Everything is not what it seems — vested interest has a significant but unspoken influence
If a dollar saved is a dollar earned, why aren’t Canadian companies challenging the colossal cost of unnecessary treatments received by thousands of employees collecting disability benefits?
Here’s the problem: Everything is not always what it seems in the disability management industry. Vested interest has a significant but unspoken influence. So if you’re a disability case manager who sometimes feels like Alice in Wonderland, allow me to debunk some myths about disability management based upon my experience reviewing the reports from more than 60,000 independent medical examinations.
Myth 1: Treatment is good for you
Treatment can be very beneficial for patients when it is evidence-based, medically appropriate and time-limited. However, treatment providers for the disability management industry often succumb to the financial motivation of unnecessarily extending expensive “treatments” well beyond evidence-based medical necessity, thereby delaying an appropriate return to work.
Many treatments involve the inappropriate use of narcotics and modalities with little evidence-based support. These treatment “industries” include passive physiotherapy, massage, craniosacral therapy, TENS (transcutaneous electrical nerve stimulation), facet joint injections, dry needling/IMS (intramuscular stimulation), trigger point injections, acupuncture, naturopathic and chiropractic “therapies,” prolotherapy… the list is as long as an insurance carrier’s willingness to pay.
But unnecessary or excessive treatment is not just a waste of money — it can actually harm otherwise healthy employees by medicalizing them into believing they are truly disabled and unfit to return to their normal life, including work.
Myth 2: Disability is an insurance matter
Wrong. While the insurance carrier is a critical partner in disability management, disability claims are first and foremost a medical issue.
Wonderful things happen for employees (and companies) when diligent case managers have a well-supported medical diagnosis as the basis for approval of time-limited and medically effective treatment. This is the best strategy to optimize a safe return to work, while simultaneously preserving self-esteem and minimizing retraining costs.
With timely and appropriate medical direction, any conscientious case manager can significantly reduce the number of long-term claims, thereby decreasing the insurance carrier’s premiums — while increasing corporate wellness, productivity and profitability.
Myth 3: The family doctor’s note is sacred
Family physicians and general practitioners are frequently thrust into the difficult situation of being asked for a disability note before necessary diagnostic investigations or specialist referrals can be completed. In the absence of such evidence, it is ethically challenging for any physician to provide a note for the patient’s employer that estimates the duration of disability — recognizing that GPs are not only providing medical services, but also operating a business that depends on satisfying the expectations of customers.
Consequently, vague disability notes from GPs — or the “Elephant-in-the-room syndrome” — are, in my opinion, the single biggest contributor to the massive cost of disability in Canada.
Surprisingly, many disability case managers are unaware of their right to challenge unsupported GP opinions. And many doctors are not always fully aware of their obligations for information sharing. (Information guidelines for employees, employers and doctors are generally available from human rights commissions across Canada.)
Family doctors and specialists may disagree on diagnoses, causation or treatment, but when there is disagreement, the independent opinion of a specialist pertinent to the disability generally takes precedence.
Myth 4: Case managers are powerless
Many of the outsourced disability case management companies in Canada could be more accurately described as “case-monitoring” companies — relaying messages to-and-fro, often with little resolution, between the family physician, the employer, treatment providers and the insurance carrier. And employers generally accept the resulting annual insurance premium increase if it is within an approved budget band, even if it could have been avoided.
In fact, all case managers have every right to ask an employee’s GP for further information (within the limits of privacy legislation) if the original note is unsatisfactory — even if the case has been accepted for disability coverage by the insurance carrier. If subsequent information is still unsatisfactory or unsupportable for ongoing disability, then case managers have the right (indeed, the duty) to challenge the medical authenticity of disability claims with an independent medical examination (IME) or document review — which is often paid by the insurance carrier as per contract provisions.
While case managers will never create revenue for their employers, they are not always fully cognizant of the scale of savings that can result from more medical involvement in decision-making. For example, one major Canadian city reduced its long-term disability claims by 38 per cent over just a couple years — a saving of millions of dollars. This corporate wellness achievement was realized simply by adopting a diligent management philosophy that required medical substantiation for every case that failed to achieve a return to full-time work after time off for appropriate treatment. And the resulting water cooler gossip very effectively communicated this organization’s new evidence-based protocol.
In other words, while Canada’s disability management industry might superficially appear to be functioning reasonably well, a significant number of vested-interest stakeholders sometimes — quietly and inappropriately — benefit; whether they be GPs, treatment providers or outsourced case management companies.
However, I have the highest regard for case managers toiling in-house for employers and within insurance companies as their sole focus is the very difficult job of getting employees back to work safely and efficiently.
In summary, all disability case managers need to be constantly alert for claims that go in endless circles or claims that just don’t appear to be reasonable. Positive, timely intervention is sensible and accessible anywhere in Canada. The myths of this industry can be cost-effectively countered with independent medical expertise — and much-needed, frank dialogue
Roger Hodkinson is the CEO and medical director of Western Medical Assessments in Edmonton. He can be reached by email at email@example.com.