The great thing about the society we live in is the ability to speak freely and offer different perspectives. It allows the opportunity to share ideas, create thought provoking moments, and sometimes stir the pot when it needs to be stirred.
Peter Rousmaniere’s article “Response to DePaolo” led me to read David DePaolo’s original article “Stop RTW”. Both excellent and interesting articles. My first reaction to DePaolo’s title was, “Wait a minute! Stop RTW? That’s not right.” As usual, DePaolo’s write up is great at provoking discussion and thought. In his article, DePaolo’s writes:
“Return to work has nothing to do with workers’ compensation or the recovery of the injured worker. Return to work is a nice outcome, but it can not be a goal because the only person who can determine whether there will be a return to work is the injured worker!”
And then later, “Workers’ compensation is about medical treatment for an injury and indemnity for the infirmity only. It is not designed to motivate an employment decision (and every time legislatures try that, it fails…)”
And then, “While return to work is nice for the employer because it lowers the experience, and is nice for employees because work is so essential to human being’s identity – there has to be something other than just collecting a pay check for return to work to be successful. And those are things that we have absolutely no control over. Return to health is a much better, and more realistic, goal. Getting the injured worker healed up as good as we can is what the medical treatment component of workers’ compensation is about.
The emphasis added is mine because they stood out for me. There is so much talk about how the “system” is broken. As workplace injury rates fall the costs of disability continue to rise. A recent article from the Stanford Report reports that Stanford Law Professor Alison Morantz found that company costs dropped by about 44 percent when firms chose to replace workers’ compensation with private plans. Certainly this is good news for the economic costs of workers’ compensation. In contrast, the NPR report, “Unfit for Work: The startling rise of Disability in America” paints a bleaker picture on the human and social costs of disability and suggests that while corporations are saving costs, these costs are being shuttled to other systems like LTD plans and SSDI. Much like robbing Peter to pay Paul. The human, social, and economic costs of disability are, ironically, disabling the system(s). This is not just workers’ compensation but also non-occupational injury/illness. And as we try to control the economic costs I fear it is at the sake of the human and social costs.
In his rebuttal, Rousmaniere’s assertion that “return to work is an integral part of workers’ comp, more now than before” is an intriguing thought and in stark contrast to DePaolo’s position. I would argue for Rousmaniere’s position as well and add that the only consistent stakeholder at the center of it all is in fact the worker. They are the lead character in this movie. Everyone else has supporting roles. However, I often see the supporting roles try and become the lead and this is where it often breaks down.
The American College of Occupational and Environmental Medicine (ACOEM) in their position paper Preventing needless work disability suggest that there are escalation levels to the The Stay at Work/Return to Work Process. At the very base level, 0, there is only one person who is involved and that is the worker. And consistent with DePaolo’s observation they further suggest that it is the personal decision of the worker that triggers the process. In fact, it is not until the worker decides to RTW that anything actually every happens.
Qualitative interviewing of injured workers and employers seems to corroborate this. Employers will say, “It is the doctor who is holding the RTW up. They just won’t release them back to work.” Workers will say, “I will RTW when my doctor says I can.” Here is where the insight comes in. While the employer and the worker are making the doctor the lead role, further questioning reveals that the emperor has no clothes on. Simply asking the employer, “So what do you think ACTUALLY happens in the appointment between the doctor and the worker when they have the [form] in front of them?” Or, “If the average appointment is 7 to 9 minutes, how does the doctor know they can stand for an hour? Lift 20lbs?” Invariably they answer, “The doctor just writes what the worker wants.” Ask the worker, “How does your doctor determine if you are ready to RTW?” Invariably they answer something like this, “He just asks me if I think I can.”
So, it seems that ACOEM has it right. DePaolo has it right. Rousmaniere has it right. The decision or motivation to RTW rests with the worker and with no one else. Everyone else has supporting roles and RTW is an integral part of the health outcome.
So what is RTW Motivation anyway?
Motivation is a funny thing. It is not a simple on or off switch. In fact it is bit more complicated than that. The website pavementrunner.com says it best, “Motivation is all around us. You just have to know where to look.”
As DePaolo points out, certainly money is not the sole motivator to RTW. I would suggest that the only time money is the motivator is when there isn’t any. We have all experienced the ‘spontaneous RTW’ when a person’s claim is terminated. I challenge back with this question, “Do you want the person motivated before you have to terminate their claim or after?” Most answer that they would prefer to have an engaged and motivated person before the line is drawn.
