Evaluation of the Washington State Workers' Compensation Managed Care Pilot Project I: medical outcomes and patient satisfaction

Suggesting global insights to local challenges: expanding financing of rehabilitation services in low and middle-income countries

Purpose

Following the rapid transition to non-communicable diseases, increases in injury, and subsequent disability, the world-especially low and middle-income countries (LMICs)-remains ill-equipped for increased demand for rehabilitative services and assistive technology. This scoping review explores rehabilitation financing models used throughout the world and identifies "state of the art" rehabilitation financing strategies to identify opportunities and challenges to expand financing of rehabilitation.

Material and methods

We searched peer-reviewed and grey literature for articles containing information on rehabilitation financing in both LMICs and high-income countries.

Results

Forty-two articles were included, highlighting various rehabilitation financing mechanism which involves user fees and other innovative payment as bundled or pooled schemes. Few studies explore policy options to increase investment in the supply of services.

Conclusion

this paper highlights opportunities to expand rehabilitation services, namely through promotion of private investment, improvement in provider reimbursement mechanism as well as expanding educational grants to bolster labor supply incentive, and the investment in public and private insurance schemes. Mechanisms of reimbursement are frequently based on global budget and salary which are helpful to control cost escalation but represent important barriers to expand supply and quality of services.

An E-Mental Health Solution to Prevent and Manage Post-Traumatic Stress Injuries among First Responders in Alberta: Protocol for the Implementation and Evaluation of Text4PTSI and Text4Wellbeing (Preprint)

Background

First responders are confronted with traumatic events in their work that has a substantial toll on their psychological health and may contribute to or result in posttraumatic stress injuries (PTSIs) for many responders. Persons with a PTSI usually seek management therapies. Evidence indicates that digital delivery of these therapies is an innovative, efficient, and effective way to improve PTSI symptoms as an adjunct to in-person delivery.

Objective

This project aims to implement and provide accessible, convenient, and economical SMS text messaging services, known as Text4PTSI and Text4Wellbeing, to first responders in Alberta, Canada; to prevent and improve the symptoms of PTSI among first responders; and to improve their overall quality of life. We will evaluate posttraumatic symptoms and the impact of Text4PTSI and Text4Wellbeing on stress, anxiety, and depression in relation to the correspondents’ demographic backgrounds.

Methods

First responders who subscribe to Text4PTSI or Text4Wellbeing receive daily supportive and psychoeducational SMS text messages for 6 months. The SMS text messages are preprogrammed into an online software program that delivers messages to subscribers. Baseline and follow-up data are collected through online questionnaires using validated scales at enrollment, 6 weeks, 12 weeks, and 24 weeks (end point). In-depth interviews will be conducted to assess satisfaction with the text-based intervention.

Results

We hypothesize that participants who enroll in this program will have improved PTSI symptoms; increased or improved quality of life; and significant reduction in associated stress, depression, and anxiety symptoms, among other psychological concerns. Improvement will be determined in comparison to established baseline parameters.

Conclusions

This research will be beneficial for practitioners and will inform policy-making and decision-making regarding psychological interventions for PTSI. Lessons from this study will inform the scale-up of the intervention, a cost-effective, zero contact therapeutic option to manage PTSI.

International Registered Report Identifier (IRRID)

PRR1-10.2196/30680

Mapping first-line health care providers' roles, practices, and impacts on care for workers with compensable musculoskeletal disorders in four jurisdictions: A critical interpretive synthesis

BACKGROUND

First-line health care providers are the primary access point for workers' benefits. However, little is known about their impact on quality of care and return-to-work. Our objective was to critically compare literature on the practices of first-line providers for workers with musculoskeletal injuries in Ontario and Quebec (Canada), Washington State (United States), and Victoria (Australia).

METHODS

A critical interpretive synthesis of peer-reviewed scientific literature was conducted. The search across six databases yielded 59 relevant publications that were critically appraised.

RESULTS

Three themes emerged: 1) how policies about first-line health care providers' modulate worker access to care, 2) how these providers' roles, practices, and training shape disability management, and 3) how the quality of care and disability outcomes are evaluated.

