CASE MANAGEMENT

Work-related musculoskeletal disorders represent an increasing source of worker disability and employer compensation cost. Active case management methods are emerging as a means to improve quality of care, maintain the individual's vocational wellness, and minimize the employer's direct costs of injury and illness. These services are offered in various ways, such as nurse case management, expert systems, specially organized rehabilitation units, or even enhanced claims management. In addition to these methods, outcome assessment research is just beginning to define cost effective treatment plans and workplace interventions.

The Americans with Disabilities Act establishes statutory requirements that have mandated an escalated effort to accommodate impaired individuals in the workplace. The process of "management" of repetitive trauma disorders in employment discrimination claims against an employer will be explored. The potential liability of health care providers and others who undertake the responsibility for managing and treating these types of injuries in the workplace will also be discussed.

This session will focus on those modes of case management for which either the medical literature, or substantial field experience, suggest improved outcome and cost savings. The time of application of case management will be shown to be critical to disability prevention as well. Further needs for scientific research and better policy definition will then be explored.

Session Arrangers

Patricia K. Bertsche, MPH, RN, COHN-S, Manager, Ohio State Univ. Inst. for Ergonomics
Brian Peacock, PhD, Ergonomics Advisor, General Motors Technical Center

Presenters

Nancy L. Schott, Esq., Counsel-General Litigation, Ford Motor Company
Case Management Under the Americans With Disabilities Act

Bruce J. Kaye, Esq., Leventhal and Bogue, P.C.
Representing a Worker on Claims of Employment Discrimination Under the Americans With Disabilities Act:
A Lawyer's View of Case Management

Gary M. Franklin, MD, MPH, Res. Med. Dir., WA State Department of Labor & Industries
Case Management, Disability Prevention, and Outcomes Research

Robin S. Baver, MD, MPH, Medical Director, Springfield Opns., Navistar International Corp.
Outcome Assessment of Occupational Carpal Tunnel Syndrome in a Cohort of Truck Assembly Workers

Discussants

Bradley Evanoff, MD, MPH, Head, Occup. & Env. Med., Washington Univ. in St. Louis
Kathleen P. Buckheit, MPH, RN, COHN-S, Ergo. Health Spec., NC Ergonom. Resource Center
Kenneth Mitchell, PhD, Senior Vice President, Acordia Workers' Compensation Services
Dan Wolens, MD, MPH, President, Kentuckiana Occupational Health Associates

Mr. DAVID FELINSKI, AAMA

Good afternoon everyone, and welcome back from lunch. It's my pleasure to introduce to you this afternoon's Session Moderator for the session on Case Management. Brian Peacock qualified as a physiotherapist and worked in that profession for a number of years before returning to Loughburrough University to study ergonomics and cybernetics. He later obtained his Ph.D. in Engineering Production at Birmingham University. He is a fellow of the Ergonomics Society, a certified professional ergonomist, and a licensed professional engineer. Brian's academic career included appointments at Birmingham University, the University of Hong Kong, Monash University, Dalhousie University and the University of Oklahoma. He joined General Motors as a manager of the Advanced Vehicle Engineering Product Human Factors Group followed by an appointment as manager of the Access Car Program. Since 1990, he has been manager of the Corporate Manufacturing Ergonomics Laboratory with additional responsibilities for interfacing with industrial, government, and academic organizations on ergonomic matters. Brian is also the chair of AAMA Ergonomics Task Group. Brian has published many papers, as well as books, on statistical distributions in automotive ergonomics. He is the Director of the Board of Certification of Professional Ergonomists, a past director of the IIE Industrial Ergonomics Division and twice chair of the Industrial Ergonomics Technical Group of the HFES. Dr. Peacock, the session is yours.

Dr. BRIAN PEACOCK, General Motors Corporation

Thank you very much, Dave, for that introduction. I'm going to start with only a couple of minutes introduction before I introduce the speakers. I'm going to discuss some issues associated with the BCPE and the issue of competence and policy in ergonomics. But first of all, this morning we were talking about genetics and individual differences and some of the policy issues there. I'm going to refer you to the birth of my second child which I attended some 23 years ago. And given that we've got some doctors and lawyers here, she appeared with the cord around her neck and she came out a remarkable color of blue. The medical student who was in charge at the time said, I'm sorry, I must go and get a doctor. Now that wasn't very comforting to me as the father. We're going to discuss later the issues of competence. Now 22 years later, my daughter emerged from the University of California-Berkeley, and she is now a remarkable color of pink. And that is the issue here. The issue of politics and policy and ergonomics. Now ergonomics is neutral. We can use Don Chaffin's model or we can use Bill Marras' model to hurt people if we choose to do so. Or we can apply those models to stop people from getting hurt. So the issue of ergonomics must remain politically neutral. The discussion today is about policy, which is somewhat independent of the science and technology of ergonomics. I think the profession of ergonomics has come of age because most of the people on the panels here are doctors and lawyers. That means we've attracted a lot of attention, which is very good I think. Now on the issue of competence, we now have a Board of Certification of Professional Ergonomists. There are currently 700 or 800 certified professional ergonomists around this country which are trying to raise the standard of competence of this profession. And I guess I've got a few of them here. Could you raise your hand if you are a CPE: Yes, we have a handful here. One thing that the Board is arguing over is developing a Certified Ergonomics Technologist level of certification which will address the level of competence in this profession because the standard of competence is very important in the use of the various tools such as we discussed this morning. I hope we've got you warmed up and now you want to hear from the panel.

