1. Balancing Employee Health and Safety with Company Goals Michael Erdil MD, FACOEM Occupational and Environmental Health Network Johnson Occupational Medicine Center

2. Potential Challenges In Workers Compensation n Conflicting goals and multiple parties u Worker u Employer, supervisor u Treating providers (Primary WC and specialty MD/DO, DC, PT/OT, PCP, other) u Insurer / TPA, adjuster, case manager, utilization review u Attorneys

3. Potential Challenges In Workers Compensation n Adversarial relationship among entities n Non evidence based care with suboptimal outcomes and excessive cost n Delayed recovery and associated indemnity and replacement costs n Communication breakdowns and poorly coordinated care and RTW n Lack of effective efforts regarding prevention

4. Costs of Musculoskeletal Disorders n LBP estimate $20-50+ billion annually u 5-10% = 80-90% of costs n Upper extremity MSDs u 25% = 89% total costs n Indirect costs perhaps up to 4x direct cost n Non-monetary considerations n Impact of comorbidities

5. Organizational Commitment to Safety n Establish and communicate goals n Active health and safety committee n Effective reporting of injuries, etc. n Consider injuries, non-acute MSDs, near misses as opportunity for improvement

6. Align Goals and Educate n Timely evaluation and effective treatment n RTW goals n Communication standards n Facilitate payment to workers and health care providers n Track outcomes

7. New Employee Orientation n Lifestyle issues: weight, smoking, etc. n Safety goals and prevention n Understanding timely injury reporting and WC system n How to obtain care n Most conditions respond to conservative care

8. New Employee Orientation n Home exercise and PT / OT n Early imaging not needed in the absence of red flags n Prolonged opioids and side effects, delayed recovery u CDC Risk Mitigation Strategies n Excessive lumbar spine surgery u 2/3 patients with lumbar fusion disabled at 2 years u Opioid dose often increases post-op u Opioids and post-op mortality

9. Death from Drug Overdoses

10. * Per 100,000 population. † Coded according to the International Classification of Diseases, Ninth Revision, during 1979--1998 and according to the Tenth Revision during 1999--2004. Additional information regarding classification of deaths according to intent and mechanism is available at http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_10.pdf.http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_10.pdf Age-Adjusted Death Rates* for Leading Causes of Injury Death, † by Year - United States, 1979--2004

11. Opioid Deaths vs Daily Dose n Bonhert JAMA 2011

12. New Employee Orientation n Early RTW at modified duty often not harmful and can improve outcomes u Support from ACOEM, ODG, AAOS, AMA, other

13. Low Back Pain at Work - Principal Recommendations n Carter JT, Birrell LN (Editors) 2000. n “Epidemiological and clinical follow-up studies show that early return to work (or continuing to work) with some persisting symptoms does not increase the risk of 're-injury' but actually reduces recurrences and sickness absence over the following year”

14. Meet With Primary Occupational Health Providers n Need for facilitated initial medical evaluation and follow-up n Clear description of treatment plan and appts u Evidence based medicine guides n Describe work capabilities and estimated full duty RTW target u Evidence based LOD targets n Real time communications n Outcomes

15. Employer Expectations for WC Providers n Rousmaniere 1999 J. Work Comp n Ability to define and document work restrictions n Responsiveness n Appropriateness of referrals to specialists n Timeliness of reports from initial care providers n Quality of clinicians

16. Patient Satisfaction and Provider Communication re: LBP n Shaw et al 2005, Dasinger et al 2001 n n Took problem seriously n n Explained condition clearly n n Tried to understand my job n n Advised ways to prevent re-injury n n Discussed my behavior that might influence recovery n n Discussed my readiness for RTW

17. Provider Factors and Increased Length of Disability n Not knowing modified duty available n Provider unwillingness to cooperate with case management and RTW n PCP concerns re: offending patients n Difference of opinion on RTW among providers

18. Worker Factors and Increased Length of Disability n Short job tenure n Lower job satisfaction n Poor expectation on RTW n Coping issues n High pain levels and fear avoidance n Reporting delays

19. Worker Factors and Increased Duration of Disability n Perceived lack of coworker support n Perceived lack of supervisor understanding and assistance on RTW

20. Work Factors and Increased Duration of Disability n No modified duty n No RTW coordinator n Higher physical demand levels n Supervisor support

21. Employer Opportunities n Train supervisors on responding to injured workers u Inform workers of efforts to improve safety u Improve opportunity for worker injury reporting u Express concern for reported symptoms u Minimize blame and stigma

22. Employer Opportunities n Provide information to worker on obtaining treatment n Develop temporary alternative work options u May require communication with other departments n Involve worker in problem solving to address barriers to RTW at same job, modified job, other jobs n Overcoming fear of RTW and reinjury with graded RTW and monitoring

23. Employer Opportunities n Monitor worker during RTW transition n Coping issues n Dealing with heavy work demands with alternative solutions n Provider communication, ergonomic evaluations, assistance with PT / OT if questions regarding work demands and worker abilities

24. Worker with Prolonged LOD n Discuss RTW abilities/goals with worker, supervisor, provider, insurer n Encourage active worker participation n Return to own vs. any job n Use of FCE and IME n Barriers of collective bargaining agreements, employer policies