CONCLUSIONS

First-line health care providers have a critical influence on workers' trajectories of care. A focus on their role while taking the complexity of the context into account will help orient future policy changes.

Patient Satisfaction Measurement in Occupational and Environmental Medicine Practice

: High patient satisfaction is a desirable goal in medical care. Patient satisfaction measures are increasingly used to evaluate and improve quality in all types of medical practices. However, the unique aspects of occupational and environmental medicine (OEM) practice require development of OEM-specific measures and thoughtful interpretation of results. The American College of Occupational and Environmental Medicine has developed and recommends a set of specific questions to measure patient satisfaction in OEM, designed to meet anticipated regulatory requirements, facilitate quality improvement of participating OEM practices, facilitate case-management review, and offer fair and accurate assessment of OEM physicians.

Return-to-work coordination programmes for improving return to work in workers on sick leave

BACKGROUND

To limit long-term sick leave and associated consequences, insurers, healthcare providers and employers provide programmes to facilitate disabled people's return to work. These programmes include a variety of coordinated and individualised interventions. Despite the increasing popularity of such programmes, their benefits remain uncertain. We conducted a systematic review to determine the long-term effectiveness of return-to-work coordination programmes compared to usual practice in workers at risk for long-term disability.

OBJECTIVES

To assess the effects of return-to-work coordination programmes versus usual practice for workers on sick leave or disability.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), MEDLINE, Embase, CINAHL and PsycINFO up to 1 November 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled workers absent from work for at least four weeks and randomly assigned them to return-to-work coordination programmes or usual practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full-text articles for study eligibility; extracted data; and assessed risk of bias from eligible trials. We contacted authors for additional data where required. We conducted random-effects meta-analyses and used the GRADE approach to rate the quality of the evidence.

MAIN RESULTS

We identified 14 studies from nine countries that enrolled 12,568 workers. Eleven studies focused on musculoskeletal problems, two on mental health and one on both. Most studies (11 of 14) followed workers 12 months or longer. Risk of bias was low in 10 and high in 4 studies, but findings were not sensitive to their exclusion.We found no benefits for return-to-work coordination programmes on return-to-work outcomes.For short-term follow-up of six months, we found no effect on time to return to work (hazard ratio (HR) 1.32, 95% confidence interval (CI) 0.93 to 1.88, low-quality evidence), cumulative sickness absence (mean difference (MD) -16.18 work days per year, 95% CI -32.42 to 0.06, moderate-quality evidence), the proportion of participants at work at end of the follow-up (risk ratio (RR) 1.06, 95% CI 0.86 to 1.30, low-quality evidence) or on the proportion of participants who had ever returned to work, that is, regardless of whether they had remained at work until last follow-up (RR 0.87, 95% CI 0.63 to 1.19, very low-quality evidence).For long-term follow-up of 12 months, we found no effect on time to return to work (HR 1.25, 95% CI 0.95 to 1.66, low-quality evidence), cumulative sickness absence (MD -14.84 work days per year, 95% CI -38.56 to 8.88, low-quality evidence), the proportion of participants at work at end of the follow-up (RR 1.06, 95% CI 0.99 to 1.15, low-quality evidence) or on the proportion of participants who had ever returned to work (RR 1.03, 95% CI 0.97 to 1.09, moderate-quality evidence).For very long-term follow-up of longer than 12 months, we found no effect on time to return to work (HR 0.93, 95% CI 0.74 to 1.17, low-quality evidence), cumulative sickness absence (MD 7.00 work days per year, 95% CI -15.17 to 29.17, moderate-quality evidence), the proportion of participants at work at end of the follow-up (RR 0.94, 95% CI 0.82 to 1.07, low-quality evidence) or on the proportion of participants who had ever returned to work (RR 0.95, 95% CI 0.88 to 1.02, low-quality evidence).We found only small benefits for return-to-work coordination programmes on patient-reported outcomes. All differences were below the minimal clinically important difference (MID).

