Ideal disability management practices: a survey of disability management advocates and practitioners.
Various authors have suggested specific practices, such as early intervention (Jarvikoski & Lahelma, 1981), medical case management (Perham, 1984), employers showing concern for injured workers (Bradford, 1987), new employee medical screening (Hester, Decelles, & Keepper, 1989), transitional work centers (Habeck, Williams, Dugan, & Ewing, 1989), employee assistance programs (Akabas, 1984), and home employment opportunities (Belau, 1985).
DM advocates have also promoted good DM practices by presenting descriptions of various employer-based DM programs (e.g., Beaudway, 1986; Hood & Downs, 1985; Scher, 1985; Tate, Munrowd, Habeck, et al., 1987). Galvin (1986) and Gottlieb, Vandergoot, and Smart (1987) have gone beyond the mere presentation of program descriptions by identifying characteristics of good programs. In addition, some researchers have conducted employer surveys to determine employers' hiring and job retention practices for disabled people (Louis Harris, 1987), employers' cost-containment practices (Hester, Decelles, & Planek, in press; Schwartz, 1986), and corporate resistance to DM policies (Shoemaker, 1989).
One approach, previously untried, is to ask those people involved in advocating or practicing disability management what practices they recommend. This study was undertaken to do just that. We felt that surveying those who were involved in providing employer-based DM services, consulting with employers, and/or advocating DM services would serve two purposes. First, it would provide a guide to some generally accepted ideal DM policies and practices. Second, it may identify some possible DM practices that are controversial and thus stimulate critical research.
One hundred and sixty-three people, who, on the basis of their positions, could reasonably be expected to be knowledgeable of disability management, were sent survey forms. Of these, 62 people (38 percent) responded.
Of those responding, 32 percent work for universities or nonprofit rehabilitation agencies, 23 percent work for corporations or public employers, 18 percent are in private rehabilitation practice, 11 percent are employed by insurance carriers, and the remaining 16 percent work for state workers' compensation boards, the Federal Government, state vocational rehabilitation agencies, and labor unions. The respondents have been in their current positions for an average of 6.9 years.
As far as their expertise in disability management is concerned, 95 percent are corporate DM managers or consultants to employers and/or write or speak on disability management. Some 76 percent have been providing DM consulting services to employers and have an average of 8.8 years in disability management consulting. During this time, they consulted with an average of 48.5 employers. Fifty-five percent of the respondents indicated that they authored an average of 6.9 publications on disability management; 74 percent have given an average of 34.4 DM presentations; and 29 percent have taught an average of 4.4 college courses on disability management.
The Ideal Employer-Based Disability Management Practices survey was loosely based on the employer survey developed by the Menninger Return to Work Centers (RTWC's) in cooperation with the National Safety Council (Hester & Decelles, 1990). It consisted of 41 items grouped according to various aspects of employer-based disability management programs (i.e., benefits, disability cost containment, preventing employee disabilities, job retention programs, return to work programs, and the team approach to disability management). Twenty-four of the items were statements to which the respondent indicated on a seven-point Likert scale (Likert, 1932) the degree of their agreement or disagreement (with "1" indicating the highest agreement and "7" representing the strongest disagreement). Four of the items dealt with disability prevention, optional work arrangements in job retention and return to work programming, and the composition of a disability management team. In these items, various programs or staff were listed and the respondents were asked to indicate the importance of each in the accomplishment of the stated task (e.g., prevention of employee disabilities). The importance of each was also rated on a seven-point scale (with "1" signifying very important and "7" representing very unimportant). Since each program or staff person was considered separately, the respondents could rate all of them as very important or very unimportant. Twelve of the items concerned the appropriateness of various departments or individuals in performing different job retention or return to work tasks (e.g., monitoring the progress of services). One item asked the appropriateness of various timeframes (e.g., 3 days or less after injury or illness) for contacting employees who become disabled. The appropriateness of staff or timeframes was rated on a seven-point scale (with "1" indicating very appropriate and "7" for very inappropriate).
Using the data from all respondents, we computed the means (M) and standard deviations (SD) for all 41 items. On those items that consisted of multiple parts (e.g., who should provide services) we ranked the ratings on the basis of the means carried to two places, although only one place is shown.
In addition to the analysis of the ratings of all the respondents, we also wanted to compare the responses of employer-based disability managers with active DM consultants and advocates. Therefore, after analyzing the data from the group as a whole, the ratings of the 14 employer-based disability managers were separately analyzed. As a comparison group, we picked a DM "expert" group. In order to develop this group, we picked the 14 individuals (not those in the employer-based group) who have been the most visible in the DM field. Admittedly, this procedure is quasi-scientific at best; however, a review of these people's experience indicates that they have above average credentials. All of these DM experts are engaged in providing DM consultations to employers, and have been for an average 12.0 years. During this time, they have served as consultants to an average of 73.4 employers. All of these DM experts have written on disability management and have averaged 9.6 publications per person. Likewise, all of these DM experts have made DM presentations. The average number of presentations per person is 68.9. Seventy-one percent have taught an average of 6.1 college courses on disability management.