When a worker is injured the focus of a case management team is well defined. The objectives are return to work and the prevention of long term disability. But we all know that there are many and various motivations, strategies and pitfalls in this process of return to work. Today we have a panel of speakers and discussants who are very knowledgeable and experienced in all aspects of this process. This session will be co-chaired with Pat Bertsche from Ohio State University and myself, Brian Peacock from General Motors. I will chair the presentation sessions and do my best to keep the enthusiasm of these speakers down to 20 minutes. If time permits we will allow one or two questions before the break. After the break, Pat will take over as the session chair and encourage the discussants to limit themselves to 7 minutes of presentations. And following these presentations we will accept questions from the floor. The order of presentations will be as listed in the program.

The first speaker will be Nancy Schott. Nancy Schott is Counsel-General for Litigation, with the Office of the Counsel, General Counsel, Ford Motor Company. She has been with Ford since obtaining her JD degree from Suffolk University School of Law in Boston, Massachusetts in 1980. Since 1983, Ms. Schott has specialized in employment law, including civil rights, labor relations and union matters, advice and counseling on issues affecting employers and employees and litigation management. She is a frequent speaker on the Americans with Disabilities Act, and other employment legislation. I welcome Nancy Schott.

Dr. Brian Peacock, GM: Thank you, Nancy. Our next speaker is Bruce Kaye. Bruce practices law in Denver and is a shareholder with the firm of Leventhal and Bogue. He graduated from the University of Denver and received his law degree from the University of Denver College of Law. He practices in the area of plaintiff's personal injury law, insurance law including bad faith and employment law. He regularly litigates cases involving no-fault benefits and recently tried a case involving a managed care provider. Welcome.

Dr. Brian Peacock, GM

Thank you very much, Gary. I'm reminded of a paper I just reviewed for the Ergonomics Journal. It was about the Internet and the use of your television, your home television. Instead of using a keyboard you're going to use pointing devices. The problem is tremor and how it is affected by the aging process. Clearly a good measure of the aging process is the amount of tremor you have with these pointing devices. I suspect in the next five years you're all going to suffer from the problem of aging and tremor when you're pointing to use your television as the Internet interface. Our final speaker, is Robin Baver. Dr. Baver is presently the Medical Director for the Springfield Operations of Navistar International. She received the Bachelor of Engineering degree in chemical engineering from the University of Dayton, Doctor of Medicine from Vanderbilt University School of Medicine, and the Master of Public Health from the University of Michigan School of Public Health. Dr. Baver completed internal medicine training at the Jewish Hospital of Cincinnati, and the academic and practicum portions of her occupational medicine residency at the University of Michigan and the University of Cincinnati, respectively. Welcome Dr. Baver.

Dr. Brian Peacock, GM: Thank you very much. We're going to continue straight on with the discussions. Pat Bertsche will do that.

Ms. PATRICIA BERTSCHE, Ohio State University: Well, my personal thanks to all of our presenters for doing such a fine job. I very much appreciate you making the trip and coming and presenting some very informative information to us. I'm pleased to have the opportunity to introduce our discussants to the group here. Dr. Bradley Evanoff is an M.D., M.P.H., the Head of the Section of Occupational and Environmental Medicine at Washington University in St. Louis. And he'll be the first person that will comment on what has been presented. Brad.

Dr. BRADLEY EVANOFF, Washington University, St. Louis

I wanted to make a short comment that's relevant to what we've seen over the last 3 days and then make a couple very brief comments on the four excellent presentations we've just heard. There's a huge body of evidence that links high exposure jobs to high incidence or prevalence of musculoskeletal disorders in the workplace. And it shows that reduction of exposures reduces musculoskeletal disorders in the workplace. There's also a body of evidence that shows that there's no relationship between exposure and musculoskeletal disorders but it's a much smaller body of evidence and I think not as carefully discussed. What we've seen, I think, over the last few days is the conclusion that can be drawn from this body of evidence which is "that's life." These are aches and pains and nothing that's really work-related. Unfortunately I think the conclusion that we've seen from the discussions of the larger body of research is a focus on what we still don't know and what future research needs to be done. I think researchers want to present their own little small bits of this much larger picture and then talk about what needs to be done with their bit. We need to look at what we still have to learn. I'm concerned that both of these trends are leading us to confusion about what really is known and to the wrong conclusion, which is that we should do nothing pending further study. Dr. Marras and Dr. Chaffin to some extent addressed that this morning. What we haven't seen is sort of an overview of the very large body of literature that we do know. And all of the reasons that we have for moving forward with trying to prevent work-related musculoskeletal disorders. So, that was the editorializing. Now I can get down to my real job which is commenting on the four talks that we've seen.