AUTHORS' CONCLUSIONS

Offering return-to-work coordination programmes for workers on sick leave for at least four weeks results in no benefits when compared to usual practice. We found no significant differences for the outcomes time to return to work, cumulative sickness absence, the proportion of participants at work at end of the follow-up or the proportion of participants who had ever returned to work at short-term, long-term or very long-term follow-up. For patient-reported outcomes, we found only marginal effects below the MID. The quality of the evidence ranged from very low to moderate across all outcomes.

Disability prevention and communication among workers, physicians, employers, and insurers—current models and opportunities for improvement

PURPOSE

To review prevailing models of disability management and prevention with respect to communication, and to suggest alternative approaches.

METHOD

Review of selected articles.

RESULTS

Effective disability management and return to work strategies have been the focus of an increasing number of intervention programmes and associated research studies, spanning a variety of worker populations and provider and business perspectives. Although primary and secondary disability prevention approaches have addressed theoretical basis, methods and costs, few identify communication as a key factor influencing disability outcomes. Four prevailing models of disability management and prevention (medical model, physical rehabilitation model, job-match model, and managed care model) are identified. The medical model emphasizes the physician's role to define functional limitations and job restrictions. In the physical rehabilitation model, rehabilitation professionals communicate the importance of exercise and muscle reconditioning for resuming normal work activities. The job-match model relies on the ability of employers to accurately communicate physical job requirements. The managed care model focuses on dissemination of acceptable standards for medical treatment and duration of work absence, and interventions by case managers when these standards are exceeded. Despite contrary evidence for many health impairments, these models share a common assumption that medical disability outcomes are highly predictable and unaffected by either individual or contextual factors. As a result, communication is often authoritative and unidirectional, with workers and employers in a passive role.

CONCLUSION

Improvements in communication may be responsible for successes across a variety of new interventions. Communication-based interventions may further improve disability outcomes, reduce adversarial relationships, and prove cost-effective; however, controlled trials are needed.

The influence of a continuum of care model on the rehabilitation of compensation claimants with soft tissue disorders

STUDY DESIGN

Population-based before-and-after design with concurrent control group.

OBJECTIVE

As continuums of care have been little studied, we evaluated the impact of the Workers' Compensation Board of Alberta (WCB-Alberta) model on sustained return to work, satisfaction with care, and cost.

SUMMARY OF BACKGROUND DATA

Musculoskeletal conditions, such as back pain, continue to be leading causes of disability and work loss. From 1996 through 1997, the WCB-Alberta implemented a continuum of care model to guide rehabilitation service delivery for claimants with soft tissue injury. The model was designed as a decision-making tool to promote a consistent, evidence-based approach to care within the jurisdiction.

METHODS

The model was implemented province-wide so the entire population of workers insured by the WCB-Alberta was studied. Data were extracted from the WCB-Alberta administrative database from 2 years before implementation (1994-1995) to 5 years after (1996-2000). An intervention group was created from patients filing soft tissue injury claims for the low back, ankle, knee, elbow, and shoulder. The comparison group was formed of workers experiencing fractures or other traumatic non-soft tissue injuries. Satisfaction was measured through surveys. Primary outcome was cumulative days receiving wage replacement benefits. Multivariable Cox regression was used to determine the model's effect.

RESULTS

Over the entire study period, 70,116 claimants filed soft tissue injury claims while 101,620 claimants experienced non-soft tissue injuries. Significant improvement was observed in intervention group return-to-work outcomes after model implementation (hazard ratio = 1.54). Median duration of benefits decreased from 13 to 8 days. Little change was seen in the control group's disability duration (median duration, consistently 10 days). The majority of claimants were satisfied with care received. Cost savings over a 2-year full implementation period was $21.5 million (Canadian).

CONCLUSION

Implementation of a soft tissue injury continuum of care involving staged application of various types of rehabilitation services appears to have resulted in more rapid and sustained recovery.

Measuring return to work

BACKGROUND

It is argued that one of the factors limiting the understanding of return to work (RTW) following work disability is the use of measurement tools that do not capture a complete picture of workers' RTW experiences. To facilitate the investigation of RTW, the current authors proposed a developmental conceptualization of RTW, which argues for an expanded awareness that encompasses four phases: off work, work reintegration, work maintenance and advancement. This paper reports on work undertaken with the aim of operationalizing the conceptualization.