The results follow for each of the six survey categories. Unless otherwise indicated, any differences between the employer-based disability managers and the expert DM groups are not significant. The lower the score, the more the group agreed with that item or the more appropriate or important the department or practice was seen.
On average, the respondents were in moderate agreement that short-term disability (STD) programs should be fully funded by employers rather than having employee contributions. However, they disagreed about long-term disability (LTD) funding, with 40 percent agreeing that they should be fully funded (indicated by ratings of "1," "2," or "3") and 52 percent disagreeing (as shown by ratings of "5," "6," or "7"), and 8 percent undecided (as shown by the rating, "4").
As far as which types of disability benefits should be deducted from LTD benefits, the respondents felt most strongly that workers' compensation (WC) benefits should be deducted from LTD benefits. They were less positive, in general, about deducting social security disability insurance (SSDI) benefits and even less about deducting disability retirement benefits. In the case of disability retirement benefits, the expert DM specialists were more in favor of deducting disability retirement benefits from LTD benefits than the employers were. This difference is significant.
The respondents generally agreed that the occurrence of a disability should be a reason for being allowed to take a corporation's early retirement benefits. Employer-based disability managers were significantly more in favor of this than the group of expert DM specialists. The expert DM specialists were also divided on this issue, with 57 percent in favor and 43 percent opposed.
Disability Cost Containment
As expected, 90 percent of the respondents rejected the idea that it is impossible for employers to reduce their WC costs and 92 percent indicated that they believed that returning disabled employees to work would greatly reduce the employer's costs of disability.
The respondents, in general, did not believe that having an employee committee approve LTD claims would properly contain LTD costs. However, this item provoked the greatest percentage (34 percent) of undecided ratings. Forty-five percent were opposed to the idea of having such committees approve LTD claims, while 21 percent were in favor of it.
The idea that auditing all types of disability claims is critical to disability cost containment was almost universally accepted. However, the employer-based disability managers were significantly more positive about the value of claims auditing than the expert DM specialist group. Virtually all respondents endorsed the idea that various disability program expenses should be shown as line items rather than being aggregated as total disability expenses or as overhead. Most of the respondents (71 percent) felt that WC costs should be charged back to the injured employee's department; however, only 47 percent indicated that LTD costs should be charged back to the disabled employee's department.
Some states have made WC records public and 53 percent of the respondents indicated that employers should know an applicant's WC history before hiring, while 29 percent disagreed and the other 18 percent were undecided.
In the event that there is a statutory waiting period before WC benefits begin, 55 percent of the respondents felt that employers should pay full wages to the employee during this period, although 31 percent disagreed. However, the respondents were generally against the practice of some employers supplementing WC benefits so that the injured employee receives a full paycheck during recovery.
Preventing Employee Disabilities
In this section of the survey, the respondents were asked how important various programs are in the prevention of employee disabilities. On-the-job safety programs were considered to be most important and employee health/preventive medicine programs were second. Back care training programs were third, closely followed by new employee medical screening programs in fourth place and employee wellness programs in fifth. The two programs felt to be least important in preventing employee disabilities are employee assistance programs (EAP's) and off-the-job safety programs.
Job Retention Programs
At the Menninger RTWC's, we developed a model of job retention programming that involves five major functions: identification of need (IN), plan development (PD), plan approval (PA), service provision (SP), and monitoring of progress (MP). In the survey, we asked the respondents to indicate how appropriate it would be for certain individuals or departments to be involved in each function. Table 1 presents the results. It should be noted that the options of insurance carrier, private rehabilitation provider, and public rehabilitation provider were not presented for the identification of need function.
The greatest number of disagreements between the employer-based disability managers and expert DM specialists involve the appropriateness of various individuals or departments in approving the job retention plan. The employer-based disability managers felt more strongly that supervisors should approve the plan than did the expert DM specialists. The employer-based disability managers were significantly more in favor of EAP specialists approving the plan. On the other hand, the expert DM specialists believed more strongly that claim managers should approve the plan.
The only other significant differences between the two groups involve the provision of job retention services and the monitoring of progress. The expert DM specialists were less adamant that claims managers should not provide these services. Employer-based disability managers were stronger in their feelings that supervisors should monitor the progress of job retention services.
