Sergio is repairing equipment at a power station when he feels a twinge of discomfort in his lower back. Per company policy, he informs his supervisor. What happens next is likely to have a critical impact on the outcome for Sergio and his employer.
Let’s assume the supervisor instructs Sergio to stop working and visit a clinic for evaluation. At the clinic, the treating provider conducts a physical exam, orders some diagnostic tests and writes a prescription for medication to relieve pain and inflammation. Sergio takes the afternoon off and returns to work the next day with restrictions. The encounter is recordable and results in a workers’ compensation claim.
Now, let’s consider an alternative scenario. Sergio and his supervisor call or use a smartphone application to contact an injury management triage center. Sergio describes his symptoms to an occupational health nurse or physician who offers reassurance and care guidance. He is given the option of a clinic visit, but with instructions from the clinician, Sergio instead voluntarily agrees to self-administer first aid.
After applying a cold pack to his back and taking a nonprescription anti-inflammatory medication approved for use at the worksite, Sergio resumes work and is able to safely finish his shift. A claim is not filed and there is no case to record.
In the first scenario, a routine complaint of low-back discomfort diverges onto a path with the potential for high medical costs, productivity loss, delayed recovery and litigation. In the second scenario, Sergio is given choices that include using work – an activity “prescription” – as therapy during recovery. Sergio is empowered to successfully manage his condition without worrying about making it worse or potentially missing work.
The Importance of Empowerment
While practicing occupational medicine in all types of industries, including the utility sector, I have observed that the vast majority of work-related injuries are relatively minor and can be effectively managed on-site at the first-aid level. So, why do these types of cases so often end up in a doctor’s office or hospital emergency room? The reasons range from entrenched provider referral patterns, to supervisors’ inexperience with injury management, to employee pain behaviors – such as medicalizing nonmedical issues – to employers’ legal liability concerns.
Environmental, health and safety professionals and others in the utility industry have an opportunity to overcome these barriers and simultaneously improve workforce health outcomes and business results by:
- Promoting healthy habits such as routine exercise, good nutrition and getting enough sleep.
- Providing support for the management of chronic conditions such as diabetes and hypertension.
- Giving employees the information they need to make informed choices about their own care.
Work-related injury rates remind us why it’s important to consider the potential positive impacts of health-care consumer education in employed populations when designing workplace injury prevention and management programs.
For example, while injury incident rates have been declining in the U.S., there were still approximately 29 million nonfatal work-related injuries in 2016, the most recent reporting year, according to the U.S. Bureau of Labor Statistics. Of those, 3.2 per 100 full-time equivalents (FTEs) were recorded and reported by covered employers to OSHA. On average, 1.6 cases per 100 FTEs resulted in days away from work, job restriction or transfer.
A significant percentage of work-related injuries are musculoskeletal disorders, which cost employers billions of dollars annually and create substantial disability burdens. Overexertion involving outside sources is ranked first among the leading causes of disabling injury in the 2018 Liberty Mutual Workplace Safety Index, with direct annual costs to employers estimated at about $15.1 billion. The index defines a disabling injury as more than five days away from work.
In addition, there are lessons to be gleaned from recent studies on provider choice and treatment value. For example:
- Researchers compared total workers’ compensation case costs in employer-directed states to costs in states that allow employee choice of provider. Costs were higher in states with employer-directed care, at least partly due to increased attorney involvement. Higher litigation rates suggest that employees are dissatisfied with the care they receive and that there are benefits associated with educating employees so they can feel more invested in their choice of provider and recovery path.
- In a multiyear review of cases in 25 states, the Workers Compensation Research Institute found little evidence of differences in average costs per claim between employer-directed and employee-choice states for workers’ compensation care. However, high-cost back injuries cost even more in choice states. These findings indicate that allowing employees to choose their provider does not necessarily equate to higher costs for employers, and that it may be beneficial to educate managers and frontline workers about factors that drive up costs in certain diagnostic categories.
- In Washington, a performance measurement tool called the MedInsight Health Waste Calculator was used to evaluate the value of tests, procedures and treatments provided in group health settings. Researchers found 622,000 people received “low value” health care services at an estimated annual cost of $282 million. In workers’ compensation cases, similar principles appear to apply.
From an epidemiological standpoint, none of the parties in the workers’ compensation system have found a way to significantly reduce costs and disability associated with work-related injuries. In the U.S., overtreatment is a fundamental problem. In particular, use of narcotics for the management of mild to moderate musculoskeletal pain has contributed to the nation’s opioid addiction epidemic.
So, what are some solutions to these issues? Preventing injuries is the goal. But when injuries occur, interventions can be used, as clinically appropriate, to empower employees to take care of themselves.
