1. De-medicalizing Disability
Management
“Accept and Assist”.
Matthew Burnstein, MD, MCFP, MRO
Chief Medical Officer – Bell Aliant
Feb 13th, 2014
Page 1

2. Objectives
• Understand Total Cost and the Drivers of
Disability
• Weakness in the Traditional Approach to
Disability Management
• Time for a Paradigm Shift?
• A New Model
• Study the results
• Lessons Learned
Page 2

3. Bell Aliant Regional Communications
• 7000 union and non union members (>60% unionized)
• 6 provinces, widely dispersed
• Customer care workers, field technicians, engineers, marketing
and sales, finance, support services
• TV, internet, home security systems and phones – ever-changing
product mix
• Former monopoly
• <2% staff turnover
• In house team of Health and Wellness (H&W) professionals
• Self insured for short term disability- up to 1 yr at full salary
• Unlimited incidental absence at 100% pay
Page 3

4. TOTAL COSTS OF DISABILITY
DIRECT COSTS
STD
INCIDENTAL
WCB
INDIRECT COSTS
(INDIRECT COSTS ARE
2.5-3.5 X DIRECT
COSTS)
Drug/health costs
Presenteeismdouble this
number!
Page 4
Overtime
Benefits
Morale
Increased stress for colleagues
Customer Satisfaction
Increased workload
Lost Sales Opportunities
Paperwork / Reporting
Training/Retraining
Cost to Employee and their Family!

5. What’s behind the high rates of
disability today?
We’ve never been healthier,
never lived as long,
never had such great medical knowledge,
yet, as a society,
we’ve never been so disabled.
Page 5

6. How does an individual end up
disabled?
An Individual with a complaint
becomes a
Patient with an illness,
who becomes a
Claimant with a disability.
In most cases, the evolution is driven by the individual,
not by the illness or the physician.
Page 6

7. Does the medical model explain disability?
Page 7

8. • “The experience of disability is more related to
society’s willingness to accommodate and
individual motivation than any underlying
impairment or limitation. Our narrow concepts of
health and disability limit our potential.
• Over the years, I have been impressed by the
relative lack of correlation between impairment
and disability….Much of disability results from
learned experiences, lack of adaptive skills and
reinforcements from physicians, family
members, attorneys, employers and others.
• We can no longer accept this societal illness;
the costs are too enormous”.
Page 8
Dr Chris Brigham
President ABIME
Preface the MDAs

9. Page 9

10. Only a small fraction of medically excused days off work is
medically required – meaning work of any kind is medically
contraindicated. The remaining days off work result from a
variety of non-medical factors such as administrative delays
of treatment and specialty referral, lack of transitional work,
ineffective communications, lax management, and logistical
problems. These days off are based on non-medical decisions
and are either discretionary or clearly unnecessary.
Participants in the disability benefits system seem largely
unaware that so much disability is not medically required.
Absence from work is “excused” and benefits are generally
awarded based on a physician’s decision confirming that a
medical condition exists. This implies that a diagnosis creates
disability.
ACOEM Guideline on Preventing Needless
Work Disability by Helping People Stay Employed
Page 10

11. Page 11

12. • “Disability is a complicated psychosocial
problem that extends beyond the sole question
of illness or injury. Many factors contribute to
the complexity of the problem.
• They include, but are not limited to an
individual’s values and beliefs; the role of
illness in the individual’s childhood..; the
specific symbolic meaning of illness or injury to
the individual; the individual’s relationship with
his employer; economic issues; workplace
accommodations made available by the
employer; and the employer’s
policies/practices, culture, and values”.
Page 12
Dr Presley Reed
The Medical Disability Advisor 4th Ed.

13. Disability is not a medical concept
 Defined by a contract, usually related to
occupation
 Therefore, it is a legal rather than a
medical concept
 Influenced by non medical factors :
–
–
–
–
Page 13
Employer, availability of alternate duties
Training, experience, education
Psychosocial factors
Personality

14. Reality check:
Doctors are trained to treat
illness,
not disability
Page 14

15. Physician’s Perspective On Disability Determination
• 86% of physicians believe that completing
disability forms adversely affects the
physician-patient relationship
• 62% feel it represents a conflict of interest
• 56% are willing to exaggerate clinical data
to assist a deserving patient
• Physicians report a lack of confidence in their
ability to determine disability (self rated ability as
4.5/10)
• 80% of physicians feel it would be better for
an independent group to determine disability
Journal of General Internal Medicine 1996 11(9)
Page 15

