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STRATEGIES
FOR MANAGING
DISABILITY COSTS
Michael E. Carbine
Gail E. Schwartz
Washington Business
Group on Health/
Institute for
Rehabilitation &
Disability
Management
Strategies
For Managing
Disability
Costs
Michael E. Carbine
and
Gail E. Schwartz
November, 1987
A Publication of the Washington Business Group on Health/
Institute for Rehabilitation and Disability Management
Produced in part through a grant from the J.M. Foundation
Acknowledgements
This disability management workbook represents findings from the "National Disability
Management Conference," held May 11-12, 1987 in Washington, D.C. The conference was
sponsored jointly by the Institute for Rehabilitation and Disability Management (a partnership
between the Washington Business Group on Health and the National Rehabilitation Hospital)
and Thomas L. Jacobs & Associates. Special thanks go to these organizations for their help in
planning and organizing the conference. In particular, we wish to thank Ellen Menton, Sheri
Farris, Susan Dickinson, Donald Galvin, Ph.D., and Sara Watson of the Washington Business
Group on Health, and Diane Yeater and Josephine Madden of Thomas L. Jacobs & Associates.
We also thank all the speakers for their thoughtful presentations, which made the conference
a success. In addition, we thank the exhibitors for making the trade show possible.
Finally, we are grateful to the J.M. Foundation and to the National Institute for Disability
and Rehabilitation Research for providing the financial support for this publication.
For more information about the Washington Business Group on Health, or to order additional
copies of this publication, please contact WBGH, 2291/2 Pennsylvania Ave. S.E., Washington,
D.C. 20003, telephone (202) 547-6644.
ii
Executive Summary
Disability costs are staggering. The private and public sectors are paying billions of
dollars for disability benefits, losses in productivity, absenteeism, retraining, replace-
ment, and disability related health expenses. Disability expenditures are becoming
increasingly costly for employers because a growing proportion of people are becoming
disabled during their most productive years (ages 17-44).
Employers are faced with the challenge of developing innovative ways to retain
employees who become disabled. At the Washington Business Group on Health's National
Disability Management Conference, co-sponsored by Thomas J. Jacobs and Associates,
over 200 representatives from major employers, providers and government convened to
discuss cost-effective strategies for managing disability. Several companies, including
Steelcase, General Motors, Federal Express, Walbro, Herman Miller, Honeywell, and
others have responded to the disability crisis by creating cost-effective return-to-work
strategies.
The companies that have developed disability management strategies view their
employees as valuable resources. Most disability management programs also share other
common elements, including:
Well-defined and articulated resource strategies;
Provisions for early intervention in all rehabilitation cases;
Cooperation between employees, providers and employers;
Union involvement from the program's inception;
Support from top management;
A system to effectively manage the disability claims function; and
The belief that rehabilitation is an ongoing process that goes beyond supportive
services and opportunities.
The majority of companies view disability management as a multifaceted system
initiation which will maintain the company's present workforce and bring people back
into the workplace to productive and rewarding jobs. The goal is to reduce disability,
lower costs and better utilize human resources.
iii
Contents
I.
INTRODUCTION
1
II.
DISABILITY ISSUES: DEFINITIONS AND STRATEGIES
3
III. COST MANAGEMENT STRATEGIES
7
A. Human Resource Strategies
8
B. Labor-Management Partnerships
10
C. Functional Assessment and Duration Guidelines
12
D. Data Analysis
15
E. Designing a Long-Term Disability Program
17
F. Corporate Medical Departments/Independent Medical Exams
19
G. Effective Rehabilitation: Management Strategies
21
H. Fraud and Malingering
24
I. Wellness and Health Promotion Strategies
26
IV. SOCIAL SECURITY/LEGISLATIVE ISSUES
28
V.
SUMMARY AND CONCLUSIONS
30
VI. APPENDICES
31
iv
I. Introduction
W
hile the problem of disability often is asso-
ciated with an aging population, statistics
"Disability is an attitude issue, not just an income
indicate that the disabled population is
issue, not even just a health or medical issue. Many
becoming increasingly younger-between the ages of
could, in fact, say it is an issue of our own learning
disability, our failure to learn how far others can go,
17 to 44-and predominantly male. Over the past 25
It is our disbelief about their ability, our prejudice
years, there has been a 400% increase in the number
about their disabilities that often stand in the way of
of severely disabled people between the ages of 17 and
us making progress together.
