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  • ACOEM Responds to Social Security Administration Request for Information on Improving Work Outcomes for Musculoskeletal Disabilities

    January 11, 2017

    Office of Regulations and Reports Clearance
    Social Security Administration
    3100 West High Rise Building
    6401 Security Boulevard
    Baltimore, Maryland 21235–6401

    Re: Docket No. SSA–2016–0036

    To Whom It May Concern:

    The American College of Occupational and Environmental Medicine (ACOEM) is pleased to respond to the Social Security Administration regarding a “Request for information on strategies for improving work outcomes for individuals with musculoskeletal disabilities.”

    ACOEM is a national association representing over 4,000 occupational medicine physicians and other occupational health professionals, who champion the health and safety of workers, workplaces, and community environments.

    ACOEM has long been an advocate for a systematic assessment of patients’ functional abilities, and a proponent of clinical and administrative initiatives that allow patients to stay at work, whether at full or modified duty, and to return to work as early as possible in order to avoid the risks of delayed recovery. In multiple publications, we have emphasized how important it is to start such interventions early in the course of treatment for musculoskeletal injuries, recognizing that patients whose return to work is delayed for even several weeks are at much higher risk of never returning to gainful employment.

    Additionally, ACOEM was one of the first medical associations to publish evidence-based treatment guidelines, calling into question the use of opioids in treating most patients with musculoskeletal pain, including chronic back pain and chronic pain related to degenerative joint disease, recognizing that no medical evidence supported the efficacy or the long-term safety of chronic opioid use in such patients, or in most other patients with non-malignant chronic pain syndromes.

    ACOEM concurs that preventing needless disability, and enabling persons with various musculoskeletal impairments to return to work is a worthy goal. We firmly believe, based on an enormous evidence base, that persons who manage to return to gainful and rewarding employment, despite some level of ongoing chronic pain and documented impairment, will find themselves healthier, happier, and more financially secure.

    We offer the following responses to the questions posed in the docket.

    General Questions

    1. What specific programs or practices have shown promise at the State or local level to assist workers with musculoskeletal impairments to remain in or re-enter the workforce?
    2. What programs and practices might be especially applicable to individuals who might be enrolled in SSDI in the absence of interventions, and how might those programs and practices be incorporated into a potential demonstration project?

    ACOEM is aware of a number of employer groups who have demonstrated significant improvements in return-to-work or stay-at-work following the opening of a workers’ compensation claim for a musculoskeletal injury. Key components of such intervention include treatment by an occupational medicine clinician or other clinician skilled in disability management, a focus on function in multiple life activities including home chores and recreational exercise, a sensitivity to “red flags” that are likely to be associated with delayed recovery, and sufficient time and provider interest in negotiating the details of work restrictions or an activity prescription. Additionally, all members of the health care team must be attuned to the importance of functional assessment and functional recovery, and must be alert to presence of emotional cues in the patient’s language and behavior, including misplaced fear of catastrophic re-injury, anger at the employer or caregivers, and hope for secondary gain. We believe that such clinical interventions, initiated as early as the first visit following a potentially disabling injury, will prevent as many as 50% of cases from progressing to a state of needless disability.

    By contrast, such interventions started later in the course of treatment have a lower chance of succeeding, but will often still be worthwhile.

    A number of research articles attest to the success of integrating the key principles of “early return to activity” and “early return to work” into medical treatment – both key concepts in the approach to patient care utilized by the workers’ compensation system and practitioners of occupational and environmental medicine. ACOEM has captured much of the scientific backing for functionally based treatment and return-to-work (RTW) in the clinical guidelines it has developed over the last two decades. The main tenet of these guidelines is to teach providers to focus on return to function, activity and work using a model of integrated care and setting expectations. ACOEM first published evidence-based guidelines in 1997 for the treatment of common workers’ compensation injuries, such as low back pain, shoulder injuries, and cumulative trauma.