METHODS

A review of the RTW and related literature, with databases searched including PubMed, EconLit, and PsycInfo. We began by extracting details of RTW instruments used by previous researchers. We then interpreted these within the context of the phases of RTW. Using the International Classification of Functioning, Disability, and Health (ICF) to inform our thinking and coding structure, we conceptualized phase-based RTW outcomes and categorized them as 'tasks and actions', 'contextual' or 'process driven'. Iteratively, we reviewed existing instruments for their use as measures of RTW. Where gaps in instrumentation were found, the wider vocational and career assessment literature was searched for instruments that could be adapted for use in RTW research.

RESULTS

Results indicate that, although numerous research instruments have been used to assess RTW, within the scientific literature some important dimensions of RTW lack instrumentation. In particular, we found that outcomes such as goal setting, motivation, expectation, job seeking, work maintenance, and career advancement require operationalization. Amongst the outcomes had been operationalized, we found considerable variation in conceptual development and application.

CONCLUSIONS

The lack of consistency and comprehensiveness of RTW measurement is one of the factors compromising the advancement of the field of RTW research. It is suggested that a more complete and psychometrically sound array of research instruments, grounded within a commonly adopted paradigm, would further the understanding of RTW and the factors affecting it.

Policy-relevant research: when does it matter?

Evidence-based medicine is most meaningful to policy makers when research questions are clearly informed by strategic health policy questions. In Washington State workers' compensation, key structural characteristics allow for the conduct of effective policy-relevant research. These include clear authority and a stable funding stream, a formal relationship between a policy agency and a University, development of appropriate research capacity, development of research questions related to strategic goals, and a robust data source. The research conducted relies on computerized medical bills and work disability records, medical records, structured telephone surveys to collect data on pain, functional status, quality of life, and computerized data on employment status. The types of policy-relevant research include identification of factors leading to preventable disability, outcomes research of specific procedures, technology assessment, and "real-time" research that addresses rapidly emerging questions. Health policy changes implemented from research have been substantial in Washington State workers' compensation, including: 1) noncoverage or partial coverage decisions for emerging technologies not proven to be of value to injured workers, 2) formal treatment guidelines and utilization review criteria for invasive, expensive, or marginally effective procedures, 3) disability prevention efforts, and 4) relatively rapid changes in policy as emerging patterns suggest harmful outcomes from existing treatments (e.g., schedule II opioids). Key structural characteristics must be in place to conduct policy-relevant research effectively. The workers' compensation system in Washington State is a single-payer system with other unique properties that have allowed the emergence of these structural characteristics and the conduct of research linked to the strategic goals of policy makers.

Occupational medicine: the case for reform

The specialty of occupational medicine is in peril, in large part because of its reliance on financing by industry, which has powerful incentives to limit costs and to favor physicians who are useful to their employers. Occupational physicians generally practice within the framework of the workers' compensation system. Serious flaws in the incentive structure of workers' compensation constrain objectivity in their practice. Under present law they are unavoidably subject to perverse influences from employers and insurance companies. A fundamental reform of workers' compensation law and practice is urgently needed to separate occupational physicians from the control of employers and workers' compensation insurers, whose interests should not be allowed to override the physicians' integrity or to compromise the specialty.

Early retirement due to occupational injury: who is at risk?

BACKGROUND

As the workforce is rapidly ageing, research on the consequences of occupational injuries in older workers is becoming more important. One adverse outcome unique to older workers, early retirement, has significant negative social and economic consequences for workers and employers. Although linked to poor worker health, the roles of workplace factors and occupational injury have not been well-defined.

METHOD

Changes in retirement plans attributed to an occupational injury were studied in a population-based sample of 1,449 New Hampshire workers aged <or=55, using a mailed survey. Questions addressed pre-and post-injury health, job satisfaction, work capacity, nature and severity of injury, medical care, employer response, work status, pain, and financial problems.

RESULT

Eleven percent planned to retire earlier due to their work injury, and their outcomes were significantly worse. In a multivariate model, pre-injury dissatisfaction with the job and with medical care, and poor physical and mental health status were related to intent to retire early.