16. Page 16

17. Certificate of Disability
Canadian Medical Association Policy
• The CMA believes it is the employer’s
responsibility to supervise an employee who
is absent from work for a short time because
of a minor illness. The medical profession
objects to being asked to police such
absenteeism.
• The association objects to the use of
physicians as “truant officers”.
• It is generally accepted that most minor
illnesses are self limiting and do not require
the intervention of a physician.
Page 17

18. Page 18

19. Medical Post 4/5/99
Page 19

20. If illness was the cause of absenteeism, then absence rates
should be similar across communities. But they are not:
Gross Absence Rates
Agriculture
1.7%
Trade & Commerce
2.3%
Finance
3.3%
Construction
3.4%
Manufacturing
4.8%
Government
5.3% (Perspectives 1999)
USA
3.5%
Sweden
6.0%
France
8.3%
Italy
11.6%
Unionized ees 13.2 days/yr vs Non Unionized ees 7.5 days/yr
(Stats Can 2011)
Page 20

21. What are the reasons we miss work?
Global/Environment
Organization
Personal
Region (NS vs AB)
Culture
Job
Climate
Type
Gender
Race
Size
Age
Economy
HR policy
Schedule
Pension Age
Relationships
Job Satisfaction
Social Programs
Quality of Supervision
Transportation
Health Services
Sick pay/benefits
Family
Epidemics
Turnover/Churn
Personality
Religion/Culture
Working Conditions
Individual Health
Health Services
Work demands
Leadership
Physical workspace
Page 21

22. The primary determinant of work
attendance is job satisfaction:
Adding Value
Being Valued
Sharing Values
Page 22

23. Drivers…
• What makes people come to work?
– Opportunity, Desire and Ability
– Global / Environment / Organization / Personal
variables can affect those
• Who decides if working is possible?
– Decision to work is made by the individual
– The decision to offer alternate duties and provide
accommodation is made by employer
– Neither is a medical decision
Page 23

24. Page 24
But beware the golden handcuffs

25. And you want employees to like their work……….
Page 25

26. Hippocrates:
“It is always more important to
know what type of person has a
disease than it is to know what
type of disease a person has.”
Page 26

27. Disability vs Disease
• Disability and disease are distinct concepts;
diagnosis does not determine disability
• Doctors don’t know disability and are not truant
officers
• Disability from work is determined by a multitude
of non medical factors
• While supporting the concept of early return to
work, doctors are patient advocates, and
ultimately, patients determine their ability to work
• The workplace/workplace policies must
encourage employees to remain at work (even
in the face of challenges)
• Engagement may reduce absenteeism
Page 27

28. So, if disability is not driven
by disease, and doctors
don’t know much about
disability or the workplace,
what do we do?
How do we determine or
manage disability?
Page 28

29. The first paradigm shift
Stop talking to
doctors and start
talking to
employees.
Page 29

30. Talk to employees
• Doctors talk to their patients - they trust them and
advocate for them, but they don’t know the workplace
• Trust your employees – they are telling you the truth*
• Treat them as you’d treat a manager or a colleague
or want to be treated yourself
• They know their job and what aspects they can do
and can’t do
• Allow them flexibility to do the job
• It is their motivation which determines outcome – so
what is motivating them to come to work or keep
them off?
* Most of the time. Why treat the 99% who are honest to catch the 1%?
Page 30

31. What’s going on?
What you see
WORKPLACE SYMPTOMS
ARE ONLY THE
Troubled or Absent Employee
“TIP OF THE ICEBERG”
Lateness
Withdrawal
Mood
Swings
Spillover
Emotional
outbursts
Spillover
What you don’t see
Life Issues
• Stress/Emotional
• Relationships
• Legal/ Financial
• Addictions
Work Issues
• Environmental
• Interpersonal
• Job-Related
KNOWING THE SOURCE OF THE PROBLEM
ALLOWS THE CASE MANAGER TO DETERMINE A
Page 31
COURSE OF ACTION
Health Issues
• Heart Health
• Nutrition
• Sleeping
• Depression

32. The Second Paradigm Shift
• Accept them and help them
• You cannot rehabilitate someone who is busy proving they are
disabled
• Malingerer’s are rare. Anxious and overwhelmed individuals are
common.
• Often the claimant is just in the wrong basket – needs family
leave, needs to change jobs, needs to be on administrative leave
or re-assigned while workplace conflict is addressed
• Chronic diseases are chronic/recurrent and need to be addressed
holistically (is public health up to the task?)
• Whatever the barrier or reason for being off work, the outcome is
better, and total cost reduced, if you support the employee and
work through the issues
Page 32

