Sitting in a crowded legislative committee and listening to parties debate a bill inspired me to ask myself a very important question: When all is said and done and my actions are measured, am I truly a worker advocate?
The debate referenced above between bill proponents and a hesitant House Labor Committee was long and impassioned. Both parties verbalized that their respective positions on the subject matter was in favor of workers in the state. It reminded me of deliberation on legislation pertinent to prescription drugs in workers’ compensation. The worker is usually the face, at least outwardly, of pending legislation in this arena. Everyone involved in the debate seems to be advocating for the worker. However, not all bills, when carefully analyzed, are drafted for the worker’s best interest.
What characteristics does a worker advocate usually possess? What position do they take on policy impacting medical care in workers’ compensation?
The Worker Advocate in the Workplace
The employer can be considered the first advocate a worker may have. Employers set the tempo for so many facets that can positively, or negatively, influence a worker’s claim, and more importantly their health outcome. Employers ultimately shape much of the worker’s psychosocial-profile that may influence motivations to return to the workplace following a work-related injury.
A clear reflection of the employer’s advocacy for the employee, or lack of, can be seen in the company’s approach to return-to-work (RTW). Loose and inconsistent RTW policies do not breed happy or healthy employees. They produce an environment that only compounds the physiological disability with potential mental health issues, such as depression and anxiety, which can be difficult to manage. These added issues can materially lengthen disability and vastly complicate the medical scenario.
There is an abundance of research that shows unemployment is strongly associated with higher mortality, poorer general and mental health, drive higher medical consultation, medication consumption and hospital admission rates.1 Absenteeism is a slippery slope where less than half of employees are likely to ever return to the workplace after a six-month absence.2
A worker advocate in the workplace must approach return-to-work with equal diligence as a physician’s focus on appropriate medical care. A worker advocate understands that the injured worker’s presence in the workplace is therapeutic, helps to promote recovery and rehabilitation, reduces the risk of long-term incapacity, and ultimately improves that individual’s overall quality of life and well-being. The advocate sees their role as an active part of the worker’s recovery and return to productivity. All options are left on the table as it pertains to RTW knowing this is the best and quickest path to recovery.
“The best ‘medicine’ for injured workers is to return them to work as soon as safely possible”.3
The Worker Advocate in Clinic
The worker advocate in the clinic, the medical provider, is potentially the most important and, for numerous reasons, may be the most respected expert involved in ushering the injured individual back to health. The provider role is afforded the best access to the worker’s injury and recovery. In other words, medical providers have the best seat in the house.
This advocate’s role in the clinic is complex. On one hand, they are tasked with performing a service for a customer who may be at a pivotal point in their life as a result of their injury and disability and could be pressured by the prospect of low patient satisfaction scores. On the other hand, the provider is bound by the ethics described in the Hippocratic Oath – to treat the sick to the best of their ability. On occasion, these two perspectives do not align and a moral struggle ensues…enter evidence-based medicine (EBM).
Having participated in many public hearings on legislative and regulatory initiatives, I’ve consistently witnessed a divide within the provider community on the use of trustworthy EBM content, such as guidelines, formularies, etc. Some medical providers have expressed that guidelines, which are developed and reviewed for quality by their peers in medical practice, are an unnecessary barrier that impedes the doctor to patient relationship. This suggests that EBM may actually prevent them from practicing the art of medicine and deemphasizes the importance of the science of medicine and the Oath’s sworn commitment to “not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another [EBM] are needed for a patient’s recovery”.4
Recent studies show that among the top concerns of healthcare executives is minimizing clinical variation in medical care for similar health conditions. Variable and inefficient care contributes materially to the Country’s total healthcare spend of approximately $3.2 trillion while continuing to under-perform on key health outcomes compared to other industrialized nations.5
The true worker advocate in the clinic realizes that when high quality scientifically based standards are provided through Clinical Decision Support (CDS) tools, outcomes are vastly improved for their patients. A study published in the winter of 2017, quantifying the duration of disability and medical costs of patients who underwent Carpal Tunnel Release (CTR) surgery found that using EBM opioid prescribing guidelines would reduce disability durations by 124,000 days per year among the CTR procedures analyzed and save $71 million in medical expenses.6 This impact is for only CTR procedures!
In a 1996 editorial in the British Medical Journal, David Lawrence Sackett defined EBM as “…the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”7 It was further noted that the practice “…means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”7
EBM is not intended to replace the worker advocate’s voice in the clinic. It is intended to compliment clinical expertise with the best available scientific evidence. A worker advocate does not reject the judicious use of high quality scientific evidence to inform their practice recommendations. They embrace all available high quality tools.