CONCLUSION

These factors may represent opportunities for early identification and intervention with individuals at high risk for poor post-injury outcomes. Longitudinal studies are needed to confirm the importance of these preliminary findings.

A communitywide intervention to improve outcomes and reduce disability among injured workers in Washington State

One pressing challenge facing the U.S. health care system is the development of effective policies and clinical management strategies to address deficiencies in health care quality. In collaboration with researchers at the University of Washington, the Washington State Department of Labor and Industries has created a communitywide delivery system intervention to improve health outcomes and reduce disability among injured workers. This intervention is currently being tested in two sites in western and eastern Washington. So far, it appears to be possible to engage physicians and health care institutions in quality improvement initiatives and to form effective public-private partnerships for this purpose. Furthermore, collaborating with university researchers may help enhance the scientific rigor of the quality improvement initiative and create more opportunities for a successful evaluation.

Primary care involvement and outcomes of care in patients with a workers' compensation claim for back pain

STUDY DESIGN

A retrospective case series of primary care patients receiving Workers' Compensation (WC) for back pain.

OBJECTIVE

To describe the extent of primary care provider (PCP) involvement in work-related low back pain (WRLBP), and whether PCP involvement is a significant determinant of patterns of care or outcomes.

SUMMARY OF BACKGROUND DATA

In general, WRLBP has inferior outcomes compared with nonoccupational LBP. Although it has been suggested that better outcomes are achieved when care for WRLBP involves specialists such as occupational medicine physicians rather than a PCP, limited evidence supports this claim.

METHODS

Adult patients were identified by electronic records from four hospital-affiliated PCP practices in fiscal years 1996 to 1998. Those with a WRLBP claim filed during the same time period were identified by searching a WC claims database. Medical records were reviewed to assess past medical history, the extent of prior PCP contacts for any visits before and for visits 2 years after the reported onset of the WRLBP claim, and detailed information on visits for this condition. Disability outcomes (total costs and days of work disability) were obtained from the WC database.

RESULTS

Among 68,710 individuals with a PCP practice visit, 118 with a WRLBP claim were identified. The final study sample included 87 patients with a WRLBP claim and at least 1 documented PCP practice visit during the study period. Seventy-eight percent of patients saw the PCP at least once in the 2 years after the claim onset date, but only 34 patients (39%) visited the PCP for their WRLBP, and 20 (23%) had more than 1 visit. Although almost all patients with a PCP visit for WRLBP saw a physician (not the PCP in 79% of cases) within a week of the claim onset date, the median number of days between the onset date and the first WRLBP visit to the PCP was 47.5. Patients with a prior history of back problems were more likely to have a PCP visit for WRLBP (odds ratio 2.9, 95% confidence interval 1.1-7.7). Patients with PCP visits for WRLBP had higher total and medical costs than those without PCP visits, but a similar number of paid disability days. After controlling for other potential predictors, involvement of the PCP was not a significant predictor of the total cost of the WRLBP claim.

CONCLUSIONS

Many individuals with a WC claim do not have a stable PCP relationship around the onset of their WRLBP episode. Those with PCP relationships uncommonly involve the PCP in their WRLBP, and if they do, it is usually later in the course because of persistent or recurrent symptoms. Disability outcomes appear to be similar regardless of whether a PCP was involved. However, PCP involvement is associated with greater medical costs, which may reflect confounding based on duration of symptoms rather than the nature of the care provided. Additional research is needed to understand how different patterns of care for patients with a WRLBP claim relate to outcomes and how these patients compare with individuals without such a claim, as well as the factors that lead patients to involve their PCP or not.

Integration of workers' compensation and health insurance prescription drug programs: how does it work and do employees use it?

BACKGROUND

In 1998, New York State designed and developed an integrated workers' compensation (WC)/health plan prescription drug program, ONECARD Rx, in response to cost inefficiencies within the then current system and in an attempt to improve the quality of care provided to WC claimants. This paper describes the benefit's design and development process and factors related to its use.

METHODS

Users and non-users of the program were surveyed through a mailed questionnaire with appropriate telephone follow-up.

