Return To Work
Only a small fraction of medically excused days off work are
medically required – meaning work of any kind is medically
contraindicated. The remaining days off work result from a
variety of non-medical factors such as:
- Administrative delays of treatment and specialty referral
- Lack of transitional work
- Ineffective communications and lax management
- Logistical problems
These days off are based on non-medical decisions and
are either discretionary or clearly unnecessary. Absence
from work is “excused” and benefits are generally awarded
based on a physician’s decision confirming that a medical
condition exists. This implies that a diagnosis creates
disability.
However, from a strictly medical point of view, people
can generally work at something productive as soon as there
is no specific medical condition to keep them from working
(see Table 4 below). The key question is what kind of work?
Many obstacles that appear to be medical are really situation-specific.
For example, an employee with a cast on the right foot cannot
drive a forklift, but can perform other tasks until the cast
is removed. A person recovering from surgery may not be able
to work a full day in the office, but could work half days.
In fact, people often sit home collecting benefits because
their employers don’t take advantage of their available
work capacity. Today, these decisions generally are
misclassified as “medical,” and as such are not examined.
Recommendation:
- Stop assuming that absence from work is medically
required and that only correct medical diagnosis and
treatment can reduce disability.
- Pay attention to the non-medical causes that underlie
discretionary and unnecessary disability.
- Reduce discretionary disability by increasing the
likelihood that employers will provide on-the-job recovery.
- Instruct all participants about the nature and
extent of preventable disability.
- Educate employers about their powerful role in
determining Stay-A-Work/Return-to-Work (SAW/RTW) results.
Current Initiatives/Best Practices: Clinicians,
employers, and insurers can now use the following criteria
(see Table 4) to determine whether a disability is medically
required, discretionary, or unnecessary. If all parties use
these definitions, clearer communication and better decision
making will result. In particular, physicians will no longer
have to make employment decisions, and employers will stop
misclassifying business decisions as medical decisions.
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Table 4 – When is a Disability Medically Required, Medically Discretionary, or Medically Unnecessary? *
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Medically Required
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Medically Discretionary
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Medically Unnecessary
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Absence is medically required when:
- Attendance is required at a place of care (hospital,
physician’s office, physical therapy).
- Recovery (or quarantine) requires confinement to bed or home.
- Being in the workplace or traveling to work is medically
contra-indicated (poses a specific hazard to the public,
coworkers, or to the worker personally, i.e., risks damage to tissues or delays healing).
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Medically discretionary disability is time away from
work at the discretion of a patient or employer that is:
- Associated with a diagnosable medical condition that
may have created some functional impairment but left
other functional abilities still intact.
- Most commonly due to a patient’s or employer’s
decision not to make the extra effort required to
find a way for the patient to stay at work during
illness or recovery.
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Medically unnecessary disability occurs whenever a
person stays away from work because of non-medical issues such as:
- The perception that a diagnosis alone (without
demonstrable functional impairment) justifies work absence.
- Other problems that masquerade as medical issues,
e.g., job dissatisfaction, anger, fear, or other psychosocial factors.
- Poor information flow or inadequate communications.
- Administrative or procedural delay.
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(Source: ACOEM Practice Guidelines, Cornerstones of Disability Prevention and Management)
Unnecessary prolonged work absence work can cause needless, but
significant harm to a person’s well-being. While on extended
disability many patients lose social relationships with co-workers,
self-respect that comes from earning a living, and their major
identity component – what they do for a living. Many key players
in the SAW/RTW process do not fully realize the potential harm
that prolonged medically excused time away from work can cause.
Many think that being away from work reduces stress or allows
healing and do not consider that the worker’s daily life has been
disrupted. With these attitudes system-induced disability becomes
a significant risk. Early intervention is the key to preventing
disability. Research confirms:
- People who never lose time from work have better outcomes than people who lose some time from work.
- The odds for return to full employment drop to 50-50 after six months of absence.
- Even less encouraging is the finding that the odds of a worker ever returning to work drop 50 percent by just the 12th week.
Recommendation:
- Shift the focus from “managing” disability to “preventing” it and shorten the response time.
- Revamp disability benefit systems to reflect the reality that resolving disability episodes
is an urgent matter, given the short window of opportunity to re-normalize life.
- Emphasize prevention or immediately ending unnecessary time away from work,
thus preventing development of the disabled mindset, and disseminate an educational campaign supporting this position.
- Whenever possible, incorporate mechanisms into the SAW/RTW process that prevent or minimize withdrawal from work.
- On the individual level, the health care team should keep patients’
lives as normal as possible during illness and recovery while
establishing treatments that allow for the fastest possible
return to function and resumption of the fullest possible participation in life.
Current Initiatives/Best Practices: Many employers and some insurers now begin return-to-work efforts on the first day
** information taken from ACOEM’s Preventing Needless Disability Guideline.
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