evolving long-term disability problem in workers’ compensation systems. In a meta-analysis of over 200 hundred studies comparing outcomes of the same surgical procedures in workers’ compensation and non-workers’ compensation health care,
Pain is at the heart of the vast majority of disablement in workers’ compensation. The 3-month inflection point in the disability survival curve in Figure 1 is co-incident with the development of chronic pain, which can be defined as approximately 3 months of relatively continuous pain in an episode of musculoskeletal injury. Thus, it is important to recognize that preventing chronic disability in workers compensation can only be accomplished by preventing the transition from acute/subacute to chronic pain. Contrary to guidelines, approximately one-third of injured workers off work with new low back injuries receive opioids during the first 6 weeks following injury, usually at the first visit [Stover et al., 2006]. In a prospective, populationbased cohort, even after adjustment for baseline pain, function, and injury severity, receipt of even 2 opioid prescriptions, or more than seven days of opioids, during this early time frame is associated with a doubling of the risk of disability at 1 year in workers’ compensation [Franklin et al., 2008]. Patients on continuous opioids for 3 months are already only 50% as likely to discontinue opioids 5 years later [Martin et al., 2011]. The most likely explanation for a unique contribution of opioids not only to the potential initiation of disablement, but to difficulty withdrawing from opioids and thus perpetuation of disablement, is the development of physical dependence [Juurlink and Dhalla, 2012]. There are now likely tens of thousands of injured workers, veterans, and active military with musculoskeletal injuries in the US on chronic opioid therapy who are opioid dependent [Zaroya, 2011; Dao, 2012]. There is little useful empiric evidence as yet on how often these types of patients could be successfully tapered. It has been stated that these cohorts of patients on opioids chronically are a “lost generation”, reflecting the doubt among some pain experts that successful tapering could ever be achieved [Meier, 2012].
Workers’ Compensation Health Care and the US Disability Problem
Policies recently implemented in WA State, including an emphasis on preventing unnecessary chronic opioid use and avoidance of high doses, have started to pay dividends. Since implementation of new guidelines on dosing, a substantial decline in deaths and incident chronic opioid use has been seen in the state workers’ compensation system [Franklin et al., 2012].
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for approval of surgery for TOS [Medical Treatment Guidelines, 2010]. This has led to near universal denial of the procedure, and a likelihood of improved outcomes from avoidance of harm related to the procedure.
Lumbar Fusion
PREVENTING DISABILITY IN WORKERS’ COMPENSATION: SYSTEM QUALITY IMPROVEMENT AND REGULATORY CHANGE
Lumbar fusion, contrary to its original purpose to stabilize an unstable spine, is now mostly done for chronic low back pain with degenerative disc disease. In randomized trials, fusion conducted under these circumstances has shown no better efficacy than intensive pain programs, and is more harmful and substantially more expensive [Washington State Health Care Authority, 2007; Chou et al., 2009]. In two population-based observational studies from WA State, twothirds of workers who received a lumbar fusion were still totally disabled 2 years after fusion, and 23% received additional spine surgery within 2 years [Franklin et al., 1994; Maghout Juratli et al., 2006]. We recently examined the likelihood of permanent total disability among workers who received lumbar fusion in our workers compensation system a decade ago: 44% have attained permanent disability status, and nearly all will likely end up on SSDI. Martin et al. [2013] reported substantial interstate variation in post-operative morbidity following lumbar fusion in workers’ compensation. That study suggests that tighter prospective utilization review, preventing the most egregious procedures, may reduce morbidity and, potentially, subsequent impairment and disability.
Improving health care delivery with a goal of preventing persistent, long-term work disability will require meaningful quality improvement (QI) at a system (population) level as well as changes in workers’ compensation regulations. Critical to QI is introducing effective incentives and improving care coordination in the early stage of treatment, before disability becomes more entrenched. QI interventions are necessary but may not be sufficient to realize meaningful improvements in workers’ compensation system performance. More aggressive prospective utilization review with application of evidence based guidelines, and regulatory changes, may be needed to address the problem of very poor care that places injured workers at high risk for long-term disability. WA State has mandated expansion of the state’s QI efforts to 100% of the state’s injured workers by 2015, established a new statewide network, and, for the first time in the US, authorized the removal of physicians who have caused harm to injured workers [Washington State Legislature, 2011]. These steps demonstrate the type of commitment that may be needed to make meaningful improvement in the performance of workers’ compensation programs.