RESULTS

Eight steps were followed in the development of the benefit. Results obtained from the assessment of ONECARD Rx suggest that factors affecting use mainly relate to the knowledge of both, employees and pharmacists, of the program. The two main differences detected between users and non-users included the state agency the employee works for and the site of residence.

CONCLUSIONS

Innovative strategies that couple private and public agencies should aim at reducing the costs and eliminating inefficiencies while improving the quality of care, of which satisfaction is an important component.

Practice characteristics and HMO enrollee satisfaction with specialty care: an analysis of patients with glaucoma and diabetic retinopathy

BACKGROUND

The specialist's role in caring for managed care patients is likely to grow. Thus, assessing the correlates of patient satisfaction with specialty care is essential.

OBJECTIVE

To examine the association between characteristics of eye care practices and satisfaction with eye care among working age patients with open-angle glaucoma (OAG) or diabetic retinopathy (DR). SUBJECTS/STUDY SETTING: A total of 913 working age patients with OAG or DR enrolled in six commercial managed care health plans. The patients were treated in 144 different eye care practices.

STUDY DESIGN

We used a patient survey to obtain information on patient characteristics and satisfaction with eye care, measured by scores on satisfaction subscales of the 18-item Patient Satisfaction Questionnaire. We used a survey of eye care practices to obtain information on practice characteristics, including provider specialties, practice organization, financial features, and utilization and quality management systems. We estimated logistic regression models to assess the association of patient and practice characteristics with high levels of patient satisfaction.

PRINCIPAL FINDINGS

Treatment in a practice with a glaucoma specialist (for OAG patients) or a retina specialist (for DR patients) was associated with higher satisfaction, whereas treatment in a practice that obtained a high proportion of its revenues from capitation payments or in a group practice where providers obtained a high proportion of their incomes from bonuses was associated with lower satisfaction.

CONCLUSIONS

Many eye care patients prefer to be treated by specialists with expertise in their conditions. Financial arrangement features of eye care practices also are associated with patient satisfaction with care. The most likely mechanisms underlying these associations are effects on provider behavior and satisfaction, which in turn influence patient satisfaction. Managed care plans and provider groups should aim to minimize the negative impact of managed care features on patient satisfaction.

Employer satisfaction with workers' compensation health care: results of the Washington State Workers' Compensation Managed Care Pilot

Developing more effective approaches to disability prevention has been a longstanding challenge for the workers' compensation system. A major obstacle to this goal has been the lack of communication and interaction between employers and physicians who care for injured workers. From 1995 through 1997, the Washington State Department of Labor and Industries sponsored a major demonstration program, known as the managed care pilot (MCP), to assess the effects of managed care on medical and disability costs, patient satisfaction and employer satisfaction. We developed a telephone survey and administered it to 243 employers as part of the MCP evaluation. Topics covered in this survey include satisfaction with treatment rendered, duration of lost work time, work modifications, and satisfaction with communication received during the employee's recovery period. Employers in the intervention (managed care) condition were more satisfied with the managed care/occupational medicine system than the employers in the comparison group were with the fee-for-service system. MCP employers were satisfied particularly with the frequency and quality of communication received from the health care provider regarding return to work and work modification issues. Improved employer-provider communication may foster early return to work and thereby have a beneficial effect on health and employment outcomes for injured workers.

Effects of provider networks on health care costs for workers with short-term injuries

OBJECTIVES

This study examines the effects of preferred provider networks on health care costs and service utilization in the treatment of work-related injuries.

RESEARCH DESIGN

A retrospective comparison of workers' compensation claims treated by network and non-network providers was conducted. Pairwise matches of individual cases are used to control for differences in case mix and severity of injury between network patients and a non-network comparison group. Cost differentials are separated into a price effect, the difference in costs attributed to network price discounts, holding services constant; and a utilization effect, the difference in costs attributed to differences in service utilization, holding prices constant.

SUBJECTS

Data include approximately 87,000 workers' compensation claims, from California, Connecticut, and Texas, with injury dates between 1995 and 1997. The samples are restricted to five common injury types and work absences of less than 7 days. Workers treated solely by network providers are compared with a matched group of workers treated solely by non-network providers.