    Research shows that states which adopted functional guideline concepts, such as those outlined in ACOEM’s Practice Guidelines, have seen significant improvement in reducing medical costs and returning individuals to function and to work. An example is Colorado, which has served in recent years as a testing ground for functionally oriented guidelines. Colorado formally educates physicians on how to incorporate functionally based treatment and RTW into their everyday clinical practices, and these physicians are compensated by the state for following and documenting these principles. After the Colorado guidelines were developed and the principles of functionally based treatment and RTW were more widely taught in the state, Colorado experienced a significant and continued decrease in disability rates and medical costs, compared to national levels, in its workers’ compensation system.

    Various other institutions are also beginning to view functionally based treatment and return to work in a new light. The Agency for Healthcare Research and Quality (AHRQ), for example, acknowledged the importance of a focus on return to work with its formulation of the Center for Medicare and Medicaid Services’ low-back pain pay-for-performance elements.

    A growing list of studies has also proven that these skills, when incorporated into institutional programs aimed at returning function to workers, can save medical costs and decrease disability. A good example is Navistar, which implemented a health and productivity management strategy in 2000 focusing on primary, secondary and tertiary prevention. The overall objective of the program was threefold: to maintain and/or improve the health of the individual; to manage and reduce the impact of health costs on the organization; and to maximize the health benefits for employees. A study was conducted on the overall costs to Navistar for employee health benefits from 2001 to 2009. Results of the study showed that total direct costs — driven by transactions that employees have with the health care system — decreased by 16%. After adjustment for other factors, the drop remained significant at 8.5% or $426 per employee. In addition, the average work limitation, the annual average number of absentee hours, and the annualized rates for workers’ compensation, short-term disability and long-term disability recorded drops that were highly significant when adjusted by relevant research factors.

    Another example is the University of California (UC), which launched a program in 2012 aimed at reducing its disability costs. Data from 2011 from one UC campus (the University of California Los Angeles) showed that 4,181 of its employees had multiple workers’ compensation claims (15,944 injuries). Of these, 968 employees had filed 5 or more claims (23%), and 223 employees (5%) had filed 10 or more claims.

    In an effort to address workers’ compensation costs and reduce multiple claims, UC launched a program to lower employee health risks, such as smoking, obesity, poor nutrition and lack of exercise. Employees selected for the program, called WorkStrong, participated in a variety of behavior modification activities, ranging from life coaching to smoking cessation, and other wellness services, including personal fitness coaching. A typical program includes 12-22 personal training sessions, 6-10 consultations with a dietitian, and a 6-month gym membership. This focus on function resulted in a decline of 29% in actual versus projected workers’ compensation claims, based on prior experience for the population in the program.

    Patients on chronic opioids present a special challenge, and in the recent few years multiple sets of guidelines have been published on best practices in managing patients on chronic opioids. ACOEM believes that many patients on chronic opioids have still never had the benefit of clinical management strategies that are becoming the standard of care, including the use of narcotic agreements, careful attention to the concomitant use of other psychoactive medications such as benzodiazepines, certain muscle relaxants, and street drugs, titration of dose to function, and appropriate consultation with other specialists including pain specialists and addiction specialists where appropriate.

    Specific Questions

    1. Should we target specific types of musculoskeletal impairments in a demonstration project? If so, which ones, and why those?

    Because lumbar spine and cervical spine problems comprise the largest subset of musculoskeletal problems producing long-term disability, patients with chronic low back and neck pain should be strongly considered for inclusion, with the caveat that patients with profound neurological impairments are much less likely to be helped by the kinds of interventions discussed above. Furthermore, patients with chronic pain in the hand/wrist (as caused, for example, by tendonitis carpal tunnel syndrome, or osteoarthritis of the wrist), shoulder, and knees but without significant joint instability might also benefit from enrollment in a demonstration project. Interventions for patients with musculoskeletal problems of the extremities might especially benefit from consultation with occupational therapists and ergonomists, to explore options for reasonable accommodation of their impairments.

    2. What is an appropriate age range of individuals with musculoskeletal impairments for us to consider targeting for a demonstration project? Why?

    ACOEM is not aware of data that would help with targeting of specific age ranges for such demonstration projects, but would point out the existence of a substantial medical literature on special challenges in disability management posed by aging workers.

    3. Which populations should we consider targeting? How can we identify these populations? How many individuals enter these populations per year?

    We recommend that populations with work-related injuries should be targeted.