The Worker Advocate in Research
Worker advocacy in the field of research is touchy. There is always a crushing amount of academic material that is thrown into the public domain – much of it under the guise of independent research. Rest assured, truly independent research is not as abundant as some would lead us to believe. Even the longest standing research institutes have financial contributors with special interest setting research agendas and ultimately slanting the research in their favor with no one being the wiser.
Institutions whose boards are mostly comprised of, and in some cases entirely comprised of shareholders with a financial interest in the published outcomes, are not worker advocates or advocates of objective scientific research. Their primary advocacy is for their membership and will shy away from putting their research through a blind peer review process that is customary for high quality, reproducible, transparent, and objective research. In other words, if the institute conducting the research is the only entity publishing its own work, there is ample opportunity to slant outcomes in favor of their and their supporters’ interest.
They are entirely within their rights to advocate for their funding sources, this should not be a point of criticism. So long as they are intentional and clear in disclosing this conflict to their audience, the research should still be assigned merit according to the quality of the development methodology and final research outcomes adherence to the established methodology. It becomes problematic when these interests are not disclosed appropriately and the research is advertised as being independently developed.
The worker advocate in research is transparent, embraces accountability, and engages in discussions with those who disagree or may have areas of concern about the research it develops.
The Worker Advocate at the State
I’ve had the privilege to meet and learn from many worker advocates at the state level – legislators, regulators, and supporting staff. Most legislators are not experts in the small labor carve out that is workers’ compensation. In contrast, the majority of regulators within state workers’ compensation agencies are deeply immersed in this world daily. Without exception, these individuals are all very highly sought after by industry vendors and system influencers.
Along with the high demands on their time, state officials have an immense amount of information that they must sift through in order to appropriately inform their recommendations for public policy. As discussed above, some information is reliable, objective and trustworthy. Unfortunately, this cannot be said for all information received. Some of it can be partial, non-transparent in its development roots, and is generally packaged as the “easy” path to the solution.
A worker advocate at the state level must be motivated to dig deep into not only the findings of the research, but also the path taken to get to the findings. This ensures that the research was developed in a manner consistent with high quality standards (i.e., transparency, disclosures, methodology, blind peer reviews, etc.). Doing so ensures that the worker’s well-being and benefit is always kept at the center of the equation.
On occasion, state officials will take the easy path. They don’t spend the necessary time and effort to quality check the information that is receive. Rather than consulting non-interested experts, they align with vendors who steer them down the path of least resistance. The outcome: Policy that provides more benefits to system vendor shareholders than workers.
Being a worker advocate is not always easy, popular, or cheap. It is difficult, uncomfortable, and demands a lot of time. Not everyone will be a worker advocate, but some will. I like to believe that those who choose to do right by workers will inspire others to do the same along the way. Workers’ compensation as an industry is being acknowledged for the progress made to eliminate the opioid epidemic; it is the outcome of many worker advocates demanding the industry do better.
Rest assured more epidemics are forming today and may take years to mature. Be certain that they will be as potent, if not more, than today’s epidemic. But, what if the next epidemic never happened?
1. Waddell GA, Burton AK. “Is Work Good for Your Health and Well Being?” The Stationery Office, London, 2006. Web.
2. New York State Workers’ Compensation Board. “Why Establish a Return to Work Program”. Return to Work Program. 2018. Web. http://www.wcb.ny.gov/content/main/ReturnToWork/RTW_Handbook.pdf
3. Jurisic M, Bean M, Harbaugh J, et al. “The Personal Physician ’ s Role in Helping Patients With Medical Conditions Stay at Work or Return to Work.” 2017;59(6):125-131. doi:10.1097/JOM.0000000000001055.
4. P. PBS. “The Hippocratic Oath Today”. NOVA. March 2001. Web. 27 March 2001. http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html
5. Zaidel K. ReedGroup. “Part 3 Medical Cost Savings Series: How the US Can Save $6B in Medical Costs: The Financial Impact of Reducing Short-Term Disability Durations.” July 2017. Web. 28 July 2017. https://reedgroup.com/2017/07/28/part-3-medical-cost-savings-series-us-can-save-6b-medical-costs-financial-impact-reducing-short-term-disability-durations/
6. Gaspar FW, Kownacki R, Zaidel C, Conlon CF, Hegmann KT. JOEM. “Reducing Disability Durations and Medical Costs for Patients with a Carpal Tunnel Release Surgery Through the Use of Opioid Prescribing Guidelines”. JOEM Vol. 59, Number 12. Web. December 2017. https://journals.lww.com/joem/Fulltext/2017/12000/Reducing_Disability_Durations_and_Medical_Costs.8.aspx#O23-8
7. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. Br Med J. 1996;312(7023):71-2.