Clinicians feel the pressure as absentee costs rise
Clinicians feel the pressure as absentee costs rise
Companies tighten up on sick leave, disability care
In the health care arena, where providers traditionally have called the shots, another stakeholder’s voice grows louder each year. More employers are actively managing the amount of time their employees are off the job from workplace injuries or other health problems. Companies continue to track the cost of care as in the past — but with an added twist. Now they measure performance when employees return. All too often, this produces prickly relationships between corporations and clinicians.
Driving this corporate activism are the direct and indirect costs of absenteeism. They’re rising on both fronts, according to the fourth annual (1999/2000) Staying@Work survey. Staying@Work is conducted by the Washington Business Group on Health (WBGH), a nonprofit organization in Washington, DC, devoted to analyzing health policy and work site issues from the large employer’s perspective; and Watson Wyatt Worldwide, a financial management consulting firm based in Bethesda, MD.
The latest findings reveal (compared to the previous survey):
• Total average costs for health and injury-related absence: 6.3% of payroll (vs. 6.1%).
• Indirect costs, including overtime, replacement employees, and workstation/job accommodations: 8% of payroll (vs. 6.7%).
"In the tight staffing and full-employment climate, companies want to avoid hiring temporary workers who are apt to make mistakes. And they want to avoid postponing projects until key employees are able to come back to work," says Jennifer Christian, MD, president and chief medical officer of Webility.md of Wayland, MA. She and other experts who spoke with QI/TQM see opportunities for providers to be proactive, improving their professional expertise as well as organizational processes in enabling people to get back to work. The fix will take old-fashioned communication at the local level and, perhaps, resourceful use of Internet technology. Some suggest that quality specialists within health care systems could start the initiatives.
Employers rely on the attending physician to determine how long an absence should be and to restore a worker’s ability to perform the job after the recovery period.
"While employers track the numbers, they report difficulty in managing provider relationships," states Bruce Flynn, WBGH’s disability management director. One strategy that has gained some popularity is for employers to talk with physicians about their expectations for return to work. "The other side of that is that physicians often have a more difficult time managing disability than managing the actual symptoms of illness."
A WBGH survey confirms that physicians are relatively uncomfortable with disability issues. They lack training. They feel underpaid for the extra work and contend that somebody else should be doing it. At stake for employers are the costs of care as well as wages paid to sick or injured workers and possibly to a replacement. For most hospitals, the chief concern is the cost of care, Christian explains. However, that may change as employers ask new questions about the value of care their health providers deliver. They are beginning to question whether their employees are healthy enough to be at work and do their jobs. "That’s the direction the market is moving," she says.
Another facet of this attitude shift is that employers are lumping the management of all health-related time off into one function instead of separately handling workers’ compensation, sick leave, and disability leave in different organizational "stove pipes." A company representative could make unprecedented inquiries about the course of treatment and the expected return-to-work date — whatever the injury or wherever it occurred. It would not matter if the injury was a concussion from a bicycling accident or a broken wrist suffered on a loading dock.
If that’s not enough, the employees stir the pot with personal agendas. Workers who suffer nonwork-related injuries are motivated to return to work so they won’t burn up too many sick days or push their insurance copayments too high. Those injured on the job, however, "get paid to stay at home, so we sometimes see a blunting of their incentive to comply with treatment requirements to expedite their return to work," Christian explains.
As employers become more aware of the connection between health and productivity, they want providers to join them in mitigating and preventing disability. Liza Greenberg, vice president of research at the American Accreditation HealthCare Commission/URAC in Washington, DC, describes an additional contributor to employer urgency to reduce lost time, especially on workers’ compensation cases. "Statistics show that the longer people are out, the less likely they are to come back to work," Greenberg says. "It used to be that employers imposed a 100%-fit criteria. Could the laborer push a wheelbarrow and lift a load of cement? But now, companies use modified-duty criteria. They want workers to stay fit and keep the work mentality."
