Niki Ellis | Breathing new life into return to work


Breathing new life into return to work

07 Jul 2016, Posted by Professor Niki Ellis in Inside OHS articles

Roseanne Barr, presumably in character on her eponymous sitcom, once said: “Excuse the mess, but we live here”.

With apologies to my many colleagues in rehabilitation provider firms, general practice, occupational medicine, insurance schemes and workplaces, that is the situation our complacency has got us into with regard to return to work (RTW).

According to the 2013/14 RTW Survey published by Safe Work Australia (SWA) there has been no improvement in our performance for more than 15 years. The proportion of injured workers in paid work 7-9 months after their injury has been steady at 84-87% for all this time.

That would be fine if system users were happy with this performance level – particularly those injured workers who are not back at work after 7-9 months. As it stands now, they will pay a high price both literally, in terms of loss of income, and figuratively, in terms of loss of health and wellbeing.


Signs are RTW set to improve

Fortunately, “mess is the material from which life and creativity are built” according to Ralph D Stacey, an expert in human organisations and their management.

My hunch is we are at a tipping point for renewed effort at improvement. There are new ideas and evidence swilling about. This was apparent at the excellent Northern Queensland RTW Conference run by the Queensland Government in Townsville in April this year.

I was invited to speak on ‘The Future of Return to Work’. I based my presentation on two things. First, the work Anne-Marie Feyer, Jane Palmer and I had done with the group life insurance industry for SuperFriend, the development of ‘A Best Practice Framework for the Management of Psychological Claims’ (it can be obtained here).

Secondly, my subsequent work as champion for the national, cross-sectoral ‘Collaborative Partnership for Work Participation’, in my capacity as Work for Health Advisor to Comcare.

My conclusions about the current state were:

  • Compensation systems causing significant secondary harm, especially to mental health
  • Treatment for mental health problems not evidence-based
  • RTW support services not best practice
  • Lack of improvement as measured by RTW indicators
  • Confusion about GP, insurer, employer and rehab provider roles
  • GPs slow to embrace health benefits of work messages
  • Employers not buying message of ROI for early RTW/stay at work (SAW)
  • Workers confused
  • Workers’ compensation operates in a silo, but is impacted by and has impact on other parts of the work disability system.

My prediction for a desirable future state was:

  • Empowered workers
  • Employers and insurers work with the superannuation industry, insurance schemes and others to achieve better primary and secondary prevention
  • GP, occupational physician, rehab provider, insurer and employer roles better defined for assessment and early intervention
  • Evidence-based treatment and rehabilitation


Innovations from regulators to insurers

My further predictions (above):

Shift from claims processing to case management

Claims management semi-automated

Multi-stakeholder outcomes focus: client, insurer, employer, superannuation fund.

In recent months I have seen innovations in many of these areas: For instance, a smart rehabilitation provider is experimenting with the empowerment of workers through self management. I have also heard a life insurance company is taking a serious approach to implementing the Best Practice Framework. There has also been a productive collaboration between WorkSafe Victoria, VicHealth and SuperFriend on mentally healthy workplaces.

Meanwhile, SWA is looking at capitalising on inroads made by some jurisdictions in GP support by taking a national approach, and hopefully this will include addressing role clarity.

Also, many schemes (w/compensation and others) have been making efforts to shift claims management from tick-box processing to a more client-outcomes-focussed case management approach. While SA has an e-certificate for work capacity.


Employers crying out for evidence based guidance

While that is a list of just some of the signs of innovation, other ideas for the future identified from a literature review and from international innovation case studies are proving more challenging to address.

Consultations undertaken for the ‘Collaborative Partnership for Work Participation’ has shown employers have not really bought the argument of productivity gains associated with the Health Benefits of Work; they have residual concerns about early RTW and stay at work; and newer concerns about extending their responsibilities to wellness.

On the other hand they are crying out for evidence-based guidance on interventions for mentally healthy workplaces. We need to understand their views better and develop a new narrative for work participation based on the health benefits of work evidence.

Quality management of RTW services – there is a growing sense nationally that payers (in w/comp these can be schemes, insurers or employers) need to have better quality management frameworks for the rehabilitation and return to work services they buy. These must be driven by client outcome performance indicators, and should include incentives and disincentives for evidence-based interventions. Similarly payers should further develop their ability to incentivise evidence-based medical treatments.

We know that much of the treatments offered in mental health are not evidence-based. A leading expert told me this is likely to be as high as 60%. Strengthening outcome-based performance measurement is doable now, but working out what evidence-based treatments and return to work services are is more challenging.

The issue is not working out what the evidence is in relation to particular treatments or rehabilitation services commonly provided, as many schemes do this in an ad hoc way now; but working out a way that this evidence is kept up to date and on tap for policy makers.

There is great potential here for university/industry collaboration.


Triaging, taking into account clients’ real social and health outcomes

For me the biggest potential is the semi-automation of claims management. Triaging claims into those that are likely to resolve with minimal or no intervention, those requiring a bit more support and those requiring more intensive case management, has become common practice in the schemes that make up the work disability system as a whole.

However in many cases the triaging models are based on the data that the insurance schemes have readily available. We need triaging models that take into account the real social and health outcomes of their clients, as well as scheme outcomes; and we need to know that the risk factors used to develop the models are evidence based. For example, Canadian academic Renee-Louise Franche developed a model for recovery risks for musculoskeletal disorders and psychological injuries from research evidence in the literature and then worked with claims managers at WorkSafe British Columbia to develop a nine-question screening tool:

  1. How are you doing?
  2. Are you getting better/worse/staying the same?
  3. How are you coping?
  4. Who is supporting you through this at work and outside work?
  5. If pain is identified rank the pain.
  6. Tell me about your job? What is your job like?
  7. Have you spoken with your employer?
  8. When do you think you will return to work?
  9. What is your regular healthcare provider telling you about your recovery and return to work? (Case study in Taking Action: A Best Practice Framework for the Management of Psychological Claims, see above link)


Automation of claims acceptance

There is huge potential to use big data to develop normative pathways for injuries of different types and levels of recovery risks. This would mean more automation of claims acceptance, allowing a more positive, trusting relationship with injured workers; and automation of claims management, with alerts for deviation from expected progression.

As one American software company said “it is like cloning your best claims manager”. Estelle Pearson, from the actuarial firm Finity, spoke at the Northern Queensland conference about the potential of big data to enable us to have better projections of claims and behaviours leading to claims.

For me though, when it comes to claims for psychological injury, the elephant in the room is the question: are we doing more harm than good?

Last year was the centenary of Einstein’s theory of relativity. He presented his theory to the Prussian Academy of Science on November 25, 1915. He of course is famous for saying, “insanity is doing the same thing over and over again and expecting different results”. We can and must do better.



First published in Thomson Reuters Inside OHS, 06 July 2016

Inside OHS Editor: Stephanie D’Souza; (02) 8587 7684; Stephanie.D’