Thoracic Outlet Surgery
SUMMARY
Surgery for neurogenic thoracic outlet syndrome (TOS) is one of the most controversial but persistently conducted surgical procedures in the US. It is so controversial that the disorder for which patients receive this procedure is termed “disputed” neurogenic thoracic outlet syndrome, because it is diagnosed based on no objective signs of brachial plexus injury. In a population-based observational study, workers who received this procedure were far more likely to be disabled 1 year following the procedure compared to those with a diagnosis of thoracic outlet syndrome who did not receive the procedure, even after adjusting for important baseline covariates, such as the duration of disability prior to the procedure [Franklin et al., 2000]. In addition, 21% of workers who received the surgery had new neurologic complaints post-operatively [Franklin et al., 2000]. In 2010, WA state implemented a guideline developed by a statutory Industrial Insurance Medical Advisory Committee that requires objective evidence of brachial plexus involvement
We would urge more empirical investigation, including randomized trials, and comparative effectiveness studies, including population-based observational studies. Greater Federal funding and prioritization is needed to determine with more certainty the potential contribution of effective secondary prevention efforts in State and Federal workers compensation systems to reduce the burden of disablement from work-related musculoskeletal disorders at the individual level, as well as at the workers’ compensation program and national disability insurance levels. If successful, these actions could help ameliorate the growing problem of permanent removal from the labor force arising from work disability, thus saving productive work lives for millions of Americans.
REFERENCES Autor DH, Duggan M. 2010. Supporting Work: A Proposal for Modernizing the U.S. Disability Insurance System. Brookings, The
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Hamilton Project and the Center for American Progress, http://www. brookings.edu/research/papers/2010/12/disability-insurance-autor (accessed August 7, 2014). Autor DH, Duggan MG. 2006. The growth in the Social Security Disability rolls: A fiscal crisis unfolding. J Econ Perspect 20:71–96. Cheadle A, Franklin G, Wolfhagen C, Savarino J, Liu PY, Salley C, Weaver M. 1994. Factors influencing the duration of work-related disability: A population-based study of Washington State workers’ compensation. Am J Public Health 84:190–196. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD. 2009. Surgery for low back pain: A review of the evidence for an American Pain Society Clinical Practice Guideline. Spine (Phila Pa 1976) 34:1094–1109. Chou R, Shekelle P. 2010. Will this patient develop persistent disabling low back pain? JAMA 303:1295–1302. Congressional, Budget Office. 2013. CBO Testifies on the Social Security Disability Insurance Program. http://www.cbo.gov/publication/43996 (accessed August 7, 2014). Crosson FJ. 2011. Analysis & commentary: The accountable care organization: Whatever its growing pains, the concept is too vitally important to fail. Health Aff (Millwood) 30:1250–1255. Dao J. 2012. For veterans with post-traumatic stress, painkillers carry risks. The New York Times, March 2012 http://atwar.blogs.nytimes.com/ 2012/03/07/for-veterans-with-post-traumatic-stress-pain-killers-carryrisks/?_php¼true&_type¼blogs&_php¼true&_type¼blogs&_r¼1 (accessed August 7, 2014). Frank JW, Brooker AS, DeMaio SE, Kerr MS, Maetzel A, Shannon HS, Sullivan TJ, Norman RW, Wells RP. 1996a. Disability resulting from occupational low back pain. Part II: What do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins. Spine (Phila Pa 1976) 21:2918–2929. Frank JW, Kerr MS, Brooker AS, DeMaio SE, Maetzel A, Shannon HS, Sullivan TJ, Norman RW, Wells RP. 1996b. Disability resulting from occupational low back pain. Part I: What do we know about primary prevention? A review of the scientific evidence on prevention before disability begins. Spine (Phila Pa 1976) 21:2908–2917. Franklin GM, Fulton-Kehoe D, Bradley C, Smith-Weller T. 2000. Outcome of surgery for thoracic outlet syndrome in Washington state workers’ compensation. Neurology 54:1252–1257. Franklin GM, Haug J, Heyer NJ, McKeefrey SP, Picciano JF. 1994. Outcome of lumbar fusion in Washington State workers’ compensation. Spine (Phila Pa 1976) 19:1897–1903; discussion 1904. Franklin GM, Mai J, Turner J, Sullivan M, Wickizer T, Fulton-Kehoe D. 2012. Bending the prescription opioid dosing and mortality curves: Impact of the Washington State opioid dosing guideline. Am J Ind Med 55:325–331. Franklin GM, Stover BD, Turner JA, Fulton-Kehoe D, Wickizer T. 2008. Early opioid prescription and subsequent disability among workers with back injuries: The Disability Risk Identification Study Cohort. Spine 33:199–204. Harris I, Mulford J, Solomon M, van Gelder JM, Young J. 2005. Association between compensation status and outcome after surgery: A meta-analysis. JAMA 293:1644–1652.