Providers, on the other hand, are trained and paid to do acute treatment. "They have no tools in their hands and receive no rewards for doing the job of helping people recover from disabilities and get back to work," Christian says. "Historically, it’s been a courtesy to give a note to the employer and disability carrier on the extent of the worker’s injury and the expected return-to-work date." It’s a low-priority task.
Employers have big money at take regarding doctors’ decisions, however. Some companies have even held training sessions for providers with the hope of achieving better compliance with paperwork completion and timely reporting. "But often physicians won’t come, and the information employers get back from them is still meager, sloppy, and late," Christian adds.
What’s the incentive for a clinician already working 12-hour days? "Neither employers nor insurers have traditionally paid providers for the paperwork involved in disability cases," Christian says. "But it may make more sense for an employer to pay $35 for on-time documentation because a late report would mean an employee is going to be out of work an extra five days at $100 a day. On the other hand, it’s silly for physicians to expect to get an employer’s business when they turn in late and incomplete reports."
The right training and incentives could quell the adversarial quality of relationships surrounding disability. "The problem is that the medical community is not perceived to be responsive to the duration of disability," says Peter Rousmaniere, of Rousmaniere Designs in Little Rock, AR, a consultant to insurers and employers on disability prevention and management in the work force.
But in truth, they need training on return-to-work issues, he observes. "Clinicians have the right to be compensated for the extra work involved in helping people who are disabled get back to work."
As Flynn sees it, "those efforts are probably best conducted locally rather than through any national grand plan. Where we’ve seen the most successful partnerships between employers and hospitals is on a regional basis where the interests are mutual. They sit down and talk about what it means to manage disability issues."
Greenberg suggests that quality or outcomes management specialists within health care systems could precipitate the kind of talks Flynn describes. She notes that much of the work will take place in the system’s outpatient clinics since the vast majority of cases are treated there.
A natural contact point with self-insured employers is the company case managers who coordinate care of employees on sick leave. In many instances, they coordinate treatment of workers’ compensation recipients as well.
Christian says that the tone of conversations between health care systems and corporations will be more constructive if both sides couch their discussions in terms of "Why I need this," instead of "I want this." Too often, each side is more interested in talking than in listening. When people focus on helping each other get their needs met, they have a baseline for collaboration and problem solving, she adds.
Corporate case managers will look for local providers willing to join employers in efficiently managing disability cases, Greenberg says. She has a few suggestions for how QI specialists can help their institutions become centers of excellence in restoring worker productivity:
- Repair or strengthen communications. "Quality managers could work with the appropriate staff in their institutions to contact employers, learn the criteria for a modified back-to-work schedule, and make appropriate care plans," she says.
- Help providers understand that medical costs are only one piece of the employer’s problem. The other is lost wages. So even resource-intensive services from physical or occupational therapies could be cost-effective from the employer’s point of view.
- Look for value-added service opportunities such as assessments of workers’ recovery in light of job requirements. This might be especially attractive for employers who are not staffed to conduct assessments in-house.
Christian suggests that Internet technology could hold solutions to communication and paperwork problems. Her firm, Webility.md, is building a system to connect doctors with employers and disability/workers’ compensation insurers on the Internet to communicate about patients’ ability to work. The purpose is to reduce medically unnecessary absences.
Webility will streamline communications by creating an electronic in-box that consolidates all requests for disability reports from multiple employers and insurers. It will use scripted dialogue to standardize the questions doctors are asked and to provide clinicians with an easy way to answer through multiple-choice questions and check boxes.
She explains that employers or insurers will be able to post their forms on a secure Web site along with instructions for physicians to write and file reports electronically. Employers also can post full and modified return-to-work criteria as well as the e-mail address and phone number of the company’s contact person.
"The employer will be virtually present in the exam room, expediting the physician’s reporting burden, and most physicians will love to be rid of the paperwork," Christian adds.
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