New Paradigm for Workers' Comp & Disability Benefits Systems

This column by Jennifer Christian, MD, MPH appeared in August 2007. See more of Dr. J's columns.

Dear Dr. J:

What is this new paradigm for disability benefits and workers' compensation that you are talking about at all these conferences? What does it mean? How will it affect me and my work? Where can I learn more about it?

Betty in Birmingham

Dear Betty:

A new paradigm means a major shift in thinking. There is change in the air for workers' compensation and disability benefits systems. I think we are shifting away from the traditional paradigm or model - efficient claims processing - towards a new one - preventing needless work disability.

Many people aren't quite sure what a paradigm is. We all use them everyday. They are fundamental presumptions that most of us share about how a basic feature of the world works -- mental models of the "big picture". A paradigm is a whole community's way of viewing a piece of reality. As a quick example, if we work from the presumption that "human beings are naturally brutish, selfish, sinful, and violent", we will interact with others differently on a day to day basis than if we work from the presumption "people are naturally good, trusting, and kind."

There are five basic underlying presumptions that I believe constitute today's traditional paradigm for workers compensation and disability benefits -- the claim processing model. They are:

• 1. Work absence or disability is necessary after illness and injury.
• 2. Work avoidance assists in recovery from illness or injury, so it is good.
• 3. Duration of work absence reflects the severity of the illness or injury.
• 4. Most people don't need any help because they will receive appropriate medical care and support in managing their health-related employment disruption.
• 5. Tragic situations and "bad people" cause most loss costs.

Since that's the context in which today's disability benefits and workers' compensation systems operate, the way we work reflects these assumptions. Thus, for example, OSHA's metric for the number of work days lost as a result of an injury is called "severity." Also, since people assume that the medical care being delivered and the work disability that is occurring is generally appropriate, they focus mostly on processing claims and managing outliers when they are noticed. The injured or ill person may be fully informed about their rights and benefits, but usually receives no timely advice about how to achieve the best possible overall outcome, in terms of long-term mental, physical, social and economic well-being. The claim or disability management system primarily observes what is happening, makes decisions about what it sees, and only intervenes when things have gone clearly "off track."

The popular use of the terms paradigm and paradigm shift got started after Thomas Kuhn's book The Structure of Scientific Revolutions was published in 1962. Kuhn's idea and vocabulary appealed first to the "hard science" community, but since then people in many different fields including social scientists and artists and business people have taken to describing themselves as rejecting existing paradigms (the traditional or prevailing view of things) for new paradigms (a new vantage point or perspective). Like us here in the workers' comp and disability field, for example!

Paradigms are by definition not permanent. They change from time to time. When first adopted, these mental models of the "big picture" fit best to the observed detailed facts and support the development of even better understanding and performance. Gradually, though, as time passes and more facts become known, the model (or paradigm) becomes increasingly ill-fitting and confining. Then that model is relatively suddenly replaced by a new one that at first looks like a great fit with the then-current detailed knowledge. For a while, the "new" paradigm supports the development of even better understanding and performance, but gradually becomes increasingly ill-fitting and confining and is replaced by another model ... and so on.

The basic design of disability benefits and workers' compensation programs have been unchanged for decades. During that period, society has undergone major changes, and we are now facing an unprecedented set of circumstances: (a) the first edge of the baby-boomer bulge approaching retirement age, (b) accelerating global economic competition, (c) uncontrollable healthcare cost increases and growth in government entitlement programs, (d) increasing dissatisfaction with the cost and quality of social and benefit programs, and so on. The dissatisfaction with current systems and the political tension that these problems are creating signals that some paradigm shifts are in the offing.

When a paradigm shifts, a "big picture" vantage point or perspective is altered, which changes the context in which we operate. In response, we change the way we conduct our everyday affairs or business. Here's a historical example that will show you more concretely what I mean. In the middle ages, virtually everybody thought the earth was flat. I've seen a map drawn during that time showing heaven above and hell down below the flat disc of the earth, which is being held up by gigantic monsters. Fisherman and naval sailors managed their everyday affairs from that vantage point, so they hugged the coastlines for fear of falling off the edge of the world. When the idea that the world was round took over (the prevailing paradigm changed), mariners became brave enough to venture straight out across the ocean and discover The New World. This change in people's basic assumptions about the shape of the world changed fishing, shipping, military operations, geographic exploration -- and even affected other less practical aspects of people's view of life -- for example, assumptions about the location of heaven and hell.

What is replacing the traditional "claims processing paradigm"? Here are five of the basic underlying presumptions that are core components of the "new" paradigm of work disability prevention.

• 1. Much of today's work disability could be foreshortened or averted entirely because work absence is not medically required for more than a few days after illness and injury.
• 2. Being active during convalescence speeds recovery, while extensive work avoidance and "rest" tend to delay it.
• 3. Prolonged absence or permanent withdrawal from work is bad for people's well-being -- mental, physical, social and economic.
• 4. Prolonged withdrawal from work is usually being driven by non-medical factors instead of medical ones.
• 5. In today's complex world, many people need pro-active instruction, advice, or even one-on-one assistance in:
  • how to navigate the healthcare system;
  • how to select doctors who will provide the most effective treatments;
  • how to cope best with a health-related employment situation.

My challenge to you is this: Start imagining what a difference it will make when most people start their work from the vantage point created by the five new presumptions above. What will happen if everyone believes that disability benefits and workers' compensation systems should meet the reasonable needs of injured/ill employees -- and their supervisors -- by pro-actively driving towards the fastest and most economical yet mutually beneficial resolution of the life and workplace "pickles" that are caused by illness and injury?

This new perspective will change the details of what we will do on an everyday basis. Let's explore how specific things will look different from an operational perspective. Here's a sample of this kind of change in ways of doing business: In the new paradigm, the claim intake process should be transformed from an "information vacuuming process" in which the main focus is on collecting data from the worker, the supervisor and the doctor in order to make claim decisions. In the "new paradigm", the claim intake process will be transformed into a multi-channel event, with information collect as one of the channels. The other channels, however, will include courteous and kind customer service plus just-in-time training. Attention will be paid to learning about and attending to the reasonable normal human needs of a newly-injured or disabled (and possibly upset) worker, his supervisor who is dealing with an unfamiliar workplace situation and distraction from daily routine and workplace, and the doctor who may be uncertain about how to respond to the injured/ill worker and give useful guidance to the employer.

I LIKE the promise of better results that this new paradigm will produce: improved service to employees, better life outcomes for employees, lower medical and work disability benefit costs, less crankiness, cynicism, fraud, and litigation. Many of the major precepts of the new paradigm are "embodied" in ACOEM's report addressed to all stakeholders entitled "Preventing Needless Work Disability by Helping People Stay Employed (www.acoem.org).

Smiling,

Dr. J