Juurlink DN, Dhalla IA. 2012. Dependence and addiction during chronic opioid therapy. J Med Toxicol 8:393–399. Leonhardt D. 2011. Men, unemployment, and disability. New York Times, April 2011, http://economix.blogs.nytimes.com/2011/04/08/ men-unemployment-and-disability/?_r¼0. (August 7, 2014). Maghout Juratli S, Franklin GM, Mirza SK, Wickizer TM, FultonKehoe D. 2006. Lumbar fusion outcomes in Washington State workers’ compensation. Spine (Phila Pa 1976) 31:2715–2723. Martin BC, Fan MY, Edlund MJ, Devries A, Braden JB, Sullivan MD. 2011. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med 26:1450–1457. Martin BI, Franklin GM, Deyo RA, Wickizer TM, Lurie JD, Mirza SK. 2014. How do coverage policies influence practice patterns, safety, and cost of initial lumbar fusion surgery? A population-based comparison of workers’ compensation systems. Spine J 14:1237–1246. Medical. Treatment Guidelines. 2010. Washington State Department of Labor and Industries. October 1, 2010. Work-related neurogenic thoracic outlet syndrome: Diagnosis and treatment. http://www.lni.wa. gov/ClaimsIns/Files/OMD/MedTreat/ThoracicOutletNeurogenic.pdf (accessed August 7, 2014). Meier B. 2012. Tightening the lid on pain prescriptions. New York Times, April 8, 2012, http://www.nytimes.com/2012/04/09/health/ opioid-painkiller-prescriptions-pose-danger-without-oversight.html? pagewanted¼all (accessed August 7, 2014). Rangarajan A, Wittenburg D, Honeycutt T, Brucker D. 2008. Programmes to Promote Employment for People with Disabilities: Lessons from the United States Report submitted to the Department for Work and Pensions Disability and Work Division, April Princeton, NJ: Mathematica Policy Research, Inc. Reville RT, Bhattacharya J, Sager Weinstein LR. 2001. New methods and data sources for measuring economic consequences of workplace injuries. Am J Ind Med 40:452–463. Reville RT, Schoeni RF. 2003. The fraction of disability caused at work. Soc Secur Bull 65:31–37. Social, Security Administration. 2012. Statistical Report on the Social Security Disability Insurance Program. http://www.ssa.gov/policy/docs/ statcomps/di_asr/ (accessed August 7, 2014). Social, Security Administration. The Red Book—A Guide to Work Incentives. January 2013, http://www.socialsecurity.gov/redbook/ (accessed August 7, 2014). Spierdijk L, van Lomwel G, Peppelman W. 2009. The determinants of sick leave durations of Dutch self-employed. J Health Econ 28:1185– 1196. Stover BD, Turner JA, Franklin G, Gluck JV, Fulton-Kehoe D, Sheppard L, Wickizer TM, Kaufman J, Egan K. 2006. Factors associated with early opioid prescription among workers with low back injuries. J Pain 7:718–725. Sullivan MJ, Ward LC, Tripp D, French DJ, Adams H, Stanish WD. 2005. Secondary prevention of work disability: Community-based psychosocial intervention for musculoskeletal disorders. J Occup Rehabil 15:377–392.