I was happy to hear Ms. Schott's emphasis on making changes to accommodate workers. In her printed notes, she noted that employers under the law, are not required to spend, "enormous sums to bring about a trivial improvement in life or working conditions" which is appropriate. It's important to point out that at this conference and the preceding Chicago conference, we've seen many examples of where trivial sums can bring about enormous improvements in working conditions. I think national estimates of cost benefits are going to be endlessly contentious. It's very difficult, I think, to make a cost model that everyone can agree with. But what we can do instead is to look at the many examples of local plants or corporations who have implemented ergonomic programs and have seen cost savings in real dollars rather than estimated dollars. Dr. Franklin made a number of important points about case management. Especially important is the change in paradigm from disability management to one of disability prevention, including early return to functional status and the need to bring people back as productive members of the work force as early as possible. He showed us that there's many flavors of case management and that integrated programs are probably the best because of the facilitated communications. Our own experience in St. Louis is that an ergonomist as an integrated member of the health care team is important because I can order an ergonomic evaluation of the workplace just as easily as I can order physical therapy. By sending someone out to the workplace to make suggested changes, we feel that we can reduce medical treatment and reduce physical therapy visits. In order to do early return to work, employers and employees may need to be flexible and creative to arrive at appropriate modifications that allow workers to work safely, and reduce the amount of time lost that they have.

Mr. Kaye made an excellent point that health care workers, in order to do our job properly, must have a thorough understanding of the patient's job duties and the working environment. I think as employers or as representatives of labor, you can really help your employees by giving the physician and other health care workers that information. In instances where it's not possible for the physician to come out to the plant, videotapes and very descriptive printed materials about the job are enormously helpful in deciding when and if someone can return to work. And finally, Dr. Baver made an excellent point about the need for conservative treatment as opposed to a rush to surgery. Actually I was sitting next to Gary Franklin, he wants to know if some Navistar plants can be moved to Washington State so his numbers can look better. That was supposed to be funny. I think the other important point that Dr. Baver made was the importance of doing long-term follow-up of function following work injuries. I think all too often that both cost models, as well as case management end the first day that the patient is returned to work supposedly fit for full duty. As Dr. Baver's data shows, as well as data from Ontario and the University of Massachusetts, if you follow workers for more than a few months after the return to work, you see that many people have recurrences of disease, have reinjuries. And so the story doesn't end the day they are cleared for full duty, but has to be continued in order to get a more accurate picture of the burden of disability and the need for ongoing prevention and ongoing attention to work tasks that should be paid for patients with work-related musculoskeletal disorders. Thank you.

Ms. Patricia Bertsche, OSU: Thanks, Brad. Our next discussant is Kathleen Buckheit. Kathleen has a Master's of Public Health, is a Registered Nurse and a Certified Occupational Health Nurse specialist. She works as an Ergonomic Health Specialist at the North Carolina Ergonomics Resource Center. Kathy.

Ms. KATHLEEN BUCKHEIT, North Carolina Ergonomics Center

Thank you. I have three boys and I'm accused of having a big mouth. So if it gets too loud or too low, let me know, okay? The four presentations were great. I read the extended abstracts and I was really impressed and happy that I don't have to be an adversary in my comments on them. That makes me uncomfortable to confront people. But they all hit areas that face case managers every day and not just on an occasional basis. As Gary pointed out, case management uses a multi-disciplinary approach. I work with ergonomists that feel that they do case management. Well, when we talked about giving a class on case management they had one idea, I had another. So we take different views. Pat asked me to come talk about the occupational health nurse as a case manager. And I want you to know that that role also is a varying role depending on the empowerment that the company provides, the skills, the education and experience that the nurse has and when we present the conclusions on the data on how effective is case management, I'm always brought to the question of, well what kind of case management are we talking about, and who is that case manager? And I think that was brought out too. We need to look at that. How many people here have occupational health nurses in their companies? How many don't have them on-site but use telephonic case management? Okay. It's a different kind of case management definitely. And one of the reasons is if you're on-site you can actually go see the jobs, do them, feel them, touch them, see the way that employee is doing the job, and come to a better conclusion as to what work accommodations are possible to compliment the work restrictions.