44, with a clustering toward the 24-25 age cohort. These
Willis B. Goldbeck, Washington Business Group on Health
figures are significant because they represent an impor-
tant segment of the workforce in its most productive
programs can be highly cost beneficial. They represent
years.
a proven way for employers to reduce their compens-
Last year, between $120 and $160 billion in disability
able loss exposure, return workers to productive
claims benefits were paid out by business and govern-
employment, and enhance the company's profitability
ment. Short-term disability costs frequently run from
and competitiveness. They make a strong case for the
2% to 4% of total payroll, while long-term disability
argument that disability benefits need not be an auto-
costs add another 1/2% to 1% of payroll to this amount.
matic and unchallenged cost of doing business, and
For every $1 million in payroll, $50,000 is spent on
that vocational rehabilitation programs can and do work.
disability claims alone. The projected cost increases in
disability benefit plans range from 6% to 10% annually.
Each injury is now estimated to cost an average of
Disability Facts
$19,000. A company with 1000 employees can expect
to have 27 lost workday injuries each year. With a 4.5%
Over twenty-one million Americans of working age
(16 to 64) are disabled. (1)
profit margin, a company must realize $11.3 million in
Over eight and a half percent of the working age
sales just to offset these costs.
population are occupationally disabled (they are able
This data offers a compelling argument for rigorous
to work but not at the job they held before their
employee-based disability management and rehabili-
disability). (2)
tation initiatives. But disability benefits, medical ben-
Two-thirds of all disabled Americans between the
efits and workers' compensation activities typically are
ages of 16 and 64 are not working; but two-thirds of
fragmented in terms of administration, financing, data
those not working say they would like to work. (3)
collection and analysis, plan design, and case manage-
In 1982, total disability costs equalled approximately
$121.5 billion. (4)
ment. This fragmentation reduces the effectiveness of
In 1982, $67.4 billion were spent on cash transfers
an employer's cost containment efforts, increases
(SSDI, SSI, insurance payments, workers' compen-
administrative costs, and makes benefit planning, data
sation, AFDC). (5)
analysis and cost management more difficult.
Industry currently spends $7 billion a year on sick
It has only been within the last few years that employ-
leave. (6)
ers have launched comprehensive, systematic disabil-
Short-term disability costs frequently run from 2% to
ity management programs designed to maintain the
4% of total payroll, while long-term disabilty costs
present workforce and bring impaired workers back
add another 1/2% to 1% of payroll to this amount. (7)
into the mainstream of employment. Alan C. Benden,
Each injury is now estimated to cost an average of
$19,000. (8)
Assistant Director, Life and Disabilty Insurance, Gen-
A company with 1000 employees can expect to have
eral Motors Corporation, notes that one reason for the
27 lost workday injuries each year; with a 4.5% profit
delay in initiating these programs is the unchallenged
margin, the company must realize $11.3 million in
belief that disability benefits are an unfettered cost of
sales just to offset these costs. (9)
doing business. Many employers have routinely writ-
Chronic pain accounts for an estimated $70 billion a
ten off disabled employees, paying compensation claims
year in medical costs, lost working days and com-
and other benefits as an unavoidable business expense.
pensation payments. (10)
Another reason is prejudice and stereotypical attitudes
In Michigan, the rehabilitation cost of placing dis-
about disabled workers and rehabilitation.