Hashemi L, Webster BS, Clancy EA. 1998. Trends in disability duration and cost of workers’ compensation low back pain claims (1988–1996). J Occup Environ Med 40:1110–1119.
Turner JA, Franklin G, Fulton-Kehoe D, Sheppard L, Stover B, Wu R, Gluck JV, Wickizer TM. 2008. ISSLS prize winner: Early predictors of chronic work disability: A prospective, population-based study of workers with back injuries. Spine (Phila Pa 1976) 33:2809–2818.
Institute, of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century, March 2001, http://www.iom.edu/Reports/ 2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the21st-Century.aspx (accessed August 7, 2014).
Unutzer J, Katon W, Callahan CM, Williams JW, Jr., Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noel PH, Lin EH, et al. 2002. Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA 288:2836–2845.
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disability and reducing costs in workers’ compensation healthcare: A population-based intervention study. Med Care 49:1105–1111.
Van Eerd D, Cote P, Kristman V, Rezai M, Hogg-Johnson S, Vidmar M, Beaton D. 2011. The course of work absenteeism involving neck pain: A cohort study of Ontario lost-time claimants. Spine (Phila Pa 1976) 36:977–982.
Wickizer TM, Franklin GM, Mootz RD, Fulton-Kehoe D, PlaegerBrockway R, Drylie D, Turner JA, Smith-Weller T. 2004. A communitywide intervention to improve outcomes and reduce disability among injured workers in Washington State. Milbank Q 82:547–567, table of contents.
Washington. State Health Care Authority. 2007. Washington State Health Technology Assessment Program. Lumbar fusion. http://www. hca.wa.gov/hta/Pages/lumbar.aspx (accessed August 7, 2014). Washington, State Legislature. 2011. SSB 5801. An act related to establishing medical provider networks and expanding centers for occupational health and education. http://apps.leg.wa.gov/billinfo/ summary.aspx?year¼2011&bill¼5801 (accessed August 7, 2014). Wickizer TM, Franklin G, Fulton-Kehoe D, Gluck J, Mootz R, SmithWeller T, Plaeger-Brockway R. 2011. Improving quality, preventing
Zaroya G. 2011. General’s story a warning about use of painkillers. USA Today, January 2011, http://usatoday30.usatoday.com/news/ military/2011-01-27-1Adruggeneral27_CV_N.htm (accessed August 7, 2014).
Conflict of interest statement: None of the authors have any financial or non-financial conflicts in regard to this work.
Commentary
Workers’ Compensation: Poor Quality Health Care and the Growing Disability Problem in the United States Gary M. Franklin, MD, MPH,1,2,3 Thomas M. Wickizer, PhD, MPH,4 Norma B. Coe, PhD,2 and Deborah Fulton-Kehoe, PhD1
The proportion of working age citizens permanently removed from the workforce has dramatically increased over the past 30 years, straining both Federal and State disability systems designed as a safety net to protect them. Almost one-third of these rapidly emerging disabilities are related to musculoskeletal disorders, and three of the top five diagnoses associated with the longest Years Lived with Disability are back, neck and other musculoskeletal disorders. The failure of Federal and state workers’ compensation systems to provide effective health care to treat non-catastrophic injuries has been largely overlooked as a principal source of permanent disablement and corresponding reduced labor force participation. Innovations in workers’ compensation health care delivery, and in use of evidence-based coverage methods such as prospective utilization review, are effective secondary prevention efforts that, if more widely adopted, could substantially prevent avoidable disability and provide more financial stability for disability safety net programs. Am. J. Ind. Med. 58:245–251, 2015. ß 2014 Wiley Periodicals, Inc. KEY WORDS: fusion; spinal; Insurance; disability; opioids; pain; chronic; syndrome; thoracic outlet; workers’ compensation
INTRODUCTION In 2012, a New York Times editorial addressed a critical problem largely overlooked in the media—the dramatic
1
Department of Environmental and Occupational Health Sciences,University of Washington School of Public Health and Community Medicine, Seattle,Washington 2 Department of Health Services,University of Washington School of Public Health and Community Medicine, Seattle,Washington 3 Department of Neurology, University of Washington School of Medicine, Seattle, Washington 4 Division of Health Services Management and Policy, College of Public Health, Ohio State University, Columbus, Ohio Correspondenceto:GaryM.Franklin,MD,MPH,OccupationalEpidemiologyandHealth Outcomes Program, 130 Nickerson, #212, Seattle,WA 98109. E-mail: [email protected] Accepted15 September 2014 DOI10.1002/ajim.22399. Published online 20 October 2014 in Wiley Online Library (wileyonlinelibrary.com).