I'd like to just talk a little bit about what Nancy had to say. As an occupational health nurse in the role of case management, you're an employee advocate. You also work for the company, so you're an employee yourself and you're required to provide assistance to the management in making sure that they're doing the right thing. They're providing a healthy and safe environment, and they're keeping within the aspects of regulatory compliance. Now if that doesn't happen then you're not doing your job. But as Nancy pointed out, you've got to know the job, the whole process, the environment before you can apply work accommodations in an appropriate way. You've got to have the employer make the decision as to what the essential and marginal functions of the job are, and that's not always an easy task. Employers might want to think that every single little piece of that job is considered an essential function. Well when you try and apply worker accommodations, it may not be that essentially functional. So it's a little difficult to decide. As long as the employer is able to defend that when it comes to a question, then you're okay. But as we see with some of these case studies they're not always defendable. The occupational nurse as the case manager has to coordinate all the efforts of the team. And the team would include the engineers, and the HR personnel. By the way I used to report to Personnel and now I report to Human Resources. Does anybody know why they changed that? We think that the resources are just as important as the human being. The human being is the most important resource we've got. We're supposed to be protecting our most important resources. The occupational health nurse also ensures that the aspects of ADA are covered like preplacement examinations. How many of you have preplacement examinations in your companies? Do you know what that information is used for? Anybody? Well, hopefully, it's not used to screen out employees to get rid of employees before you develop problems based on whatever you found. Hopefully it's used to assign the appropriate jobs to those people and not discriminate against them. And that's one of the things that is difficult for an occupational health nurse to convince management of. If you've got a problem, that must mean we're going to have a problem develop down the line, and that costs money. Employee participation is starred in a hundred places in any of my notes. If you can bring in the employee and actively engage them in the selection, the development, the evaluation of whatever jobs you're considering to use as a work accommodation, you're going to be farther ahead than if you just call somebody in and say, this is your job, now go do it. Including the rationale in why you're selecting certain jobs or certain tasks is very essential. Very essential. How many times have we told employees to do something and they don't do it? But you explain to them later why you need to do it. It's just like a kid. Another thing is safety behaviors. You have to make sure they're doing it the right way and stay on top of things.

Bruce talked about how employers have problems with having light duty programs, and that's not uncommon. It's also a problem for the occupational health nurse to make sure that whatever those work accommodations and light duty programs are, treat that employee as a human being. I disagree with him a little bit because there are certain jobs that usually have to get done and if that particular employee is placed on that job it might not be to his or her satisfaction but it's a job, it's a task, it's not going to hurt them. Hopefully it's going to promote their recovery and some of those jobs are reasonable to ask them to do. I'm going to charge the occupational health nurses as the case manager to challenge management to address these issues and make sure that they're enforced. Gary talked about the occupational health nurse as one of the case managers in this study which is true. Again, there are differing backgrounds and different expertise that nurse brings. We need to identify that. Robin was good and raised a lot of questions for me in that study as to what the differing variables, as far as the treatment and the attitude and the philosophy of the positions, were. When we bring somebody back to work, we want to make sure that they're on the same wave length. We understand that we provide work accommodations. What are their expectations? What are their goals for the surgical outcome? I'm wondering with so many surgeries performed, did they get them early enough, at the soreness stage where the early interventions could have made a difference and prevented the disease from progressing? Thank you very much.

Ms. Patricia Bertsche, OSU: Thanks Kathy. Our next discussant is Dr. Ken Mitchell. Ken is the Senior Vice President of Accordia Workers' Compensation here in Ohio. I'm pleased to have the opportunity to introduce him.

Dr. KENNETH MITCHELL, Accordia Workers' Compensation

Case management is like nailing Jell-O to the wall. Sounds like it'd be fun to do but just try it. All too often we find that when you go out and talk to an employer, they all do case management. And what we heard today was, from all the presenters, is that case management appears to be something that most everyone tries to do both at a state level and a private level. When one actually goes out and looks at these operations and one takes a look at the data and looks at the process, one finds that there's not much case management going on. What one finds is a lot of movement of paper and information, but with little planning that might be involved. So from that standpoint, we have to take a look at these four presentations and begin to understand, what does the role and what does the definition of case management tie together in terms of the process of bringing that person back to work? One of the areas that intrigued me was the case management function. We talk about this in almost all the proposals, we're talking about external case management and from the standpoint of an external focus. I think from that standpoint we have to look at case management more as a continuum. What I see in the continuum is that some case management done at some plants is direct harassment of the employee. Some of it is what we call 'surveillance light,' that is just keeping in touch with the individual. A third type of case management is medical follow-up. And the fourth, which I believe is the most important part of case management and really what we're talking about, and that's return to work planning. As a matter of fact, I would prefer that we discard the term case management and really talk about what we want to do, which is return to work planning. I can define a return to work planner in a company much easier than I can define a case manager. One of the areas that we've talked about that seems to be very common in all the papers is the disconnect between case management, those types of planning activities, and the ergonomic and accommodation functions. First of all, we talk about return to work planning. When we look at the statutes, both state and federal, it's an option. It's not a requirement. So from that standpoint, we have to look at the process of what's expected. We see this disconnect between accommodations, return to work planning, the case management and the process of applying ergonomics in an appropriate way. I'd like to be able to invite people to look at accommodation pathways. The process by which we bring a person back to work is when we talk about the politics of disability. I thought that was a very interesting comment that people talked about. The disability really is not necessarily an objective point of view. It's a subjective component and that subjectivity lends itself to understanding that we can negotiate it. What do we do with it, what are we able to do with it. That's the part that I think we have to struggle with is, not what we physically do but what do we want to do in that particular process.