The availability of optional work arrangements can be an important component in facilitating the job retention of employees with progressive or chronic disabilities, However, it is most likely that various optional work arrangements are not considered to be equally important. The respondents, as a group, rated the availability of part-time/flexitime work, the possibility of job transfer, and equipment/tool modification as the three most important options. Job duty redefinition was fourth and the possibility of light duty was seen as the fifth most important option, while retraining was considered to be the least important option.
Return to Work Programs
The Menninger Return to Work (RTW) model identifies seven distinct functions within return to work programs: initial contact (IC), tracking progress during recovery (TP), identification of need (IN), plan development (PD), plan approval (PA), service provision (SP), and monitoring progress (MP). Table 2 shows how appropriate the respondents felt various individuals or departments would be in assuming each of these functions,
The expert DM specialists felt that claim managers should be more involved in approving the return to work plan. Likewise, the expert DM specialists believed that the occupational health staff are appropriate providers of return to work services, which is significantly different from the belief of employer-based disability managers. Also, the expert DM specialists felt that the occupational health staff should be more closely involved in the monitoring of the progress of return to work services. On the other hand, the employer-based disability managers believed more strongly that private rehabilitation specialists should be involved in monitoring the progress of these services. The employer-based disability managers also felt more positively that public rehabilitation specialists should be involved in monitoring services.
In addition to seeing how much involvement each of the two groups felt each individual or department should have in each return to work function, we also looked at how the two groups perceived what their overall involvement should be. We found that the expert DM specialists felt that occupational health staff should be more involved in return to work programming. On the other hand, employer-based disability managers believed that public rehabilitation specialists should be more involved in return to work programming.
An important part of an effective return to work program is the availability of optional working arrangements to facilitate the return to work process. The respondents, in general, felt that part-time return to the same job is the most important option, followed closely by having a light work opportunity available. The other options that are seen as slightly less important are: work hardening, employment in a different job, job duty redefinition, retraining, and having a separate area set up as a transitional work center. As far as having home employment available as an option is concerned, the respondents were quite divided as to its importance. Forty-four percent felt that it is important, 35 percent that it is unimportant, and 21 percent were undecided.
As shown in Table 2, the respondents expressed the belief that the employee's supervisor is the most appropriate person to make the initial contact with the employee; 76 percent of the respondents felt it should be done in person rather than by telephone. In addition, 77 percent of the respondents believed that this initial contact should never be done by mail.
Regarding the timing of this initial contact, 85 percent felt that it should be done within the first 3 days after the injury or illness. Seventy-seven percent of the respondents indicated that 4 to 10 days after the injury or illness would still be appropriate. The other options presented were considered progressively inappropriate: 11 or more days after the injury or illness, when the employee becomes eligible for disability benefits, an indeterminate time after injury or illness, and when the employee has used up available sick time.
In other matters concerning return to work programming, 94 percent of the respondents felt that if the employee were injured on the job the employer should help the employee file for WC benefits. Eighty-nine percent of the respondents indicated that if a company is unionized, the union should be involved in the establishment and operation of the return to work program.
In this survey, we also asked about the employers' responsibility to those disabled employees who cannot return to work with their former employers. Eighty-five percent of the respondents indicated that the employers should help these employees find an appropriate job with another employer, A smaller percentage (62 percent) indicated that employers should assist these people in obtaining SSDI benefits.
Ninety percent of the respondents felt that it is important to routinely designate a group of professionals to direct or manage job retention or return to work efforts and 95 percent believed that if a DM team were established, the employee's supervisor should be part of the group. In addition to the employer's supervisor, the respondents, in general, stated that it was most important for a rehabilitation specialist to be part of the DM team; they indicated that the next most important person would be an industrial physician. In descending order, the importance of other staff according to the respondents are: safety/occupational health specialist, industrial nurse, personnel or human resources staff, EAP specialists, industrial engineer, benefits specialist, and psychologist or psychiatrist.
In their choices of which staff should be part of a DM team, there were some significant differences between the employer-based disability managers and the expert DM specialists. The employer-based disability managers were more in favor of having an industrial engineer on the team. The employer group also felt that it is more important to have a psychologist or psychiatrist on the DM team. Finally, the employer-based disability managers were more in favor of having personnel staff on the team. On the other hand, the expert DM specialists were somewhat more adamant about having a rehabilitation specialist on the team.
Discussion Ideal Employer-Based DM Program
Of the 41 items in this survey, the respondents were in reasonable agreement on 28. We arbitrarily considered that a consensus was formed if 75 percent of the respondents were in agreement on an item. Using this as a guide, we can define some elements of an ideal employer-based DM program after pointing out that there was general agreement that employers can reduce their WC costs and that returning disabled employee' s to work will greatly reduce the employer's costs of disability.
The respondents indicated that in the ideal employer-based DM program all types of disability claims should be audited in order to contain disability costs. They were also in agreement that the expenses of the various disability programs should be shown as line items rather than aggregating them as total disability expenses or as overhead.