ß 2014 Wiley Periodicals, Inc.
growth of the population permanently out of the labor market in the US [Leonhardt, 2011]. It pointed out that even in the worst economic times of the 1950s and 1960s, about 9% of men aged 25–54 years were not working; by 2010, that number was 18%. Many of those (including women), normally in the prime of their working lives, are disabled. By 2012, about 8.8 million people were collecting disabled worker (SSDI) benefits totaling $200 billion annually ($120 billion disability cash payments, $80 billion medical benefits), a 75% increase in the number of working-aged people receiving such benefits compared to 2000 [Social Security Administration, 2012; Congressional Budget Office, 2013]. Almost completely overlooked in discussions and analyses of this growing national problem is the functioning of workers’ compensation systems and the health care they pay for and regulate. We believe a major contributing factor to the growth of work disability and the
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reduced labor force participation rate is the failure of workers’ compensation systems to provide effective, timely health care and secondary prevention aimed at reducing long-term disability and at promoting recovery and return to work.
WORK DISABILITY AND SOCIAL SECURITY DISABILITY INSURANCE This rapidly expanding swath of disabled workers has been swelling the ranks of the Social Security Disability Insurance (SSDI) benefits program, whose trust fund is projected to be depleted within a few years. Using national data from the 1992 Health and Retirement Study (HRS), Reville and Schoeni found that 16–17% of respondents aged 51–61 either receiving SSDI or with a substantial disability reported becoming disabled from a work-related injury, illness or accident [Reville and Schoeni, 2003]. Using more recent data from the Survey of Program Participation (SIPP), also used by Reville and Schoeni to validate their HRS findings, [Reville et al., 2001] we find remarkable stability over time; 16.5% of persons aged 51–61 in 2008 also reported becoming disabled from a workplace injury. Thus, the proportion of all Americans self-reporting work-related disability has remained substantial and relatively consistent. The most prevalent conditions associated with disablement in the working age population are musculoskeletal and mental conditions. In 1983, 22% of SSDI applicants had cardiovascular conditions, and 13.4% had musculoskeletal conditions (Table I). In 2012, those proportions were approximately 8.4% cardiovascular and nearly 30% musculoskeletal [Autor and Duggan, 2006; Social Security Administration, 2012]. Similarly, mental disorders nearly doubled between 1983 and 2012 among SSDI awardees. The burden of both musculoskeletal and mental disorders in the US was recently brought into sharp focus: three of the top five conditions accounting for the most Years Lived with Disability (YLD) in the US in 2010 were back (3.18 million
TABLE I. SSDI Insurance Awards by Diagnosis Group, 1983, 2003, 2012; Social Security Disability Insurance Awards (%) by Diagnosis Group Diagnosis group
1983
2003
2012
Heart disease Musculoskeletal disorders (e.g., back pain) Mental disorders Cancer Nervous system Lupus Endocrine system (e.g., diabetes)
21.9 13.4 16.3 11.8 8.4 5.0 4.8
11.4 26.3 25.4 9.4 8.5 3.8 3.1
8.4 29.8 31.8 3.1 9.3 4.1 3.4
Autor and Duggan [2006], Social SecurityAdministration [2012].
YLD), other musculoskeletal (2.6 million YLD), and neck (2.13 YLD) conditions [US Burden of Disease Collaborators, 2013]; mental disorders (anxiety and depression) accounted for the other two of the top five conditions. Much of the policy discussion surrounding the disability burden problem has centered on late stage analysis, after disability has become a fact of life: how to re-employ those already on SSDI, how to incentivize employers to re-employ those already disabled, and the like. Policies targeting these late-stage interventions have shown little effectiveness [Rangarajan et al., 2008; Social Security Administration, 2013]. Earlier interventions may hold more promise [Autor and Duggan, 2010].