The one slide from Washington was an extremely informative one about the number of people that are case managers, or identify themselves as case managers. I think we have to look at that type of provider. I think that's where we end up with this fragmentation in this process that lends us to the confusion that is being presented. A sense is that everyone may consider themselves part of the case manager and process, but no one's really planning that person's process back to work. There would be one caveat that I would put in this process and that is don't let your attorneys be your case managers or return to work planners. We find that when that happens, we end up with significant problems because for the company that lawyer may end up being like a 'disability police,' and for the representative of the employee they may look like a 'disability choreographer.' So from that standpoint I think it's very critical as we look at all these models, that we establish a model that begins to promote the issue of an internal return to work planner. It's within that component that you'll begin to reduce the fragmentation. And all these projects and all these activities talk about this, but I think we have to synthesize it down to that particular level.

Another component that was presented was restricted duty. I think that and light duty is an antiquated topic. We've seen time and time again the issue that restricted duty and light duty become difficult concepts to define. We all generally understand the idea, but it's very difficult to measure. So I believe that we need to be looking at the focus of transitional work, ramping, gradual return to work that focuses on a defined process of bringing that person back to work over a graded period of time. We see this now commonly referred to as a dual track program where there's accommodations being met at the work site, but also a process of functional improvement because what we find is that light duty becomes a career path, an outcome unto itself. And that has to be avoided, in the same way that unmanaged restricted duty, we believe, often times creates secondary injury. I think that was important from Robin's point of view, is that in the terms of the data she presented, the low number of people that were getting re-injured, those that were re-injured did not have ergonomic changes or they were not successfully led to very lengthy secondary times off work. The issue is the value of case management. We talked about that, and we heard about that. Is it expensive, or not? Bad case management costs you. Good case management pays. So it's very important as we move away from that idea of just case management and talk about the focus of return to work planning. We've seen some of the data that suggests that about $2,500 is the average cost of an outside external case manager per case when they get involved. About 30 to 40 hours of action and activity. That can be very expensive monitoring if it's not doing anything for you. And so from that standpoint we have to look at the cost, that individual hourly rate that an external case manager - a rehab nurse or insurance person - may be doing from that particular standpoint. That's why I believe it's very critical that we really look at a model that puts the return to work planning right at the heart of the corporate center, at the company, at the site. That's a process that's already going on and it's your self interest to bring that person back to work.

It's important that we can do case management screening. I would invite each of you to be able to establish a return to work predictor for your company. The statistics that were presented here are excellent. For example, Robin's data and the Washington data suggest predictive outlines. But by going into your own company and looking at your own return to work predictors, your own treatment outcomes, you can establish your own predictors in a way that allows you to look at patterns. Now I couldn't see how many occupational health nurses we have here, but I'll guarantee you that most of those nurses, when that person walks through the door and tells them they have an injury, they can tell you if they're coming back to work or not. Because they have their finger on the pulse of that particular workplace. But we have to be a little bit more scientific. So we can design our own return to work predictors for our companies. We've done that with a variety of models.

In conclusion, taking what we heard today and some of the issues that I think are important for discussion is, one, we need to discard the term 'case management' and move to a 'return to work planning' function at the corporate site and certainly at the operational site. We need to establish return to work incentives for supervisors. I think that one of the areas that was missing in our discussion today is the role that the supervisor plays because we have to establish an incentive for supervisors to engage and support ergonomic changes. Because we know, for some supervisors, that was the best day in their life when that guy got hurt because now they don't have to deal with that guy, and he's out. From that standpoint we have to deal with that very sensitive political issue of incentives to supervisors. And so that has to be part of that return to work planning process. Finally we have to establish conditions of return to work in our corporate policies. And most importantly in our collective bargaining agreements. When we establish that type of balance for return to work we end up with an opportunity to establish data that can be discussed and then can be transplanted from one company to another. Thank you.

Ms. Patricia Bertsche, OSU: Thanks, Ken. Our last discussant is Dr. Dan Wolens. Dan is an M.D. and has a Masters in Public Health, and is the President of Kentuckiana Occupational Health Associates. I'm pleased to turn the microphone over to him.

