Fundamentals of successful disability management

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Fundamentals of successful disability management
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Introduction

• Business case Rising medical and disability
  costs create business pressure that can mean the
  difference between success and failure to a
  company.
• Aging work force
• Economies of the knowledge worker
• Resurgence of medical inflation
• Excess costs of replacement workers

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Scope of problem

• An estimated 35-49 million people in the U.S.
  have a disability.
• Estimated direct and indirect costs (including
  medical and lost work days) total 170 billion.
• Nearly one in five people will become disabled
  for five years or more prior to age 65.
• 15 of all U.S. health-care dollars are
  attributable to sedentary lifestyle 12 of costs
  are obesity related.

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How to tie the pieces together

• Disability management is a combination of
  prevention (primary, secondary or tertiary), and
  is done best within the context of the shared
  goals and objectives of the employer, employee
  and medical provider.

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Defining the players

• Injured worker
• Employer and TPA central role
• BWC administrative body
• MCO medical manager (responsible for first
  level of the alternative dispute resolution
  process)
• Provider/physician of record (POR)
• Vocational rehabilitation case manager

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Energizing the game plan

• Putting goals and objectives in order
• Working in collaboration
• Understanding the multidimensional aspects of
  disability management
• Putting key levers in place to prevent injury,
  provide speedy treatment, and enable safe and
  timely return to work

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Injured worker

• Notification of injury to the employer
• BWC, employer, MCO and physician manage
  expectations
• Should be taught the value of being an integral
  part of his or her recovery
• Should be willing to return to work, prior to
  full recovery, with restrictions from the
  physician (comfort level is needed)

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Employer

• Consideration Most organizations are not
  designed to work closely with external partners.
  
• Make the injured worker feel valued and encourage
  return to work.
• Understand the challenges your employee faces
  when returning to work.
• Maintain a list of modified or transitional
  duties for disabled employees.
• Communicate with MCO, employee, POR, etc.

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BWC

• Administrative body for the adjudication of the
  claim allowance assigned claims service
  specialist (CSS)
• CSS is a part of a multidisciplinary team
  (vocational rehab specialist, nurse, employer
  specialist) works directly with MCO
• Performs claim evaluation two-point contact,
  determination of causal relationship, reviews
  medical, makes claim determination and creates
  the order

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MCO

• The MCO is responsible for the medical management
  of the claim, including
• Establishing treatment guidelines
• Performing utilization review to evaluate the
  necessity or effectiveness of medical care
• Making initial treatment decisions
• Performing case management and acting as a
  liaison between all parties to a dispute.

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POR

• In charge of patient care and progression
  (always)
• Provides limitations/restrictions of injured
  worker for application in the employers work
  site to encourage and support an early, stable
  return to work
• Encourages and supports the injured worker in
  maintaining proper level of functioning (not
  always related to work site)

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Vocational rehabilitation case manager

• Enters the claim at the appropriate time as
  recognized by the other players
• Coordinates services required to restore or
  improve functional capacity
• Communicates with MCO case manager, employer,
  injured worker and provider
• Determines common goal for progressing injured
  worker back into the workplace

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The plight of the injured worker

• He or she receives instruction, direction,
  guidance, etc. from all players
• Non-medical reasons for absence from work
• Pre-determined opinions prior to injury or
  disability
• Must have next steps guidance in his or her
  travel through BWC processes

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Common barriers to successful disability
management

• Misunderstanding among the players regarding the
  role each plays in the progression of disability
  management
• Perception of lack of support from the provider
  (lack of comfort level and/or trust)
• Excluding the injured worker from the plan
• Delays in appropriate interventions, such as
  vocational rehab, remain at work, etc.
• Confrontational or adversarial relationships
  surface with provider, MCO, employer, injured
  worker and BWC
• The mindset of the injured worker he or she The
  injured has ultimate control over early return to
  work

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Vocational rehabilitation

• Individualized and voluntary program for an
  injured worker with a lost-time claim which
  requires assistance with return to work
• Focus on vocational vs. medical treatment
• Medical stability is required
• Emphasizes restoring or maximizing an injured
  workers abilities minimizing long debilitating
  absences from work
• Identifies skills and abilities to assist injured
  worker in obtaining alternative employment

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Best practices Lessons learnedQuestions
answers