Prevention as a Strategic Goal in Workers’ Compensation Systems Occupational safety and health professionals have strategically and appropriately focused on primary prevention, or injury prevention, to reduce the burden of work-related injury. A focus on secondary prevention, or prevention of disability once a worker has been injured, has not been a principal strategic emphasis in the field. Frank et al. may have been the first to differentiate between primary prevention and secondary prevention [Frank et al., 1996a,b] for work related injuries and disability.
Secondary Prevention of Disability in Workers’ Compensation Figure 1 represents the disability “survival” curve for a large statewide sample of workers who received state workers compensation disability benefits in Washington State in 1987–1989 [Cheadle et al., 1994], and in 2010. The data added for 2010 was done using the same methods reported by Cheadle et al. [1994] for the earlier period. In both epochs, the shape of the curve remains essentially unchanged. Half of workers starting out with even a few days of disability leave the disability state quickly and normally return to work. However, by about 3 months of receipt of disability benefits, the chances of still being disabled at one year are already about 50%. For workers on the “flat” side of the curve, the chances of ever returning to full time productive work at anything close to what a worker was making prior to injury is vanishingly low. In a national sample of privately insured low back claims, across multiple years from 1988 to 1996, about 5–10% of all injured workers, those who end up on the flat part of the disability curve, account for up to 90% of disability days and up to 85% of total workers’ compensation expenditures [Hashemi et al., 1998]. Very similarly shaped survival curves have been reported in Canada for neck disorders [Van Eerd et al., 2011], and in the Netherlands [Spierdijk et al., 2009].
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TABLE II. Ultimate SSDI Status for Compensable Cohorts1997^2007 Incident claim years
Percent compensable claims with SSDI by 2012 Percent compensable claims with SSDI or at risk for SSDI by 2012
1997 (%)
2007 (%)
2.1
2.9
5.4
9.2
disability from workers compensation. Thus, the likelihood of “definite” transition from workers compensation to SSDI is on the order of 3% among compensable claims, but the likelihood of “possible” transition among compensable claims may be as high as 9%. Achieving effective secondary prevention of disability in workers compensation will require a focus on (1) improved delivery of occupational health best practices to workers at risk early on after injury, and (2) a reduction in ineffective or harmful health care services through evidence-based coverage policies.
Improving Health Care Delivery for Injured Workers to Achieve Secondary Prevention
FIGURE 1. Survival curves of incident compensable claims from 1987 to 1989 and 2010.
The data reported for 2010 in Figure 1 demonstrates worsening of the likelihood of long term disability over the past 20 years. In 1987–1989, approximately 11% of all compensable claims accumulated 1 year of disability. For the 2010 cohort, approximately 19% of compensable claims developed 1 year of disability. Additional data were obtained from the Washington State Department of Labor and Industries actuaries regarding the proportions of workers whose claims were initiated during the 1997–2007 decade and who had follow-up through 2012 (Table II). The likelihood of receipt of SSDI increased nearly 50%, and the likelihood of increased risk of receipt of SSDI nearly doubled, during this decade. We used four criteria to define a broader range of potential risk of SSDI, including (1) receiving Social Security offset, (2) having received disability cash benefits for at least 5 years, (3) having received a permanent partial disability award 50% impairment, or (4) receiving total permanent
The most consistently reported early predictors of persistent disability after onset of low back pain are a high degree of pain interference with ability to work, important psychosocial variables, such as high fear avoidance and catastrophizing, low expectations of return to work, and employer factors, including no offer of work accommodation [Turner et al., 2008; Chou and Shekelle, 2010]. The Washington State Department of Labor and Industries (DLI), in collaboration with business and labor leaders, has been pilot testing for over a decade a community-based health care delivery innovation (Centers of Occupational Health and Education, COHEs) with a principal goal of preventing disability. The key component of the pilot has included both financial and non-financial incentives to deliver occupational health best practices within the first weeks after injury [Wickizer et al., 2004]. Direct payment for these best practices and for care coordination within the health care delivery system are elements similar to those called for in the Institute of Medicine report regarding improving healthcare in the US [Institute of Medicine, 2001], and embodied in the accountable care organization concept of the Affordable Care Act [Crosson, 2011]. With 25% of workers in WA participating, we have demonstrated a reduction in long-term (1 year) disability by about 30% for low back injuries [Wickizer et al., 2011]. We have completed preliminary analysis of the
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FIGURE 2. Reduction in risk of transitioning to Social Security Disability Insurance, 8 years of follow-up from 2002 to 2010 for original COHE cohort.