Dr. DAN WOLENS, Kentuckiana Occupational Health Associates

Thank you, Pat. Actually, Ken, I just wanted to say that I think that's the first time in my life I've heard a dynamic speaker from an insurance company. That was very impressive. It's always tough being the eighth speaker in the afternoon after lunch, especially when everything's been said. So what I'd actually like to do is focus a little bit more and expand a little bit on Gary and Robin's comments because as a physician and primarily a clinician, I'm most interested in how the health care system impacts disability through it's delivery of health care. When I think of case management I think of it as primarily being the active involvement in the management of an employee at the time or shortly after the time of injury through that time when that employee has reached what we call maximal medical improvement and/or has returned to work. The health care systems today, however, have changed dramatically. They used to be the employer and the physician and the employee. However, now we have with these dramatic changes, changes in the systems of how health care is delivered. We now have managed care organizations, we have utilization review, medical bill auditors. We have provider panels, practice guidelines and all kinds of other things that have changed how health care is delivered to the employee. What I would suggest to you as both leaders of labor and leaders of corporations is to become intimately knowledgeable about what these systems do and how these systems function. I thoroughly believe that the best care that can be delivered to the employee is best for everyone involved. However the best care doesn't mean the most care. The best care also doesn't mean the least care. There's an optimal amount of care that needs to be delivered by people who are knowledgeable about the workers' compensation in the occupational medicine system. You have to remember that these systems that you know now go out and buy the managed care organizations and the other health care delivery systems. They're not there to help you. They're there like any other corporation, to make money. How well they provide that service is very much up to you as a consumer. It's not in the distant past that we used to ask something of our health care systems. Today the market is much different. You, as employers and labor organizations have more power and more control over how health care is delivered than ever before. One of the biggest problems with the health care systems that are there now and as Dr. Franklin had noted on his slide, is that there are numerous people today who are now involved in the process. Again, we have the nurse case manager, the utilization of review nurse, the vocational rehab coordinator, the ergonomist, the on-site safety person, etc., etc. Every one of those people who touches the employee or touches the patient impacts on the outcome and impacts on the level of disability with that patient. It's, therefore, again very important for you to know the system and to know the people in that system. Gary had also touched upon the fact that you need to have knowledgeable physicians. You'd probably be shocked at the number of kidney cutters and tonsil removers out there that are semi-retired and practicing occupational medicine. Again, it's a very large proportion. In the community from which I come I think there are now about 15 people practicing strictly, Occupational Medicine. Not one of them had been residency trained in the field. So, again, it's very important to look to see who you're using as your providers. This goes not only for physicians, it also goes for ergonomists. Ten years, or 15 years ago when I first started doing Occupational Medicine, high school dropouts were becoming ergonomists. Why? Because they could. There weren't any requirements to be ergonomists. Obviously that's now changing today with professional certifications. So basically in summary what I simply wanted to exemplify was the fact that it's very important to know how health care is delivered to your employee because how that health care is delivered greatly impacts upon the level of disability and the rate at which an employee will return to work. Therefore, it's very important, again, to make sure that you have the proper systems in place long before your employee ever becomes injured. Thank you.

Ms. PATRICIA BERTSCHE, OSU: I'd like to ask our speakers and discussants to come up onto the stage. We will invite any questions at this point in time. Having spent 8 years at OSHA, I understood that there was some contention surrounding this issue even though one would like to say that there isn't any contention. However, when I started talking to the people that were going to come and present or possibly discuss, it didn't seem so contentious. So I know there are issues out there that we need to address. I invite you to bring your issues to the table so we can have a good discussion again in the hope to move things along.

Dr. Dick Warren: Hi. I'm Dick Warren from the Ergonomic Technology Center in Connecticut. I'm struck by the disconnect in this conversation between primary prevention and everything else. It seems at times we have no problem about talking about changing the workplace for return to work as far as biomechanical stressors. I'm very struck by Dr. Franklin's separation between cause 1 and cause 2 in the model. I agree with him that there are very often very different causes, just to remind us in the pathway between actual stress and injury, and cause 2 which was that of the pathway between injury and disability, if I have your process correct. He suggested, as I think many people here have, that psychosocial issues are essentially relegated to the cause 2 area, that there are ways in which our mind effects the way we see things, report pain, move towards disability. I want to challenge you to think about the fact that there is a large and growing body of evidence that psychosocial issues are important in cause 1 also, particularly coming out of Scandinavia, particularly work in the Netherlands and Finland suggests that there are direct main effects of stress, psychosocial characteristics of the work organization upon actual injury, and in the development of injury. We have no problem seeing this when we think about heart disease. It's well accepted that stress and psychosocial factors in the workplace can cause and exacerbate conditions of cardiovascular morbidity and mortality. Somehow when we get to issues of soft tissue disease we lose that possibility. So I want to challenge people to think about the possibility and remind us that there is a growing body out there in which this is the case.

The second piece that I think is important comes from industry. When we talk about tertiary prevention suddenly we think about psychosocial issues we are going to introduce, which I think Dr. Mitchell referred to. I would like to submit that if your injured employee has not had a lot of connections with his supervisor and the pecking order of company, and whatever comes from a distorted social situation in the workplace before the injury, a couple of calls from the employer or the case manager after the injury is not going to make a very big difference in his return to work. So what we're really talking about when we're talking about psychosocial issues affecting the move towards disability is that it is very important to think about the psychosocial characteristics and the actual work organization and characteristics of the organization as a primary cause of injury and also as those characteristics of the workplace as being important from the start in these issues. Not much of a question, but definitely a comment.

Ms. BERTSCHE: Do you want to comment, Gary?

Dr. GARY FRANKLIN: The literature on the prediction of disability once injured has been going on for decades. It's very extensive and as I said earlier the factors are medical, administrative, work, psychosocial and legal. What I said was that it's probably true that only the medical, administrative and work factors are modifiable. So that if you were going to think about trying to prevent disability it is those three areas that you would focus on the most. It's not likely that you're going to be able to modify the psychosocial background or the kinds of very complex history of abuse 30 years ago. They may help predict some disability but it's not likely you're going to be able to modify that factor. The same question is, what are the factors leading from exposure to injury and what are the modifiable factors. All I was really trying to get at is the fact that if there are psychosocial factors leading from exposure to injury, they're probably a different set of factors than those psychosocial factors that may be part of leading from the exposure to the injury than from the injury to the disability.

