Wednesday, August 24, 2011

The 5 Stages of Work Comp Death

Dr. David Dietz, VP, National Medical Director for Liberty Mutual Group, asked the audience at the 66th Annual FWCI Workers' Compensation conference in Orlando, FL yesterday how many would choose workers' compensation for their health care over their general health insurance.

No hands went up.


That is a sad statement on the perceived value of workers' compensation medical - and it is a statement that is recognized by the people that are responsible for making the system work.

How can we, as an industry, justify our expense, our existence, when even those of us who are intimately familiar with, and answerable for the operation of workers' compensation?

Dr. Dietz hit the nail on the head - what is the value that we are delivering as an industry?

How do you define value? Is it providing services that are proven through scientific methodology (i.e. repeatable processes) to simultaneously provide medical services, indemnity AND increase injured worker return to work statistics?

Is it delivering health care and a positive experience for both the employee AND the employer so that they can see the big picture and work towards a mutually beneficial resolution of a bad situation (i.e. a work injury)?

One thing is certain - the evolution of workers' compensation has transcended its intended goals to a complex system that fails to deliver value to either the employer or employee. I believe that Dietz again hit the nail on the head by noting in his speech that workers' compensation systems have through the years become a perverse set of incentives that promote the wrong outcomes.

What are these wrong outcomes? Surgery without scientifically established clinical findings that end up creating greater disability for the injured worker than doing nothing at all; rewarding disability so well that for many (and not necessarily injured workers by the way) find it more financially beneficial to ensure greater levels of disability; system checks and balances (such as utilization review or medical fee schedules) that had the good intention of keeping costs in check but which unwittingly shift treatment choices to more destructive and costly alternatives.

How do we get out of this? With apologies to Elizabeth Kubler-Ross, whose award winning 1969 book, On Death and Dying, gave us her brilliant 5 stages of dying, Dr. Dietz gave attendees a path towards some sanity, in order:

  1. Denial - we in workers' compensation have LOTS of data about our system and we use some of that data to make decisions, but is it the right data?
  2. Anger - when we really look at the data and analyze it, we believe that our data stinks and this makes us angry.
  3. Bargaining - after coming to terms with the fact that our data stinks, we look at it from a different light, in a different way, and come to an understanding that the data might be okay but that it doesn't really apply to "me" (i.e. us as individual participants in the industry).
  4. Depression - okay, maybe this data which we have determined isn't that bad after all does in fact apply to "me".
  5. Acceptance - yes, death is inevitable and so is the realization that we can not only accept that the data applies to "me" but that it is measurable and that all of us can work together to make the system better.
Perhaps this is a bit of a simplistic view of the troubles we face as an industry, but it is a start. We are in the first stage of the five stages - denial. Sure, we all complain that certain aspects of workers' compensation doesn't work, but we are all in denial that the systems don't work as a whole. 

We all complain of individual elements, and we always seek to correct the elements that we believe require fixing, without looking at the "big picture" to really appreciate and understand how individual elemental changes can affect the overall system - where are the holes, what are the perverse incentives, how will changes affect other elements, just what is the human behavioral components that will be triggered by any particular system change?

The answer to these questions is the mind set of those of us in the workers' compensation delivery system, whether you are a physician, an attorney, a claims examiner, a broker/agent, an executive, risk manager, case manager - whatever. The answer is VALUE. 

Stop focusing on COSTS. What is the value that we deliver to the employee and employer?

Value, Dr. Dietz correctly notes, is quality divided by costs. Quality is the health outcome of the injured worker.

We have the data, but we don't use it effectively and when we do use it we measure the wrong components. Understanding the value proposition requires states to invest in analyzing the data and understanding the outcomes. Only then can one deliver value.

Group health has its own problems which the Federal government, and some state governments, seek to improve. But ask yourself - would you rather get medical treatment through workers' compensation or your group care?

My bet is that you prefer the latter. 

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