abled employees with new employers was on aver-
age twice that for returning them to their former
Several companies are demonstrating, through var-
employers. (11)
ious disability management strategies, that carefully
(See Appendix 3 for sources)
planned and coordinated disability and rehabilitation
1
On May 11-12, 1987, the Washington Business Group
tical suggestions and recommendations that emerged
on Health's Institute for Rehabilitation and Disability
from the conference. It also offers brief case histories
Management (a partnership between the Washington
and summaries of topical issues. The information is
Business Group on Health and the National Rehabili-
indicative of what has worked for individual companies
tation Hospital) joined with Thomas L. Jacobs & Asso-
in specific circumstances. Because companies vary sig-
ciates, Inc., a benefits consulting company, in sponsor-
nificantly, not all strategies will be appropriate when
ing the first National Disability Management Confer-
designing and implementing disability management
ence. The topic for the conference was "Strategies for
initiatives. Strategies must be selected and modified to
Effective Cost Control." Through workshops and panel
fit individual situations.
discussions, representatives from employer-based dis-
Section II discusses the general issue of disability
ability management programs, insurance companies and
management and rehabilitation, including the prob-
rehabilitation facilities shared their experiences and
lems associated with program design and implemen-
offered practical advice on how to reduce and control
tation. Section III offers nine strategies for designing
disability costs through employee-based disability
and implementing cost-effective disability manage-
management and rehabilitation initiatives.
ment initiatives. Section IV describes current political
This workbook represents a collection of program
issues. Section V concludes with a discussion of topics
design and implementation strategies as well as prac-
for exploration and research.
2
II.
Disability Issues: Definitions and Strategies
M
odel employment-based disability manage-
Despite these challenges, experiences from several
ment and rehabilitation initiatives target the
companies demonstrate that with proper planning and
early identification of job-related disability
careful thought, disability management programs can
problems; management of physical symptoms; planned
not only serve the economic and productivity goals of
management of disability-related costs; the willingness
employers but also enable disabled employees to attain
to modify jobs; and development of personnel policies
levels of functioning that permit them to return to their
that facilitate work return and job retention for the
old jobs or to new jobs, and to remain productive mem-
injured, disabled or chronically ill worker. These ini-
bers of the nation's workforce.
tiatives must be a coordinated activity that becomes
part of a company's total work system. As a cost-man-
agement strategy, disability and rehabilitation initia-
Challenges and Solutions
tives reflect an awareness of the high costs of illness,
Many companies lack an integrated policy concern-
injury and disability, and a realization that there are
ing disability management, rehabilitation, and well-
cost incentives for returning occupationally disabled
ness. Most employers (62% according to a 1986 survey
employees to suitable employment at the earliest pos-
by the Institute for Rehabilitation and Disability Man-
sible time.
agement) have not designated someone within their
Disability management initiatives must also take into
company as responsible for coordinating and managing
account the multitude of "disincentives" inherent in
disability benefits. Few companies employ full-time
the system, factors which can, if unaddressed, deter
rehabilitation counselors. Nor do many companies have
companies from achieving their disability management
mandatory rehabilitation provisions within their long-
goals. For example, the "disability system" at times
term disability policies.
appears to complicate the process of rehabilitation and
On the other hand, companies with successful dis-
return to work. State workers' compensation programs
ability management programs typically have a clear,
often do not do an effective job in ensuring that workers
concisely articulated disability policy. This policy serves
with job-related disabilities are helped to recover lost
to integrate the disability function into the company's
abilities and return to their previous jobs or, when this
work system and mandates strong coordination among
is impossible, to learn new skills.
related activities. When outside medical, social and
The stresses and trauma associated with chronic ill-
rehabilitation resources are used, they are brought under
ness, injury and disability can hinder a person's moti-
the company's management system to the extent pos-
vation to participate in rehabilitation. In the face of
sible. In many instances, the function is an integrated
economic, physical, social and psychological threats,
part of the company's medical, counseling, employee
disability benefits become an attractive and secure
benefits, and/or employee assistance program.
alternative to continued rehabilitation and return-to-
Early intervention strategies and a high level coop-
work efforts. Finally, employee or employer ignorance
eration between disabled employees and employers
of, and skepticism towards, disability management and
are the keys to successful rehabilitation and return to
rehabilitation techniques often work against successful
work. These intervention strategies motivate employ-
rehabilitation and employment. Any or all of these rep-
ees to participate actively in the rehabilitation process,
resent significant challenges to the disability manage-
and are successful in preventing short-term disabilities
ment field.
from becoming long-term disabilities.