Dr. DAN WOLENS: As you probably noticed in the preceding days at this conference, there's a lot of polarization as to what does and what does not cause injuries. In an unfortunate sense, one of the counter arguments is that it is psychosocial factors that cause injuries. Certainly there is a contribution of psychosocial factors, but it's not really a competing hypothesis. I don't think anyone can really claim that psychosocial issues cause injuries to occur. That is, psychosocial factors are not pathological in and of themselves. Where psychosocial factors really come into play as was represented in Gary's slides when people get to the flat end of the curve, when they've been out of work for a year, that tends to be predominantly psychosocial factors. As Gary pointed out, a lot of those people don't even really have an injury. They twisted their ankle, they twisted their wrist, they have a strain or something of that nature. In general, these people don't even really have injuries. What they develop are what we call chronic pain syndromes. The chronic pain syndrome they develop really has very little bearing on the initial injury. And so to say that a psychosocial factor causes an injury, I think, is quite incorrect. I do, however, think that psychosocial factors are very important in causing disability.

Dr. FRANKLIN: The last point is that I would agree that issues around work organization and work stress, if you want to call them psychosocial factors, may have something to do with all of this in terms of the exposure and the injury. However, they're very different issues than the psychosocial factors that we're talking about that are associated with leading to disability.

Ms. BERTSCHE: I think in the interest of time I'd like to take a question from someone else. This gentleman in the middle.

Dr. Peter Dorman: I'm Peter Dorman, Michigan State University. There are 3 reasons I can imagine for why a firm would bring somebody back to work. The first is the concern to restore this person to a productive life. The second reason is for purposes of retaining the value of the employee in whom there's been an investment. And the third purpose would be workers' compensation costs. We've heard discussions here of very well meaning programs or perspectives which are primarily focused on the first, second and then the third. But we know that there are employers out there who are not so well meaning and whose motivations are primarily not medical and not in the interest of the worker involved, and who may not even be investing very much in their work force, and so therefore may not have much in motivation, and they're simply trying to get people back as quickly as possible to cut down on workers' comp costs. This is particularly the case, I would suspect, where you would have a lot of temporary employees and a lot of people who are not going to be working there very long anyway. You get them back long enough so that you don't have to worry about whatever happens to them in the future. Is there any way to identify these situations? Is there somebody from the outside, for instance, that knows whether or not a firm is being well meaning or not well meaning in its return to work policy? Is there any data that would distinguish between medically appropriate and medically inappropriate programs for return to work. If anyone would like to comment.

Dr. DAN WOLENS: One quick answer is, I don't think it would take very long for a good case manager or claims manager who's quickly in touch with the employer to be able to tell whether the employer was intending to take the worker back or not. We just had a case last week up in the Everett Long Disability Prevention pilot. They did staffing for me and the director where they presented a case of a 30-year-old who had been out or work for six weeks. Had worked for a small place for about a year. The first conversation with the employer was that they were not intending to take the worker back. I was dumbfounded. What about the impact on your rates? Well I'm not sure that the evidence is there that experience rating is nothing but disincentive to actually have employers bring people back to work. And that's a really serious question because our whole system is based on experience rating premiums. So that's just a short answer. My own experience is that, you can tell pretty quickly if you're in close touch with the employer and the worker.

Mr. BRUCE KAYE: This is very anecdotal, but two weeks ago I took a deposition of a personnel manager who admitted under cross examination that he had conducted a meeting where there was supposed to be discussion among the personnel people, the supervisors and the worker about going back on a restricted duty job. The personnel manager admitted on cross examination that before the meeting her instructions from her boss were to terminate the employee. This is an employee who had been on this graveyard restricted duty work pool for probably 14 months and then returned to work on restricted duty for another year, and then was simply terminated. So, there's an example and it's of record.

Dr. KEN MITCHELL: Some of the predictors we look at are if there's a high incidence of employee turnover. We see this in the long-term care industry where nursing homes have anywhere from 70 to 150% turnover a year. That suggests a certain management problem that deals with some significant areas. Also we look for high profile labor/management problems. We know when we have an impending strike or other types of labor unrests that go on between labor and management, we end up with a situation of elevated disability costs and disability time off work. So there are two predictors we see in terms of being aware of what's going on within that organization.

Dr. PEACOCK: I think we've got time for just three more - Barbara, Denny and the gentleman in the middle. Barbara.

Dr. Barbara Silverstein: Barbara Silverstein, Washington State. This is for Dr. Evanoff. With respect to the model that you displayed. I'm a little perplexed. You have one line running down from the large body for it shows if you increase the exposure, you increase the incidence for prevalence of musculoskeletal disorders, and if you decrease it you decrease the prevalence. And the other slide is the small body of information that says that there's no association. And then you ran down the two lines to the bottom of your model where the scientific side that says, we don't have enough information or we need more research. Then the others say, that's life. And the conclusion that you come to is that we, therefore, can do nothing until more research is done. Is that your conclusion?