the summary odds ratio of 3.79 suggested far worse recovery in the injured workers for nearly every procedure [Harris et al., 2005]. None of this explains why an injured worker may be worse off, and these studies do not take into account in any substantial way the indications, desirability, or appropriateness of the surgical procedures performed. Three specific examples of potentially inappropriate medical care are presented to support our view of work disability and workers’ compensation as a public health problem: (1) chronic opioid therapy, which until recently most physicians did not know was contributing to long term disability; (2) lumbar fusion surgery, which most spine surgeons still do not recognize as potentially harmful; and (3) thoracic outlet surgery for disputed neurogenic thoracic outlet syndrome, a procedure infrequently conducted by a very small percentage of surgeons in each state.
Opioids impact of the COHEs on receipt of SSDI; Figure 2 demonstrates a 26% reduction in the proportion of compensable claimants receiving SSDI benefits 8 years after injury associated with COHE care. Thus, effective secondary prevention efforts through incenting occupational best practices and greater integration of care can reduce both long-term disability and subsequent transition of the long-term disabled to SSDI. The WA legislature, with nearly unanimous support from business and labor leaders, passed legislation in March 2011 expanding the quality improvement (COHE) effort to 100% of WA workers by 2015 [Washington State Legislature, 2011]. Recruitment of additional COHEs has resulted in what is expected to be near universal access to occupational health best practices for workers statewide. Further testing of promising structured interventions, such as activity coaching, that specifically address some of the psychosocial barriers to return to work, are now underway [Sullivan et al., 2005]. Development of additional health services coordination functions within the health care delivery model are also planned; these include potentially promising primary care/ surgery “hand-off” coordinators, and behavioral health coordinators [Unutzer et al., 2002].
IMPROVED SECONDARY PREVENTION BY USING EVIDENCE-BASED COVERAGE POLICIES TO IMPROVE OUTCOME AND PREVENT HARM Much less research has been conducted on the medical factors which may be at the heart of the evolving long-term disability problem in workers’ compensation systems. In a meta-analysis of over 200 hundred studies comparing outcomes of the same surgical procedures in workers’ compensation and non-workers’ compensation health care,
Pain is at the heart of the vast majority of disablement in workers’ compensation. The 3-month inflection point in the disability survival curve in Figure 1 is co-incident with the development of chronic pain, which can be defined as approximately 3 months of relatively continuous pain in an episode of musculoskeletal injury. Thus, it is important to recognize that preventing chronic disability in workers compensation can only be accomplished by preventing the transition from acute/subacute to chronic pain. Contrary to guidelines, approximately one-third of injured workers off work with new low back injuries receive opioids during the first 6 weeks following injury, usually at the first visit [Stover et al., 2006]. In a prospective, populationbased cohort, even after adjustment for baseline pain, function, and injury severity, receipt of even 2 opioid prescriptions, or more than seven days of opioids, during this early time frame is associated with a doubling of the risk of disability at 1 year in workers’ compensation [Franklin et al., 2008]. Patients on continuous opioids for 3 months are already only 50% as likely to discontinue opioids 5 years later [Martin et al., 2011]. The most likely explanation for a unique contribution of opioids not only to the potential initiation of disablement, but to difficulty withdrawing from opioids and thus perpetuation of disablement, is the development of physical dependence [Juurlink and Dhalla, 2012]. There are now likely tens of thousands of injured workers, veterans, and active military with musculoskeletal injuries in the US on chronic opioid therapy who are opioid dependent [Zaroya, 2011; Dao, 2012]. There is little useful empiric evidence as yet on how often these types of patients could be successfully tapered. It has been stated that these cohorts of patients on opioids chronically are a “lost generation”, reflecting the doubt among some pain experts that successful tapering could ever be achieved [Meier, 2012].