Companies with effective disability management
programs tend to define disability as a medical impair-
Attitudes About Returning to Work
ment that affects physical functioning on the job. But
disability also is seen as a condition affecting the indi-
"Many of us can work and many of us would like to
vidual's social, psychological and intellectual environ-
work and live independently in our own communities
and homes. But we need certain kinds of support and
ment. In effect, it is not just an income issue. It is a
assistance to do this. Recent data from the Harris Poll
medical, health and productivity issue as well, and a
suggests that more than half of those with disabilities
state of mind.
would give up their benefits in order to go back to work
A comprehensive disability management program
if they had the opportunity."
should encompass multifaceted, systematic initiatives
Lex Frieden, National Council on the Handicapped
which will maintain the company's present workforce
and bring people back into the workforce to productive
3
and rewarding jobs. Disability should be seen as a
behavior, the sum total of the physical and psycholog-
General Motors' Disability
ical impairments that may exist. But as a behavior, it
Claims Cost Control System
can be learned and unlearned. The goal is to reduce
disability, lower workers' compensation costs, and bet-
In 1969, sickness and accident payments at General
Motors exceeded $100 million for the first time. The
ter utilize our human resources.
company began meeting with its union (the United
Rehabilitation also means more than bringing an
Automobile Workers of America) and insurance carrier
individual back to a minimum level of functioning. It
(Metropolitan Life) to see how benefit costs could be
is an ongoing process that should extend well beyond
controlled. The meetings resulted in a comprehensive
this point to providing supportive services and oppor-
and integrated disability cost management system.
Metropolitan Life began by initiating a disability
tunities that will help people maintain and exceed their
management training program at each company plant
performance levels SO they can realize as much of their
(General Motors administered disability benefit pro-
potential as possible.
grams at each location while Metropolitan administered
Successful disability management programs start from
the long-term disability plan from its headquarters)
a well-defined human resource strategy. This strategy
The two-week training program. evolved into a local
study group program through which study teams
encompasses the company's corporate culture and val-
reviewed the benefit systems and procedures used at
ues, reflects how the company views its employees,
each plant. Where deficiencies were found, new claims
and dictates the kinds of services offered employees.
payment procedures were instituted and new control
This is, in effect, the company's "people philosophy."
systems put into place. Intensive team and one-on-one
This philosophy typically reflects a belief that employ-
training programs were also offered for claims super
visors and analysts.
ees represent an investment, a resource, and an appre-
A UAW proposal resulted in the creation of a joint
ciating asset. And it reflects a genuine concern for and
impartial medical opinion program under which
commitment to the employee, especially when illness,
employees submitting disputed claims are examined
injury or disability strikes.
by physicians selected jointly by the UAW and GM.
The company's attitudes toward disability also will
Because this program involvés a binding opinion fea-
ture, claims litigation has dropped significantly,
impact on program success. Too often, a company's
Each claim is managed by the plant medical clinic
approach to disability focuses on the negative and
on a case-by-case basis. General Motors currently is
stresses limitations when it should look for and create
developing regional benefit centers where GM has a
opportunities that will help impaired workers better
concentration of facilities to handle life insurance and
manage themselves and contribute to company pro-
disability claims. These regional centers offer the
advantages of full-time staff; trained, stable workforces;
ductivity. Alan C. Benden of General Motors puts it
and administrative flexibility not generally available
this way: we should think positive about disability, i.e.,
when local plants administer the process. A pilot national
rather than saying that an employee can't lift over 25
center is also being developed to service life insurance
pounds or must sit 50% of the time, why not say that
and disability claims for the company's stand-alone
the employee can lift up to 25 pounds or can walk 50%
plants.
