ACOEM lists 8 ideas for reforming workers' comp

One of the best improvements to the workers' compensation system would be to reduce injuries by establishing greater linkages between injury and illness care and prevention programs, according to a list of potential improvements released recently by the American College of Occupational and Environmental Medicine (ACOEM) in Arlington Heights, IL.

ACOEM also recommends changes in specific regulatory and procedural areas which have made recovery from injuries unnecessarily complicated in the workers' compensation system. These are the eight ways that ACOEM says the workers' compensation system can be improved:

1. View workplace injuries and illnesses as evidence of prevention failure, and use them to target safety and enforcement programs.

Information about preventable injuries and illnesses should be analyzed for each worksite and used to direct employers' workplace health and safety programs, insurers and payers loss control consultations, and government compliance inspections.

2. Require active linkages between injury and illness care services, prevention strategies, and disability reduction programs.

Organizations set up to provide managed health care for workers' compensation should show connections actively linking injury and illness care, prevention, and disability management. For example, patients with injuries requiring more than a few days away from work should receive disability management. Patients with sentinel conditions which may indicate workplace hazards such as toxic exposures or multiple cases of repetitive strain injury should trigger evaluation of the workplace by health and safety professionals.

3. Make sure job-related health decisions are made by health care professionals with appropriate training and expertise.

Occupational medicine expertise should be required of either treating or consulting physicians when the illness or injury is unusual or rare outside the workplace, such as toxic chemical exposures or certain repetitive strain injuries; involves significant questions about safety or temporary or permanent fitness for work; or is the subject of medical uncertainty or dispute as to work-relatedness.

4. Expect active participation by both employers and injured workers.

Employers must inform their employees about their mutual rights, roles, and responsibilities in the workers' compensation system - preferably both at the time of hire and immediately post-injury. Employees should be obligated to mitigate their losses following work-related injury or illness by cooperating fully with reasonable medical therapy and seeking medically appropriate temporary transitional work.

5. Begin management of job and life disruption as soon as disability begins.

The impact of work-related injury and illness on job and life should be actively managed from the outset, even while medical care is ongoing. Employers should be strongly rewarded for providing both temporary transitional duty and permanent modified duty, both of which have been documented to speed recovery and prevent unnecessary disability.

6. Use evaluation and ratings systems based on objective, standardized methods as the basis for awards for both physical impairment and vocational disability.

In order to reduce disputes and variability of results, physicians should be required to use standardized technique in physical impairment evaluations, applying methodology adopted by widely respected national health professional organizations.

Since impairment ratings alone are often unfair when used as the sole basis for determining awards, a similar objective approach should be adopted for evaluating resultant vocational disability. ACOEM recommends that persons with minor, functionally insignificant physical impairments not receive awards in order to save resources for those with major vocational disadvantages.

7. Encourage workers' compensation managed care organizations to innovate; when provider choice is limited, require proof of quality.

Managed care organizations should be encouraged and given the flexibility to innovate as long as they demonstrate a commitment to collect, track, and report indicators of performance in quality and service to appropriate regulatory authorities. Quality accreditation of managed care workers' compensation services by national organizations with health care expertise is recommended to protect employees.

When injured employees are not free to seek care from whomever they choose, employers or managed care organizations should be obligated to demonstrate that providers they select meet commonly accepted medical quality and customer service standards and that the providers impartially attend to the legitimate needs of both patients and employers.

8. Demand better and more standardized data, and use them to guide medical care, to direct reforms, and to inform purchasers.

Expand standard data sets. Traditional claims databases are inadequate to support quality improvement in workers' compensation health care and outcomes. Regulators, payers, employers, and service providers should contribute to a standard set of medical, vocational, and financial data for every ill or injured worker, preferably in electronic form. These new data will provide detail now unavailable for use in improving the system.

Kreuter MW, Scharff DP, Brennan LK, et al. Physician recommendations for diet and physical activity. Preventive Medicine 1997; 26:825-833.

Doctors are more likely to base recommendations on diet and physical activity on the patient's appearance rather than more objective measures of the patient's actual lifestyle and needs, according to this research from St. Louis University.

The researchers followed 915 adult patients and 27 physicians from four community-based family medicine clinics in southeastern Missouri. Patients completed a self-administered behavioral and health questionnaire while waiting to see their doctors. That information then was compared to the advice given the patients by the doctors.

Are physicians ignoring lifestyle factors?

The comparison revealed that a high body mass index was the strongest predictor of receiving advice to increase physical activity, and a high cholesterol level was the strongest predictor of receiving advice to eat less fat. Patients were more likely to be advised to eat less fat if they had elevated cholesterol or a body mass index greater than 27. But interestingly, the actual content of the patient's diet and level of physical activity had no association with the likelihood of receiving that advice.

Doctors may be missing the needs of many patients by concentrating on the obvious indicators of a poor diet and lifestyle, the researchers say. It is not that the doctors should avoid giving that advice to those who are obviously obese and sedentary, but rather, they also should be giving that same advice to many other patients.

"In this study, almost one in five patients (18.5%) ate a diet high in fat or engaged in insufficient physical activity but had no other indicators of compromised health. Only 22% of patients with this profile received physician advice to make behavioral changes," the researchers write. "On a population basis, this represents a substantial unmet need - 14.4% of the known sample, 11% to 22% of all patients, in this study."