While many programs can help in preventing disability, the respondents felt that the most important are: onthe-job safety, employee health and preventive medicine, back care training, and new employee medical screening programs.
According to respondents, supervisors should identify employees who need assistance. While the job retention plan should be developed by the medical or occupational health department, the employee's supervisor should be the one to approve the plan and make the decision to initiate it. After approval, a private rehabilitation specialist should provide the services and the employee's supervisor should monitor the effectiveness of these services. An ideal job retention program should allow part-time or flexitime working arrangements in order to assist in the retention of employers with progressive or chronic illnesses. Programs should allow employees to transfer into jobs more compatible with their abilities and/or permit their equipment or tools modified according to needs.
In an ideal employer-based RTW program, the initial contact with a worker who has been seriously disabled by injury or illness would be done by the employee's supervisor. This initial contact should be done in person during the first 3 days after the injury or the onset of an acute illness. If the employee cannot be visited in person, the supervisor should telephone. Initial contact by mail should never be done. If the employee was injured on the job, the employee should be told during this initial contact that the employer will help the employee in filing the necessary WC forms.
While the employee is convalescing, the medical or occupational health department would be following the person's progress. The tracking of recovery enables the medical or occupational health department to identify the need for RTW services. At this point a private rehabilitation specialist should be brought in to develop the RTW plan to be sent to the insurance carrier for approval. The RTW services would be provided by the private rehabilitation specialist and this specialist would also monitor the progress of the services.
The employer should also allow for some optional work arrangements to facilitate the RTW process. The respondents indicated that the most important options are: part-time return to their own job, the opportunity to do light work, work hardening programs, and the opportunity to be employed in a different job. For those disabled employees who cannot be employed in their former jobs and the employer does not have other appropriate jobs, the employer should assist the employees in finding appropriate jobs in other companies. The respondents also felt that if an organization is unionized, it is very important that the union is involved in the establishment and operation of the RTW program.
As far as disability management in general is concerned, the respondents believed that it is critical to routinely designate a group of professionals to manage the job retention or RTW process. In addition to the employee's supervisor, the respondents indicated that the following people, at least, should be included on this DM team: a rehabilitation specialist or disability manager, an industrial physician, a safety or occupational health specialist, an industrial nurse, and a personnel or human resources staff person.
Among the respondents as a whole, the disagreements primarily centered on benefit and cost-containment practices. Only 57 percent of the respondents felt that STD programs should be fully funded by employers and only 40 percent felt that LTD programs should be fully funded by employers. When considering LTD offsets, 64 percent of the respondents believed that WC benefits should offset LTD benefits. Sixty-one percent said that SSDI benefits should offset LTD benefits and 52 percent indicated that disability retirement benefits should be considered as an offset. Only 54 percent believed that the occurrence of a disability should be a reason for an employee being allowed to take a corporation's early retirement benefits.
While the majority (71 percent) of the respondents indicated that it was important to charge WC costs back to the injured worker's department, only 47 percent said that LTD costs should be charged back. Generally, the respondents (71 percent) were against the practice of supplementing WC benefits so that an injured employee receives a full paycheck during recovery; however, 55 percent felt that employers should pay full wages to an injured employee during the WC waiting period required in many states.
Some states allow employers access to the WC records of job applicants. Slightly over half (53 percent) of the respondents indicated that they believe that employers should know an applicant's WC claim history before hiring.
The cost-containment practice of having an employee committee approve LTD claims is rather rare and, therefore, possibly took some respondents by surprise. This may explain why this item provoked the greatest percentage (34 percent) of undecided ratings. While 21 percent indicated agreement, 45 percent were opposed to this practice. On the other hand, it is a common practice for employers to assist disabled employees who can no longer work at their company in obtaining SSDI benefits. This practice, however, was only endorsed by 62 percent of the respondents.
On the basis of this study, we can see that there is a reasonable consensus on many of the components of an ideal employer-based DM program. The major differences primarily involve issues concerning disability benefits. These controversial issues are ones which appear to deserve more research and discussion. For instance, are employees who partially bear the costs of their LTD coverage more cost conscious, or does this fact contribute to a feeling that it is a benefit they have paid for and should use if possible?
Employer-based disability managers and DM consultants should be particularly attentive to those DM practices on which they disagree. In some cases it may be that the employer-based disability managers are more realistic than the DM consultants. On the other hand, they may have become so accustomed to traditional employer practices that they have not seen the other options.
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Dr. Hester is Director of Research, Ms. Kenagy is Research Assistant, and Dr. Decelles is Research Associate at Menninger Return to Work Centers, Topeka, KS.
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|Author:||Decelles, Paul G.|
|Date:||Dec 22, 1992|
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