Dr. BRADLEY EVANOFF: Obviously I didn't do a good enough job explaining the rest of the slide which we left off because it was too busy. Actually the big arrow should be going from that large box of all the evidence we have showing exposures being related to musculoskeletal diseases, and should point to a big sign that says, we know a lot - let's do something now.

Mr. Dennis Ankrum: Denny Ankrum, Nova Solutions. Gary, have you looked at all at the relationship between culture and worker involvement by the company in relationship to days off and return to work? I was fortunate enough to hear about the experience of Levi Strauss in Dallas. And they seem to be exemplary in that they have meetings every week where they get all their disabled workers back and have a meeting. They keep them involved as much as possible in what's going on in the company. Then at the same time they're trying to change the attitudes of supervisors and workers in terms of how they look at restricted work. They've had a tremendous positive experience.

Dr. GARY FRANKLIN: As I mentioned earlier, I think that medical, administrative and work factors are the key factors that are modifiable. And the only point I made about psychosocial factors is that there's a large body of evidence that they are one of the five. In any individual worker it's hard to predict as they come through the door. I think that any employee involvement and anything that can keep the worker involved no matter how bad their injury is, in terms of reactivation and keeping them…making them feel like they are still part of the company and part of the work force is the most important thing that you can do. And the message that the worker should get from the health care provider on the very first visit is that there's no pot of gold at the end of the rainbow. You can ruin your life in this system and we need to find a way to help you become productive again at a reasonable income.

Dr. PEACOCK: One last question.

Mr. Jim Cauley: Jim Cauley, Perdue Farms. This questions is for Dr. Baver. In her presentation she was saying something about the operations for carpal tunnel syndrome. And apparently the method of treatment was to have surgery. Our experience has been that if you educate your employees at the outset so they go in for early intervention to be treated during the stages of soreness, then you get away from surgery. Our experience in the past has been that when we related to surgery used and that was our cure, the people coming back had similar experiences that were cited where the woman couldn't hold her child because of bilateral surgery on the hands. I don't know of too many cases where there's been surgery where there was 100% recovery.

Dr. ROBIN BAVER: No, I said permanent…total permanent. There was permanent partial awards and then for a period of time there was a wage loss eligibility. But carpal tunnel syndrome does not typically qualify an individual for a total and permanent disability.

Mr. Cauley: See, that's the difference then in case law also then, as by state. In the states that we do business it's different there. I guess my point is that I was kind of amazed that you had so many surgeries and not be proactive in trying to prevent surgeries in the first place.

Dr. BAVER: The study was a retrospective study, so basically what was done was there, and I'm reporting on it. Certainly in our ongoing care we provide a trial period for the cases occurring presently and we will continue. We try conservative treatment, modification. At the one facility we have a full-time ergonomist who we'll send out to modify jobs. So my practice pattern, or our current practice pattern, has evolved since '89. But the study itself was a retrospective study looking at what historically had been done. We could not intervene in those cases that had already undergone the surgery.

Dr. GARY FRANKLIN: If you can keep the worker at work with conservative treatment, that's probably the best first thing to do. But if conservative treatment is not helping to keep the worker at work, as is the evidence from Maine, which has not been published yet but it's very substantial from a prospective study in that surgery is far better than ongoing conservative treatment in terms of functional status, measurements at baseline and six months after surgery. That data has not been published yet. I don't disagree with your early use of conservative treatment as long as the worker can be kept at work with that conservative treatment. But beyond that, surgery is probably better than conservative treatment in the data that has not yet been published.

Dr. DAN WOLENS: Just one thing I want to say and that is about how you can predict outcome with carpal tunnel release and actually where you can predict surgical outcome for almost any condition. And that is you have to ask, is there truly disease? Unfortunately, there are many people who get operated on that don't have the disease for which they're getting treated for. Second question you need to ask is, do you have a good surgeon? Is the surgeon technically skillful at what he does, or claims to do. And third, do you have a good patient. That is, is the patient a good surgical risk? Are there psychosocial factors that are going to impact the outcome on this patient. So those are three things that I try to look for before I recommend that a patient has surgery. Is there identifiable disease, can it be confirmed? Two, is it a good surgeon? Three, is it a good patient? And that really is what determines whether or not your patient will do well after surgery.

Dr. FRANKLIN: I was just going to ask Dr. Baver if there was just a couple of surgeons that were doing most of the surgeries, or whether you were talking about a lot of different doctors that were doing treatment. Because it seems to me that if you got a lot of consistency with two very good surgeons who chose people well, you might get better outcomes.

Dr. BAVER: Springfield is a small community of about 70,000 people with Dayton and Columbus nearby. Certainly we had a subset of patients that do travel to those larger communities. But by and large, there is about three or maybe four, either orthopaedists or neurosurgeons who conduct most of the intervention. The other thing is those physicians also work more closely with the facilities and understand the process, the system, etc. So you don't have someone out there saying you can come back to work but don't ever use your hands again.

Dr. PEACOCK: We're going to have to cut this off now. But, thank you, speakers, for outstanding presentations. You've got a 10 minute break. We'd like you back here at 3:30. Thank you.