Digging a bit into Motivational Science helps us grasp some understanding of what motivation is. Essentially, motivation boils down to two things; what a person will gain by doing something and what they would lose by not doing it. They are two sides of the same coin and work well but effect motivation differently. As DePaolo stated, “there has to be something other than just collecting a pay check for return to work to be successful” So while we frame RTW in terms of benefits and features and what they will gain, it is equally important to understand the loss they might incur if they didn’t RTW. These two factors, gain and loss, are the “something other” that DePaolo speaks of. People RTW for all kinds of reasons, not just money. They even RTW to jobs they don’t like. But these two factors do nothing by themselves other than tell us if the worker is in fact pointed in the right direction (read: RTW). It does not tell us if they will follow through. In other words, it only answers this – Are they even on the bus? So a person can be motivated, or on the bus, but appear to be unmotivated because there is no gas on the bus.
So here does the gas come from? This is where the known risk factors of work disability come into play. Without proper assessment of these, you have no idea if there is gas, how much gas, or if in fact if they are on empty. DePaolo suggests that, “And those are things that we have absolutely no control over.” I would argue that these factors are in fact influenceable. You just have to know where to look. As an industry, we seem to have been on the path to put in more processes, more legislation, more this and more that…more of just more to counteract what seemingly we have no control over. Occam’s Razor would suggest an approach of simplicity. Why don’t we just ask the worker?
ABC’s of RTW
Following the ABC’s of RTW can go a long way helping improve our outcomes.
- Affective – how they feel about RTW
- Behavioural – how they behave towards RTW
- Cognitive – how they think about RTW
Simply asking the worker to comment, discuss, and express themselves in the ABC domains will go along way to understand why they seem stuck.
- How does the worker feel about RTW? Scared, unsupported, fearful, avoidant.
- Are they behaving in a way that indicates moving towards RTW or away? Why? Are they engaged? Why not? How do we help workers with choices that are biased towards action?
- And finally, what are their thoughts about it? Will it be easy? Hard? Do they need a graduated schedule? What do they think needs to happen to RTW successfully?
Once you uncover these things you need to ensure the continuing discussion is solution focused NOT solution forced. This will keep the engagement. Forcing solutions risk disengagement.
I read a comment on a post the other day, “It’s been a while since I had an ‘aha moment.” This person may be right. Maybe there are no new ‘aha moments left.’ Maybe we know all we need to know. Maybe the ‘aha’ will come from the application of the old information in a new way. Maybe the answer lies in not just one discipline but in a variety of disciplines. Consilience refers to the principle that evidence from independent, unrelated sources can “converge” to strong conclusions. In a way the Bio-psychosocial-economic model is a form of consilience. Certainly not a new concept but maybe a re-design of the application of it is what is needed. Rousmaniere and DePaolo are both right in their positions but for different reasons. Having said that, both of their positions ‘converge’ actually at the point of the worker. Both assert in their own way that it is the worker’s decision that determines if the worker returns to work. And this is the starting point. I often say to case managers that our job is actually to help the worker decide to RTW and that means digging around to find out why they want to RTW or, get them on the bus, AND then determine what is getting in the way or, make sure there is gas to get where we are going (read: RTW).
“employers can influence employee behavior through “expectations and feedback,” “tools and resources” and “consequences and incentives.”….Those I’ve met (adjusters, worksite staff, case managers) who appear to understand RTW know about these levers.” (emphasis added is mine)
That always seems to be the case. A select few who get it. A select few who understand the concept of Positive Influence. But does the industry really get it?
DePaolo offers that the system (in his context – Workers’ Comp) “is not designed to motivate an employment decision (and every time legislatures try that, it fails…).” I would agree and this may be the smoking gun. The system is NOT designed for it. Is it time to re-design it? Is our commitment to stay at work or return to work really targeting the right things that are causing work disability or is our commitment only for economic reasons? Where we fail is when we try to put in more processes to mitigate for OUR failure to engage the worker, uncover the root causes of work disability, and ultimately understand that RTW Motivation really starts with the worker’s decision to RTW. Why before How, How before When…the When will follow. We often have it backwards. We often start with When then figure out the How and THEN wonder “WHY are they not returning” instead of Why do they want to return in the first place. Maybe we have the order wrong.
Let’s start thinking about setting the stage that helps a person “decide” to RTW. These are things influenceable; you just need to know where to look.
The real innovation will come when we, as an industry, begin targeting the factors that predict work disability in a methodical and deliberate way, AND put the worker in the center where they should be. Not just by a select few who get it, but as an industry. While I agree with DePaolo’s assertion that Return to Health is an outcome, I would add that Return to Work IS Return to Health and that Return to Work is a Health Outcome.
Rousmaniere said, “Getting back to work is the only good proof of successful recovery and of a successful workers’ comp system.” Without Return to Work as an outcome there is no central focus, no unifying purpose for all the stakeholders, and no deliberate effort to prevent Work Disability. And, ironically, they whole concept of preventing Work Disability relies on RTW as an outcome and this make RTW a strategic initiative for all stakeholders.