    4. What types of sites (for example, state vocational rehabilitation agencies, medical practices, etc.) would be the most beneficial for us to consider.

    Large state funds, large workers compensation carriers, health and welfare funds (ERISA), large unions are good candidates for sites. In addition, we recommend large multi-state clinic systems such as Concentra and large employers, such as Safeway.

    5. Are there sites we could look to as exemplars based on current practices for serving individuals with musculoskeletal impairments? What evidence exists to suggest these sites are effectively providing early intervention services for workers with musculoskeletal impairments?

    Washington State, emerging programs in Colorado, and perhaps other states which are beginning to add more innovative programs, such as Ohio.

    6. How might we consider structuring a demonstration project to investigate the potential for screening workers for their likelihood of responding to employment supports?

    As suggested in our reply to the “General Questions” above, individuals who have not had the benefit of clinical interventions likely to prevent needless disability may be the highest priority. That is, SSI applicants, or other individuals with chronic disability, might be queried about their previous care. Individuals who have not been cared for by an Occupational Medicine team, or other clinical team skilled in disability management, or who are taking chronic opioids without the benefit of current techniques for chronic opioid use, or who have ongoing “red flags” for delayed recovery that have never been addressed, should be a priority for additional interventions.

    7. What types of health services should we consider for workers with musculoskeletal impairments?

    ACOEM recommends that clinicians should be guided by the use of evidence-based clinical guidelines, such as the ACOEM Practice Guidelines, which describe which clinical interventions have been proved to help. (Such a consideration will also be relevant to Questions 8-10.)

    8. When should these services be provided?

    We believe the best intervention time is at the initial visit and within the first 3 months. Our guidelines advocate early intervention as continued time off work leads to permanent disability even in the absence of significant physiological findings.

    9. To what extent should we prioritize certain services, whether case management, care coordination, or other on-site work support services?

    No response

    10. Are there rehabilitative and pain management healthcare delivery models that we should consider combining with other work support services? What specific healthcare practices and models should we avoid or discourage?

    See above

    11. What are the best ways to involve workers with disabilities in planning and implementing a demonstration project in order to ensure that demonstration project services will be effective in meeting their needs?

    ACOEM believes that workplaces with structured health-and-safety committees that include joint labor-management participation have the highest likelihood of achieving a culture of health, and of successful problem solving with regard to accommodation of workers with musculoskeletal impairments.

    12. What health service program designs and interventions demonstrate promise for improving long-term employment outcomes for workers with musculoskeletal impairments? What evidence supports these interventions?

    We would like to propose a project using a clinical decision support tool embedded in the electronic medical record to support primary care clinicians in preventing and managing work disability. As part of a NIOSH funded project, ACOEM convened a group of subject matter experts to create a Knowledge Resource that provides the scientific basis and framework for a clinical decision support tool for this purpose. The project team focused on acute low back pain with and without leg pain because of its prevalence, association with disability and cost to society and patients. The tool would auto-populate a return-to-work prescription and provide other just-in-time clinical support for disability prevention and management. This tool should reduce provider burden and reduce disability. Full details of the project are expected to be published in February and posted on the ACOEM web site (www.acoem.org).

    13. What specific employment related interventions related to skill development, job training, job placement, or pre- and post-placement services should we consider for individuals with musculoskeletal impairments?

    No response

    14. What employment program designs and interventions demonstrate promise for improving long-term employment outcomes for workers with musculoskeletal impairments? What evidence supports these interventions?

    This question may be the most important one of all. In response, we would point to the growing body of literature demonstrating that workplaces with a strong emphasis on worker well-being and with a goal of achieving a culture of health have a proven track record of decreased injuries, a dramatically reduced risk of causing long-term disability, improved worker productivity, and business success. Encouraging employers to adopt best practices with regard to total worker health is a key goal of ACOEM, and should be a key goal for the nation.

    Thank you for your consideration of our comments. Please do not hesitate to contact me or Patrick O’Connor, ACOEM’s Director of Government Affairs, at 703/351-6222, should you have any questions.

    Sincerely,

    James A. Tacci, MD, JD, MPH, FACOEM, FACPM
    President