Frontline supervisors and safety professionals who leverage collaboration with occupational health and ergonomics experts are better equipped to detect and manage conditions that increase workers’ injury risk. Such factors include poor physical fitness, obesity, aging, depression, fatigue, substance abuse and chronic disease. Experience shows the sooner these types of conditions are detected and managed, the greater the likelihood of positive results across the board.
Examples of preventive interventions include on-site coaching on the use of proper body mechanics, ergonomic assessments and workstation adjustments, time-of-need training and targeted wellness programs based on population health risk assessments. On the non-occupational side, many group health and self-insurance plans offer incentives and disincentives to encourage or discourage certain behaviors.
Giving the workforce a voice in the selection of preferred providers also may pay dividends. Depending on community and workplace culture, employees may express a preference for on-site services, remote telehealth access to clinicians, or use of alternative modalities such as chiropractic care, acupuncture or noninvasive massage techniques. When surveyed, employees often express a need for stress management, mental health, substance use and personal counseling services, as well as physical fitness, weight control and smoking cessation programs.
No matter how minor an injury may be from a medical perspective, it is not trivial to the person who is experiencing it. A common pitfall in injury management is reliance on a supervisor without clinical training to make a clinical judgment. Employers who respond to injured employees’ expressed needs by providing access to an established care management process tend to fare better than those who do not.
Astute safety professionals who are responsible for protecting dispersed workforces are learning to take advantage of communications technology that uses secure platforms for the confidential exchange of protected health information between a medical professional, such as an occupational health nurse or physician, and the employee. That doesn’t mean personal contact with a health care provider does not add value; at times it is essential for an individual to be touched by a caregiver in order to get better and return to full function. Every encounter with a trusted medical professional – whether it is a telephonic exchange, a visual “touch” using telemedicine technology or an in-person visit – is a chance for employee education and empowerment.
Recommended intervention strategies include:
- Encouraging reporting at the onset of a work-related injury or physical discomfort – the sooner the better.
- Providing immediate access to qualified medical professionals to ensure employees receive the right care, at the right time, in the proper setting.
- Facilitating informed decisions about self-care options at the first-aid level in accordance with best clinical practices.
- Training all staff members on the company’s emergency medical response plan.
- Using nurses to facilitate off-site treatment encounters and provide case monitoring during recovery.
- Having an occupational physician familiar with the worksite confer with the treating provider on safe return-to-work pathways, with or without restrictions.
For example, using these strategies, an employer should expect 50 to 70 percent of employees with low back strain to elect first-aid self-care when presented with options and guidance, along with a return to full duty. Of those requiring an initial clinic evaluation, nearly all should be cleared for return to modified work.
Three particular interventions have been shown to consistently decrease the duration of time lost per work-related injury by as much as 45 percent:
- Temporarily modified duties that match an individual’s clinically and functionally assessed physical capacity.
- Sympathetic communication with the injured employee.
- Non-adversarial handling of workers’ compensation claims.
There are certain conditions, including severe intractable pain, that preclude some employees from working, even with accommodations. However, work absence is not medically necessary in the vast majority of cases.
Experience and injury incident data show that most employees with relatively minor injuries are willing to try guided self-care when a trusted source educates them about the nature of their injury and anticipated path of recovery. Developing an optimal strategy for protecting a patient from harm caused by overtreatment, including the use of opioid medications for pain relief, will help prevent the first prescription from ever being issued.
In 15 years using an injury management process that shifts responsibility for clinical decision-making from employers to trained medical professionals who educate employees about their condition, our company has not recorded any adverse customer experiences or been the subject of a malpractice claim. With options ranging from a hospital emergency room, to a local clinic or medical specialist, to a telehealth encounter in the field, there is never a time when an employee’s health is at risk or choice is disallowed.
Simple guidance from the outset reduces the likelihood of unnecessary complexity. Regardless of the path a work-related injury case may take, the outlook is always brighter when employees feel empowered.
About the Author: Peter P. Greaney, M.D., is the president, CEO and medical director of WorkCare Inc., a national, physician-directed occupational health services company based in Anaheim, California. Greaney is board-certified in occupational medicine and a specialist in toxicology. He serves as an adviser and consulting corporate medical director in industry sectors including utilities, oil and gas, major wholesale, manufacturing and health care. Greaney travels widely and speaks frequently at industry conferences. Under his leadership, WorkCare annually protects and promotes the health of more than 1 million employees at client companies in the U.S. and abroad.
Did You Know?
The U.S. Agency for Healthcare Research and Quality Guidelines Panel completed an evidence-based review of studies and developed guidance for the management of low back pain. The panel found significant evidence that overtreatment in the acute phase of low back pain can increase sickness behavior.
This occurs partly through deconditioning of body muscles through excessive rest, and partly through labeling and attention effects that may make some people overreact to their pain. About nine in 10 adults will experience back pain at some point in their lives. When it occurs, 50 percent of all low back pain will resolve in one week and 90 percent will resolve within three to 12 weeks without any treatment, studies show.