RESULTS

Average health care costs are lower for network claims than for matched non-network claims. Price discounts explain a large part of the cost differentials for all injury groups studied, but differences in service utilization are also important for back cases and cumulative stress injuries.

CONCLUSIONS

Networks bring the traditionally high costs of health care for work-related injuries closer to the costs of health care for off-the-job injuries. The network savings primarily reflect price discounts for the same services, thereby representing an increase in the cost-effectiveness of care.

The moderators of patient satisfaction

The purpose of this study was to determine which Department of Defense (DOD) active duty patient sociodemographic, health status, geographic location, and utilization factors, predict overall patient satisfaction with health care in military facilities. A theoretical framework developed from patient satisfaction and social identity theories and from previous empirical findings was used to develop a model to predict patient satisfaction and delineate moderating variables. The major finding indicated in this study was the significance of patients' characteristics in moderating their satisfaction. Principal components factor analysis and hierarchical linear regression revealed that patient specific factors predicted patients' satisfaction after controlling for factors depicting patients' evaluations of health system characteristics. Patient specific factors provided added, although very minimal, explanatory value to the determination of patients' satisfaction. The study findings can aid in the development of targeted, objectively prioritized programs of improvement and marketing by ranking variables using patients' passively derived importance schema.

What do injured workers think about their medical care and outcomes after work injury?

Patient satisfaction is an important aspect of quality of care. Little information about injured workers' satisfaction is available. A survey instrument was developed to assess "What Do Injured Workers Think About Their Medical Care?" Survey domains included access, satisfaction, reports of physician behaviors, and outcomes after work injury. Descriptive analyses were performed on more than 800 responses. Approximately 25% of respondents reported dissatisfaction with care. Satisfaction with choice of provider, interpersonal care, claims handling, and outcomes were major predictors of overall satisfaction. Spanish-speakers were more likely to be dissatisfied with physician communications. Months after injury, many workers reported significant pain and impact on job ability and daily function. Routine evaluation of patient satisfaction with occupational medical care could facilitate quality improvement efforts and informed purchaser and worker choice of occupational health services.

Improving the quality of occupational health care in Washington State: new approaches to designing community-based health care systems

The need for concerted action to improve quality was stressed in the recent Institute of Medicine report, Crossing the Quality Chasm: A New Health Care System for the 21st Century. This article describes an innovative community-based delivery system initiative designed to improve quality and health outcomes for occupational health conditions. Known as the Occupational Health Services (OHS) project, this Washington State initiative focuses on three targeted conditions: low back sprain, carpal tunnel syndrome, and fractures. To fulfill its purpose, which is to provide clinical resources and training opportunities and foster quality improvement activities on a community-wide basis, the OHS incorporates several key delivery system components, including systems to track patient and employer satisfaction and health outcomes; formal physician agreements that will provide incentives for using best-practices; and community-based Centers of Occupational Health and Education (COHEs) that will function as a resource for providers, patients, and employers. Our experience in developing the OHS quality improvement initiative should have relevance for health care clinicians, administrators, policy makers, and researchers engaged in similar pursuits outside the field of occupational health.

Evaluation of the North Country on the Job Network: a model of facilitated care for injured workers in rural upstate New York

We describe the evaluation of a community-based program designed to facilitate access to care and return to work for injured workers in a rural, medically underserved area in upstate New York. Providers are recruited to provide easily accessible care and are oriented to concepts of transitional duty and rapid return to work as medically appropriate; companies are recruited with the agreement to provide transitional work for injured employees. Registered nurses, hired by the local hospital, serve as case coordinators to facilitate care and coordinate communications among all parties. Over 3000 injured workers received care through the program in the first 56 months, with a decline in the number of transitional days over time. The number of days that the cases remain open has steadily declined, and the number of return-to-work cases has increased. The success of this initiative provides an excellent background for continued improvement in delivery of care to injured workers and proactive efforts at improving workplace safety and health in a rural area.

Two-year health and employment outcomes among injured workers enrolled in the Washington State Managed Care Pilot Project

BACKGROUND

Increasing numbers of injured workers are being treated through managed care delivery systems, yet little is known about the long-term effects of care provided through these systems. We analyzed health outcomes, return to work, and employment status at 2 years post-injury among a cohort of workers who were previously enrolled in the Washington State Managed Care Pilot Project.

