Perhaps the most fundamental condundrum of workers compensation (and other forms of disability insurance) is this: when a worker is paid for being sick, there is a strong disincentive for getting well. Employers and insurers have long been frustrated by this problem. Attorneys have long viewed it as a business opportunity. And now the doctors are beginning to confront this profound fault line in the world of medicine.
In an article by E. J. Mundel at drkoop.com, a "meta-analysis" of 211 research studies from across the globe reveals that indemnity (lost wage) payments have a strong influence on medical outcomes. (The full article, available only to subscribers, is in the April 6 issue of the Journal of the American Medical Association.) In all but one of the studies, workers receiving financial compensation for work-related injuries were almost four times more likely to have poorer long-term medical outcomes than uncompensated workers.
"Essentially, the worker is getting paid for being sick, and it's hard for anyone who's being paid to get sick to get well," said Dr. Robert H. Haralson, immediate past president of the American Academy of Disability Evaluating Physicians, and the current executive director for medical affairs at the American Academy of Orthopaedic Surgeons.
According to Haralson, who was not involved in the study, this phenomenon "has been known for years" among orthopedic surgeons treating such common, tough-to-diagnose workplace problems as back pain or carpal tunnel syndrome.
"It's very frustrating" for doctors," he said. It's very frustrating for employers and their insurance carriers, I would add.
It's no surprise that attorney involvement has an adverse effect on medical outcomes. "If a lawyer is involved, it's five times as expensive as if a lawyer is not involved," noted Dr. Edward Bernacki, director of occupational medicine at Johns Hopkins University School of Medicine, and past president of the American College of Occupational and Environmental Medicine. While the workers might experience some ambivalence about getting better, there is less ambivalence for the attorney: it's in his or her financial interest to present the medical aspects of the disability in the most negative possible light. The better the employee feels, the less money is in it for the attorney. If the employee fully recovers, the attorney is out of a job!
Doctors are catching on to the need for a quick return to work. Dr. Haralson says that the most common problem in these situations is back pain, and "there's good evidence that what you ought to do with back pain is head back to work within a couple of days -- even if you continue to have some pain."
Back at work, the injured workers should initially avoid tasks that might exacerbate symptoms. (We call this "temporary modified duty.") The important thing, according to Haralson, is to keep injured workers from what he called the "disability cascade."
We are in total agreement with Dr. Haralson's comments. Indeed, they provide a concise restatement of the defining principles of a well-structured return-to-work program. We also agree with him that few workers plan out a disability path for themselves. "It's not that the patient lays awake at night thinking "OK, I'm going to go fool the doctor tomorrow,'" he said. "It's much more complicated, it's more of a natural human phenomenon." What�s so natural? When you are paid for not working, your subconscious may have difficulty generating the motivation to get back to work.
We are not suggesting that there is no role in the system for attorneys. Indeed, when employers and carriers deny legitimate claims, attorneys are essential. We are also not implying that indemnity payments are not needed or that injuries never require time away from work. But we do believe that the main cost driver in the workers compensation system is delayed recovery and medically unnecessary time away from work. That's why we urge employers to move aggressively in the first hours and days following an injury: support the worker, secure first class medical treatment, and get the worker back to the workplace as quickly as possible. When a worker is away from the workplace, being paid not to work, there is a powerful risk of a bad outcome for everyone.