Workers’ Compensation Health Care and the US Disability Problem
Policies recently implemented in WA State, including an emphasis on preventing unnecessary chronic opioid use and avoidance of high doses, have started to pay dividends. Since implementation of new guidelines on dosing, a substantial decline in deaths and incident chronic opioid use has been seen in the state workers’ compensation system [Franklin et al., 2012].
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for approval of surgery for TOS [Medical Treatment Guidelines, 2010]. This has led to near universal denial of the procedure, and a likelihood of improved outcomes from avoidance of harm related to the procedure.
Lumbar Fusion
PREVENTING DISABILITY IN WORKERS’ COMPENSATION: SYSTEM QUALITY IMPROVEMENT AND REGULATORY CHANGE
Lumbar fusion, contrary to its original purpose to stabilize an unstable spine, is now mostly done for chronic low back pain with degenerative disc disease. In randomized trials, fusion conducted under these circumstances has shown no better efficacy than intensive pain programs, and is more harmful and substantially more expensive [Washington State Health Care Authority, 2007; Chou et al., 2009]. In two population-based observational studies from WA State, twothirds of workers who received a lumbar fusion were still totally disabled 2 years after fusion, and 23% received additional spine surgery within 2 years [Franklin et al., 1994; Maghout Juratli et al., 2006]. We recently examined the likelihood of permanent total disability among workers who received lumbar fusion in our workers compensation system a decade ago: 44% have attained permanent disability status, and nearly all will likely end up on SSDI. Martin et al. [2013] reported substantial interstate variation in post-operative morbidity following lumbar fusion in workers’ compensation. That study suggests that tighter prospective utilization review, preventing the most egregious procedures, may reduce morbidity and, potentially, subsequent impairment and disability.
Improving health care delivery with a goal of preventing persistent, long-term work disability will require meaningful quality improvement (QI) at a system (population) level as well as changes in workers’ compensation regulations. Critical to QI is introducing effective incentives and improving care coordination in the early stage of treatment, before disability becomes more entrenched. QI interventions are necessary but may not be sufficient to realize meaningful improvements in workers’ compensation system performance. More aggressive prospective utilization review with application of evidence based guidelines, and regulatory changes, may be needed to address the problem of very poor care that places injured workers at high risk for long-term disability. WA State has mandated expansion of the state’s QI efforts to 100% of the state’s injured workers by 2015, established a new statewide network, and, for the first time in the US, authorized the removal of physicians who have caused harm to injured workers [Washington State Legislature, 2011]. These steps demonstrate the type of commitment that may be needed to make meaningful improvement in the performance of workers’ compensation programs.
Thoracic Outlet Surgery
SUMMARY
Surgery for neurogenic thoracic outlet syndrome (TOS) is one of the most controversial but persistently conducted surgical procedures in the US. It is so controversial that the disorder for which patients receive this procedure is termed “disputed” neurogenic thoracic outlet syndrome, because it is diagnosed based on no objective signs of brachial plexus injury. In a population-based observational study, workers who received this procedure were far more likely to be disabled 1 year following the procedure compared to those with a diagnosis of thoracic outlet syndrome who did not receive the procedure, even after adjusting for important baseline covariates, such as the duration of disability prior to the procedure [Franklin et al., 2000]. In addition, 21% of workers who received the surgery had new neurologic complaints post-operatively [Franklin et al., 2000]. In 2010, WA state implemented a guideline developed by a statutory Industrial Insurance Medical Advisory Committee that requires objective evidence of brachial plexus involvement
We would urge more empirical investigation, including randomized trials, and comparative effectiveness studies, including population-based observational studies. Greater Federal funding and prioritization is needed to determine with more certainty the potential contribution of effective secondary prevention efforts in State and Federal workers compensation systems to reduce the burden of disablement from work-related musculoskeletal disorders at the individual level, as well as at the workers’ compensation program and national disability insurance levels. If successful, these actions could help ameliorate the growing problem of permanent removal from the labor force arising from work disability, thus saving productive work lives for millions of Americans.
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Conflict of interest statement: None of the authors have any financial or non-financial conflicts in regard to this work.
