Thursday, November 30, 2017

Voc Rehab, Ability, and Methodology (6)

People are talking about workers' compensation, perhaps more today than ever. This is the Sixth in an 11-post series (links to the first five are at the end of this post), that attempts to overview various perspectives heard from system observers and participants. The point is that discussion is good, and if this series generates debate and interaction, all the better.

Vocational rehabilitation 

The various workers’ compensation systems have imposed requirements for provision of rehabilitation following injury and illness. In keeping with the underlying original theme of workers’ compensation, returning the employee to function and gainful employment, rehabilitation has been employed in instances where resulting “impairment” or “disability” precludes an injured worker from returning to her or his former work following the injury or illness. Vocational rehabilitation can take various forms, including classroom training, hands-on training and on-the-job training. 

Some perceive that vocational rehabilitation has represented a cost to the various systems, but without a consistent and appropriate return on investment. They lament the volume of resource that has been required in pursuit of re-employment. They perceive rehabilitation as too dependent upon individual workers' motivation, and describe examples of significant investment in such training, without a resulting successful return-to-work. In such examples, the ultimate outcome is a lifetime entitlement to indemnity benefits (permanent total disability), despite the investment of significant resources in the education and training process. 

There are those that perceive this as a natural consequence of trying to the best for the worker, an effort and investment that is worthy but not always successful. Others perceive this as a predictable outcome that they see driven by misaligned system incentives which values disability and dysfunction. They contend that system service providers profit from disability and so encourage it. 

Ability versus disability 

Expectations and motivations may be affected by characterizations and language. The workers’ compensation systems are challenged by a variety of concerns and complaints, as discussed throughout these posts. Some perceive language choices are contributing to misperceptions and confusion both about and within systems. Others are more critical, concluding that language contributes to behavior and thus overall system performance.

A poignant example of this posited phenomenon is “disability.” Various systems define indemnity benefits with this word. Benefits are for "temporary disability" or "permanent disability." Critics say that the word “disability” focuses attention upon what a person cannot do. With the focus on the “inability,” it is perhaps too easy to lose sight of the converse, i.e. “ability,” or what the person can do. There is similar concern about the use of “impairment,” and the connotation such a description may have for most people. 

This labelling is furthered by the systems; use of durational adjectives (“temporary” and “permanent”). When an injured worker is informed that she or he is “permanently disabled,” the perception of inability may override and undermine any effort to return to gainful activity. The label may prejudice the expectation and therefore the outcome. 

Some members have started to subscribe to the notion that the industry name itself leads to an improper focus in the claim process. That line of thought is driven by confusion surrounding the workers’ compensation system, and the lack of understanding of those entering it through an unanticipated injury. There has been suggestion in the industry that “Workers’ Recovery” would set a better tone for injured workers, allowing them to focus on return to function and gainful contribution to society. 

There is some consensus that the various systems should consider and try to appreciate the potential of words in creating expectations and beliefs. Jurisdictional systems should contemplate the use of language that is focused upon encouragement and enabling, rather than discouragement and disabling. 

Methodology of claims handling

There are many processes engaged across the workers’ compensation marketplace, and required to comply with various and sometimes conflicting regulatory frameworks. There are a seemingly endless assortment of tasks required to properly process, manage, and document the sequela of a work accident or illness. Just as there is a vast spectrum of tasks and responsibilities, there is a perception that there are just as many alternative models for fulfilling those responsibilities. Different payers engage different processes in fulfilling obligations and complying with regulations. 

Some perceive that the regulatory complexity drive reporting and documentation requirements that elude the expertise of payers such as insurance carriers and servicing agents. It is not that these entities cannot master a particular task or compliance requirement. The point is that it is perhaps impractical for a carrier or servicing agent to master each and every compliance requirement in each and every jurisdiction. Thus, towards a goal of specialization and simplification, a carrier might choose to acquire all expertise in-house, to acquire some and outsource other, or to outsource all. Some perceive that this drives a cycle of "cottage industries" starting, developing, consolidating.

There are at least 50 state programs and more in the various territories and the District of Columbia. Therefore, one payer might need familiarity with multiple jurisdictional requirements. Additionally, various systems may have reporting or compliance requirements under the auspices of multiple state agencies, including regulation of workers’ compensation, insurance, adjusting, medicine, legal professionals and more. 

Additionally, the interconnection between workers' compensation and medical practice requires compliance and regulatory expertise regarding the federal government, yet another jurisdiction. Thus, there are a variety of subjects, and a multitude of jurisdictions and the potential permutations are vast. A payer might limit its exposure to regulatory violation or misstep by limiting the jurisdictions in which it does business, or by outsourcing certain compliance or reporting tasks to entities which specialize in certain aspects of requirements. 

These complexities create cost for the payers. Some argue that decreases in compliance and regulatory costs would allow more and better focus on the fundamental goals of workers’ compensation, the care and treatment of injured workers. Some suggest that more consistency between the jurisdictions could create synergy, obviate some of the perceived need for specialized vendor involvement, and streamline the regulatory process. Others claim that such cost savings for payers would benefit those providers rather than injured workers. 

Other posts in this series:


(2) Benefit adequacy, Regulatory complexity, Delays in treatment even if compensable

(3) System failures, Incentive is different in WC and group health, Systems are persistently adversarial

(4) Staffing and training of the workers’ compensation professions, Permanent partial compensation, Opt out movement

(5) Injured workers beliefs - not informed or uninformed assumption, Treatment protocols, a benefit or a burden, Perceptions and education

(6) Vocational rehabilitation, Ability versus disability, Methodology of claims handling

(7) Medical ignorance, The critical point in a claim, People who are acting inappropriately

(8) Misclassification, Unrealistic expectation of full recovery and youth, Federalization

(9) A new national commission?, Employee participation in the conversation, Occupational disease

(10) Lawyers in the system, Competition between states, Roles and delineation

(11) Single payer, Outliers, Conclusions