To tighten the program's administrative features; GM
of the time? This attitudinal shift makes a difference
developed an experience rating system which set dis-
in the kinds of goals a company sets and how well
ability costs for each plant. The company also devel-
programs are able to achieve those goals.
oped standard data and acceptable disability duration
A disability program cannot be all things to all peo-
guidelines by diagnosis; instituted a regional consul-
ple. Some employees suffer functional losses that do
tant program which provides specialists from Metro-
politan Life at each facility to help with onsite evalu-
not meet criteria that would automatically bring them
ation and benefit control procedures; designed training
into the company's disability management system. But
programs for sickness and accident benefit claims
while this does not mean that they will not require
superviors; and bégan developing close contacts with
services or support, such services may be better pro-
community physicians to obtain their support and explain
vided through other programs and community-based
GM's benefit plans and disability management objec:
tives. The disability database was also redesigned to
resources. At the same time, different kinds of disabil-
provide for prompt claims payment with less input. The
ities produce different needs and entail different prob-
new system provides claim histories for each employee
lems. Temporarily disabled employees, some of whom
and allows claim analysts to spend more time on claims
may require little or no rehabilitation and can perform
control activities.
less demanding duties until recovery is complete, may
General Motors reports that to date, the company has
saved $140 million in disability costs, and is continuing
be relatively easy to place in modified work situations.
to add $180 million annually to that figure. However,
But appropriate supports must be provided so that the
the company believes that its disability costs are still
temporarily disabled do not become permanently dis-
too high and can be lowered even further.
abled. On the other hand, those with permanent impair-
4
ments who will never be able to return to their former
jobs but can be rehabilitated to perform other jobs often
Aetna's Cost Control Strategies
are more difficult to place.
Aetna Insurance uses several cost control strategies
While there may be a lack of data upon which to base
for managing worker's compensation claims. These
program design and management decisions, several
include a claims "management-by-objective" (MBO)
employers have developed innovative data systems,
system; the AELIRT system; and Medicall.
and are using these systems to institute effective case
Aetna's MBO system for claims management is a team
management strategies; categorize and assess func-
effort in which the company works with the employer,
injured employee, family and, when appropriate, the
tional impairment and capability; predict disability
attending physician to set a disability management
duration per type of injury; identify factors for success
objective, including a date when the employee will
in rehabilitation; manage disability-related claims and
return to work. Within this framework, several sup-
costs; create transitional and modified worksite pro-
porting objectives are then set involving benefit pay-
grams; and institute and evaluate comprehensive well-
ment schedules, physician re-evaluations, claims pro-
cessing targets, and other administrative factors.
ness and health promotion programs.
The MBO team includes claims representatives or
Companies with successful disability management
workers' compensation specialists; nurse consultants;
programs typically approach disability as a human
medical cost control coordinators; and home office med-
resource issue, and involve their unions in program
ical staff. The claims representative coordinates the
design and implementation. They also recognize that
team's management of lost time cases and determines
benefits to be paid. The nurse consultant works with
one barrier to returning disabled employees to work
employer, employee, family and physician to develop
often is resistance on the part of their own supervisors
rehabilitation plans and explore alternative work pos-
and employees who may be prejudiced against dis-
sibilities with the employer. The medical cost control
abled persons or feel that a restricted worker will jeop-
coordinator audits all medical bills and negotiates prompt
ardize unit productivity. For this reason, it is crucial to
payment and other discount issues with medical pro-
viders. The home office medical staff serves as an instant
secure top management support for the program; open
medical resource through Medicall (a telephone hot
and maintain lines of communciation; and build suffi-
line-see below).
cient flexibility into the program to accommodate the
AELIRT-Aetna's Large Injury Rehabilitation Team-
needs of supervisory and line personnel.
is a home office resource composed of claims techni-
Gaps in available social, medical and vocational reha-
cians, nurse consultants, physicians and rehabilitation
specialists who work as a team in the field to provide
bilitation services may make it difficult to incorporate
employers with guidance, direction, and professional
community-based resources into a disability manage-
medical resources for managing catastrophic injuries.
ment program. These gaps can include poor linkages
They act as an early intervention and medical speciality
between acute care and rehabilitation services, poorly
resource, monitoring the delivery of care by providers
understood relationships between employers and pro-
to ensure quality care and cost-effectiveness.
viders, and inadequacies in the kinds of social and
Medicall is a telephone hot line for field claims rep-
resentatives. A team of full-time physicians is available
vocational services available in the community as well
to handle technical inquiries about specific injuries and
as barriers to easy access to these services.