33. The Third Paradigm Shift: think long term
• Employees are there for the long term, so you
need to think long-term
• An injured/ill employee who could be at work,
but chooses not to rtw, generates a greater
loss to the organization over the long term
than the “extra” few weeks of sick leave. They
are disengaged.
• Presenteeism costs more than absenteeism
• Forcing an employee to rtw when they feel
they are “unfit” will cost the employer money
every day
Page 33

34. Tools to Assist the Shift: Health Assessment
A complement to, not a replacement for, a discussion between
manager and employee.
Health Assessment Type
When to use
Health Status
•Proactive
•Accommodation Issues
Attendance
•Medical issues impacting attendance
•Level 3-Attendance Support
Ergonomic
•Persistent Ergonomic Issues
Return to Work
•Assess fitness to return to work from LTD,
Administrative Leaves, etc. (used
infrequently)
Page 34

35. Train Managers to Identify Employees at Risk
• How to help employees stay at work
– Identify employees who is having difficulties, as early as
possible.
• Absence is a predictable event
– How to predict absences?
• Know the workplace / know the people and know when
action is necessary
Page 35

36. Tools to Assist Shift:
Attendance/Performance Improvement
Program
• Triggered when there is a demonstrated history of being over the average
for the department for absence or not meeting performance targets
• Absence is absence
–– it’s not why you missed work, it’s that you missed work (assumed
innocent).
• The reasons for the absences/poor performance determine the help
needed.
• Early identification is key.
• No fault, no blame but the absences/performance is an issue
–What can you do? What can we do?
• Non-disciplinary
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36

37. Transitional Return to Work
Page 37

38. Transitional Return To Work
• Focus on ability not inability
• Manager and employee (+/- health services)
• Part of corporate culture - it should be expected
(and employer should be prepared with
options)
• Time limited – it’s a transition not a move
• Progressive (but flexible)
• Must be safe (for ee, co-workers, public)
• Goal is rehabilitation – it cannot be punitive
• Work must have meaning
• Workplace must be welcoming
Page 38

39. Bell Aliant is Committed to Early and
Safe RTW (as is the Union!)
• 28.12 It is agreed that the rehabilitation of
sick and injured employees is a priority. The
Company and the Council will participate in
programs that will enable early and safe
return to work…The rehabilitation plan will be
based on the employee’s functional
capability, input from the employee’s existing
health care providers, and other health care
professionals as deemed necessary by the
company.
Page 39

40. Manager and Employee can decide on
modified duties – LRA 2008-04.
• If the employee’s restrictions are expected to last 30
days or less and the employee can be
accommodated under the terms of the collective
agreement, no action is required other than
proceeding with the accommodation request. If
however, the employee cannot be accommodated
under the terms of the collective agreement, then
medical documentation may be required. At any
time, the manager can seek input from Health and
Wellness. The manager must inform the local shop
steward of the details of the accommodation and the
duration.
Page 40

41. Mental Health Initiative
• 1/3rd of claims, last 50-100% longer
• MH issues start young and recur
• Often months of presenteeism before absence
(opportunity to intervene)
• There are often workplace drivers and workplace
solutions! (another opportunity to intervene)
• Mental health awareness training for Leaders of
people
• Educational sessions, communications
• Focus on early recognition, highlight resources
Page 41

42. Results of this Approach
•
•
•
•
•
•
Gross Absence Rate* 4.5%>4.3%>4.1%>3.6%>3.6% (2013)
SDB as % salary` 1.36%>1.28%> 1.24% >0.97% >0.99%
Denials < 1% - usually wrong basket
Grievances on denials – rare
Relationship with Union - positive
# of Health Assessments – increased (some referred by
Union)
• # of IMEs for SDB adjudication – rare
• # of IMEs for HA’s and SDB mgmnt - frequent
* Cdn GAR: Company >500 ee =4.4%;Unionized Workplace 5.3% (stats can 2011)
`SDB % of Income Cdn average 1.5% (Towers Watson)
Page 42

43. Lessons Learned
•
•
•
•
•
•
•
•
•
•
Accept and Assist trumps Deny and Defend
Think Total Cost and think long term
Talk to employees, not doctors
Engage HR/LR/Ops in program development – make them
stakeholders/ambassadors; train mgrs/union
Don’t under estimate cultural resistance
Become health navigators – focus on Chronic Disease
Orient new employees/managers
Address presenteeism- its your next SDB claim, offer help
Performance = Attendance improvement
EE who can, but won’t participate in TRTW, is likely
disengaged and a problem beyond their SDB claim
Page 43

44. THANK YOU ……….Questions?
Page 44