Nowadays, workers’ compensation is facing many problems and challenges. From the opt-out movement and constitutional concerns, to erosion of worker benefits and the Grand Bargain, to the race to the bottom to control costs, and to the various challenges on how to deal with delayed recovery.  As a result, many of these concerns have led to wider discussions (for example: here and here and here.  The last link is worth your time to read but I am betting you can see the discussion is fundamentally flawed.) about the future of workers compensation.

The majority of claims tend to resolve quickly and workers return to work but these are not the ones that burden the system.  In fact, 5% of claims cost 80% of the dollars.  Complex claims are complex for a reason and often result in delayed recovery.  Complex claims don’t just start out that way.  In fact, they become protracted, complex, and develop over time (Young, Choi, and Besen 2015).  There are many well researched determinants of work disability and many are modifiable as primary, secondary, and tertiary types of prevention measures.  Other predictors of these complex claims are not always known in advance, can change over time, and consist of many different types of interventions or tasks implemented by different people and at different times.

One of the more recent discussions that seem to be making the rounds is the ‘claims experience’ as a way to ‘fix’ the system and the many system problems that erode the experience.  The recent emergence of what is being termed an ‘advocacy-based claims model’ is a good example of this.

The advocacy model states “the goal of an advocacy approach should be to foster a positive experience and recovery rather than to be focused on cost containment.”  It is hard to argue against this goal from the perspective that cost containment is only one of the outcomes of work disability prevention (there are 4 outcomes in fact) and the advocacy-based model is an improvement for sure and will probably do what early Disability Management programs did years ago.  An advocacy model is essentially a ‘new’ form of disability management (version 2.0 if you will) as it continues to focus on the post-injury phase of injury and illness.  But, is it the right model for preventing work disability?  Or, should we just skip it and opt for a new model altogether?

“You have to look at all the factors that contribute to work disability.”

Dr. Glenn Pransky

In my last article I advocated, not for an advocacy-model, but for a “single, integrated approach to measuring the employee experience both pre-injury and post-injury that achieves marked improvements across the continuum of productivity, absenteeism, work disability duration, and return to work outcomes.”

While the advocacy-based model has elements that are worthwhile to incorporate, it inherently falls short of an Integrated Work Disability Prevention model.  Integrated Work Disability Prevention focuses on the reduction of work disability not only by addressing the post-injury determinants but the pre-injury determinants of work disability as well.  A sustainable model for improvements in our industry will come from an integrated work disability prevention model that focuses on all the determinants across the spectrum of pre- and post-injury and not just improving the claims experience.

An improved claim experience should come AS A RESULT of an improved return to work experience and that lies with the employer.  In order to prevent work disability you have to have people ‘want’ to stay at work when they can, to return work in a timely manner (read: when it is no longer medically required to be out), and more importantly actually return to work and stay there.  That has more to do with the employer-employee relationship and wanting to return to work starts long before workers become injured or ill.

What’s in a name?

There is something else about the advocacy-model that stands out to me that is worth considering and that is the name itself.  I had to look up the word ‘advocacy’ to see why it was standing out to me so much.  Here is what I found; “Advocacy:  the act or process of supporting a cause or proposal, the act or process of advocating.”

Ok, not helpful at all.  What about a the definition of advocate; “one who pleads the cause of another; or, specifically one who pleads the cause of another before a tribunal or judicial court; or, one who defends or maintains a cause or proposal; or one who supports or promotes the interests of a cause or group.”

I think this is worth considering if we are to promote a shift in the industry.  Words matter.  Concern has been expressed over words like ‘disability benefits’, ‘injured worker’, ‘policy’, ‘adjudication’ and the impact they have on the perception of the worker.  As a result of these concerns suggestions for renaming have been made.  For example, one suggestion I have heard made is instead of ‘disability benefits’ maybe considering replacing it with ‘recovery benefits’.  All positive in my opinion but is it enough?  I think the term advocacy has the potential to be terribly misleading workers.  If the worker thinks they have someone who will advocate (see definition above) on their behalf they may have misguided expectations about what that advocate can or can’t do.

Maybe we should be looking at this in a different way.  The advocacy model does correctly opine that we can make some progress by making it easy for workers to navigate through the system and RTW (Simplify process, remove bureaucracy, prevent delayed treatment, etc.).  However, it strongly presupposes, wrongly in my opinion, that the motivation to RTW is heavily influenced by the claims experience.

“Nevertheless, the employee remains the ultimate agent of change in the return-to-work process in that only he or she [makes] the final decision of going in for a day’s work.”

Franche and Niklas Krause 2002

I would continue to argue and advocate that a better claims experience does in fact promote improvements in unnecessary delays, confusion about the compensation system helping prevent workers falling through cracks in the system but it fails to address the behavioral component of recovery and return to work.

In order to influence behavior (read: return to work in a timely manner) you have to influence BOTH behavioral motivation AND behavioral ease (read: making it easy for people to behave in the way you hope they will).  Improving the claims experience satisfaction score only addresses the behavioral ease component.  And we should be mindful that satisfaction is NOT a proxy for engagement.

Behavioral Motivation

“Return to work can be conceptualized as a complex human behavior change, with the employee taking the final decision to RTW.”