rehabilitation issues, and provide written reviews for
Despite these problems, companies demonstrate that
difficult cases.
it is possible to work with providers and community
AETNA reports that the use of nurse consultants alone
(the company employs 55 consultants) in its MBO pro-
resources to create innovative programs and cost-effec-
gram produced in excess of $19 million in savings. For
tive linkages, and build strong management compo-
every dollar invested in the program, AETNA's return
nents into their contractual relationships with these
on indemnity and medical savings was $8. Hospital bill
resources. Brent England, Director, Section for Reha-
audits by the medical cost control coordinators enabled
bilitation Hospitals and Programs of the American Hos-
AETNA to save $3.5 million in 1986. In total, AETNA's
pital Association, notes that employers with successful
cost containment programs produced an 8.4% reduction.
in spending, for a savings of nearly $28 million.
disability management programs work closely with
providers, community resources and other parties to
strengthen coordination and communication. These
motion programs, since experience indicates that these
employers strive to achieve the best possible fit among
programs effectively reduce illness and injury and lower
purchaser, providers, and individual workers, based on
the costs associated with disability. Disability manage-
available resources, the impaired worker's socioeco-
ment strategies, by themselves, are part of a reactive
nomic condition, the family's ability to work with the
concern that responds to the high costs of health care
impaired member, and the employer's ability to modify
and disability benefit utilization, loss of human resources,
the worksite and provide needed logistical support.
and reduced productivity among trained workers.
One important priority should be preventing injuries
But this concern should also include a related prior-
that lead to disability by instituting worksite inspec-
ity: instituting early intervention strategies such as
tion, employee screening, and wellness and health pro-
wellness and health promotion programs to manage the
5
first signs of chronic conditions; employee assistance
Insurance Company: companies must stop being bill
programs that address worker problems that contribute
payers and start being intelligent purchasers of health
to injury and illness; and preventive worksite inspec-
care.
tion and employee screening programs to spot potential
Several principles should guide the development
risks and safety hazards, identify employees who are
and implementation of employee-based disability man-
vulnerable to certain kinds of injuries, design preven-
agement initiatives. These include:
tion strategies and training programs, and uncover prior
1. Initiatives must start from a clearly articulated human
episodes of illness and injury.
resource strategy;
Disability management, rehabilitation and health
promotion can be seen as a comprehensive continuum
2. Early intervention and return-to-work strategies are
of workplace interventions to promote, maintain and
key cost control components; they can even reduce
restore human resource capacities. Each strategy is
employer costs when the company is experiencing
applicable at various times for worker needs. As the
the same or an increasing level of claims;
focus of intervention shifts to prevention, the concepts
3. Disability management initiatives can be central-
of wellness and health promotion become logical part-
ized or decentralized depending upon the compa-
ners in efforts to manage disability. These approaches
ny's needs and operating philosophy, but the initia-
point beyond medical and rehabilitation approaches to
tives must be coordinated, integrated, and managed
the creation of new strategies for developing and pro-
within the company;
tecting employee capacity, and entering ergonomic
4. Top management must be committed to and support
considerations into the design of the work environ-
the initiatives;
ment.
5. Unions must be actively involved from the pro-
These and other experiences indicate that disability
gram's inception;
benefits need not be an automatic and unchallenged
6. A system must be created to effectively manage the
cost of doing business, and that disability benefits can
disability claims function;
and should be managed. Companies participating in
7. Strong medical provider relationships must be built
the disability management conference provided infor-
and maintained;
mation and models for cost-effective disability man-
8. Supervisors and line personnel must be kept well
agement strategies. Common to these strategies were
informed, with lines of communication established
a clear understanding of the goals and objectives of the
company's disability management program, and strong
early and kept open; and
organizational mechanisms for the use of internal and
9. Wellness and health promotion programs should be
external resources. Also common to each company's
used to prevent injuries and illnesses and, in part-
approach was a philosophy summed up by Robert N.
nership with disability management and rehabili-
McCarthy, Assistant Vice President, Claims, Aetna
tation strategies, help reduce disability costs.
6