Brouwer et al (2009)

The most robust, most researched, and most validated predictor of work disability outcomes is the worker’s expectations of recovery and return to work.  Having positive expectations requires the worker’s confidence and self-efficacy about their ability to recover and return to work.  Self-efficacy is a key mechanism by which behavioral motivation occurs and has a significant impact on rates of return-to-work.  If they think they can it is more likely they will engage in the behavior (read: return to work) in the future.

There seems to be a current debate over whether we should consider ‘return-to-function’ versus ‘return-to-work’.  I would argue that ‘return-to-function’ is a claims outcome and not a work disability outcome.  If they return-to-function but do not return to work they remain work disabled.  If the objective is to prevent work disability then the goal HAS to be to return to work.  If return to work is in fact the goal then we need to consider when goals are most meaningful and now must include a concept called self-concordance.  Self-concordance is “the extent to which a goal reflects personal interests and values versus something one feels compelled to do by external or internal pressures.”  Basically, in the context of an injured worker, being self-concordant is when it is important to return to work and they want to return work.

“An interesting finding is the significance of the importance that work represents for the injured workers. This was the only constant predictor in our multivariate models at both follow-ups.”

Francois Laisnea, et al (2013)

To not consider self-concordance in behavioral motivation is short sighted.  Which means the worker should be self-advocating for return to work.  Positive and sustainable work disability outcomes actually occur more often when the worker ‘self-advocates’.  Think about your most motivated workers.  I am willing to bet they are self-advocating to return to work, identifying barriers to their recovery and return to work, and coming up with solutions to address those barriers.  What is needed is the promotion of a ‘self-advocacy’ model not an advocacy model that is trying to alleviate the shortcomings of an inherently adversarial system and ultimately benefits 3rd party vendors that can smooth the way.

Compliance, Adherence, Concordance – Building a Better Workers’ Compensation System

I wrote about Is RTW the outcome? and noted that there were 3 areas to focus on in terms of the motivation to RTW.

  • Affective – how they feel about RTW
  • Behavioral – how they behave towards RTW
  • Cognitive – how they think about RTW

Sure, one could argue that improvements in the claims experience will impact on all three.  But the reality is that improving the claims experience primarily addresses the behavioral ease component of influencing behavior.  In other words, it only helps to make it easy for people to behave in a way we want them to.  Important?  Absolutely.  But…humans are funny.  Despite behavioral ease, we don’t always do what we intend to do and we don’t always do what we should do.  In fact, it appears we are wired for inattention and inertia.  Meaning, motivation is more complex than just providing a positive experience.  I would agree a positive experience helps by greasing the wheels.  However, the obvious challenge is; if there is no fuel in the tank it won’t matter how much grease you apply.

So we need to rethink the next generation claims model.  The old model was based on compliance.  Compliance required workers to follow a prescribed set of policy rules or course of treatment, and if they didn’t then we would label them as non-compliant.  Compliance implies passive obedience.  Compliance enforcement increases the chance of an adversarial interaction, requires tremendous manpower to monitor, and has failed in making sustainable improvements in workers’ compensation outcomes.

We hoped we could make some improvements by helping workers ‘adhere’ to treatment, policies, and return to work.  Enter early intervention, early treatment, 3rd party vendors, etc.  Adherence was hoped to improve outcomes but required oversight, albeit less than compliance.  Adherence is about our ability to ‘stick’ to the agreed upon course of action.  However, successful goal attainment (Read: return to work) requires that problems associated with getting started and persisting until they return to work are effectively solved.  This makes adherence fundamentally flawed because adhering is difficult for us if those problems are not effectively addressed and solved.

Since we already talked about self-concordance (the agreement between what is important for us and our compulsion to follow through) then we should also talk about concordance.  Concordance is very different than compliance and adherence.  Concordance “focuses on the consultation process rather than on a specific [worker] behavior, and it has an underlying ethos of a shared approach to decision-making rather than paternalism.” (The Pharmaceutical Journal, Vol. 271).  In order for concordance to work effectively it requires agreement.

“We are able to trigger those parts of our neurology that relate to motivating us when we feel in control.”

Charles Duhigg

Behavioral Motivation is highly dependent on feelings of control.  In order for the worker to have a sense of control it requires them to be part of the discussion AND to be the source of solutions, next actions, and outcomes that we can all agree on.  Agreement requires collaboration not advocacy.  Agreement comes as a result of engagement AND activation.

Maybe the better model within an Integrated Work Disability Prevention Program is a worker-centric, concordance-based model.  Maybe this will work better because it addresses the full spectrum of the affective, behavioral and cognitive domains of return to work.  It is active, not passive.  The advocacy-model suggests what is needed is a “the insertion of an objective person who is familiar with the workers’ compensation process but is not necessarily the same individual who will be adjudicating the claim.”  This seems inherently passive to me AND seems to imply the insertion of a 3rd party person which seems self-serving.  We could argue that we are talking semantics but the move from a compliance-based system to an advocacy-based system to a concordance-based system is not only an important philosophical shift but a shift in thinking about moving from disability management towards the prevention of work disability.  It requires concordance not advocacy.  We should be building a compensation model that helps the worker decide to stay at work and return to work.  We can take a lesson from high performing health care.  Engaged and activated patients cost the system less, recover faster, and have fewer readmissions.  A paradigm shift towards Integrated Work Disability Prevention requires a different purpose, a different approach, and different actions, not just simply advocating.