METHODS

Data on functional status, satisfaction with quality of life, return to work and employment status were gathered via telephone interviews and mailed questionnaires from a subset of 374 injured workers who had a time loss claim that involved 4 or more days of lost work time. Of these 374 subjects, 106 were treated through managed care and 268 through fee-for-service (FFS) arrangements. Health outcomes were assessed through the SF-36, the Health Assessment Questionnaire (HAQ), and the Satisfaction with Quality of Life (QOL) instruments. Standard univariate and multivariate statistical methods were used to compare the two groups with respect to the health and employment outcomes.

RESULTS

There were no statistically significant differences between the two groups in functional status, satisfaction with quality of life or employment outcomes, except in regard to perceived recovery. FFS patients were more likely to indicate their recovery at 2 years post injury was going well (62 vs. 45%, P = .01). Almost 90% of the injured workers returned to work at some point following their injury and 72% reported working during the 4 weeks prior to their 2-year follow-up interview.

CONCLUSIONS

Injured workers treated through managed care, based upon an occupational-medicine model, appear to experience similar long-term health and employment outcomes as workers treated through traditional FFS.

The social consequences of occupational injuries and illnesses

BACKGROUND

Most outcome studies of occupational injuries and illnesses have tended to focus on direct economic costs and duration of work disability. Rarely have the broader social consequences of work-related disorders or their impacts on injured workers' families, coworkers, and community been investigated. This paper examines a wide range of social consequences including workers' psychological and behavioral responses, vocational function, and family and community relationships.

METHODS

Literature review and development of conceptual framework.

RESULTS

Complex and multifactorial relationships are described whereby occupational injuries and illnesses produce a variety of social consequences involving filing and administration of workers' compensation insurance claims, medical care experiences, domestic function and activities of daily living, psychological and behavioral responses, stress, vocational function, rehabilitation and return to work, and equity and social justice.

CONCLUSION

A research agenda is proposed for guiding future investigations in this field.

The theory and methodology of provider profiling

Physician profiling is the comparison of physician practice patterns to determine the existence and effects of significant differences in outcomes. To optimize care quality, these comparisons can be used to influence provider behavior through awareness when outcomes are poor or do not warrant provider expenditures. To maximize the value of such a technique, the underlying bases for comparison and the uses of derived data must be understood. Several factors must be considered or controlled for when determining comparable providers. Additionally, the worth or significance of findings must also be understood. This paper seeks to provide information in these two areas for the benefit of those responsible for managing care at all levels.

Managed care in workers' compensation plans

Workers' compensation plans have lagged behind most public and private health care plans in the adoption of managed care techniques. This is largely attributable to the underlying differences between workers' compensation and group health plans. Managed care techniques were developed within group health plans with the objective of health at the lowest cost. In workers' compensation, managed care must address a different objective-restoring a worker to health and productivity at the lowest cost. It is this fundamental difference that makes the application of managed care techniques to workers' compensation plans contentious and at times inappropriate. Research on the impact of managed care on the health and welfare of injured workers is sparse, and important questions remain about the appropriateness of care delivered under workers' compensation managed care plans. In this paper, we discuss the application of managed care to workers' compensation, and highlight the barriers to effective implementation.

Evaluation of the Washington State Workers' Compensation Managed Care Pilot Project II: medical and disability costs

OBJECTIVES

This study examined the effect of managed care on medical and disability costs as part of an evaluation of the Washington State Workers' Compensation Managed Care Pilot (MCP).

METHODS

One hundred twenty firms (7,041 employees) agreed to have their injured workers treated in managed care plans. Managed care introduced two changes from the fee-for-service (FFS) delivery system currently used by injured workers in Washington State: experience- rated capitation and a primary occupational medicine delivery network. The FFS control group included injured workers employed at 392 firms (12,000 employees). Medical and disability costs were compared for 1,058 injuries in the managed care group and 1,159 injuries in the FFS group occurring between April 1995 and June 1996. Univariate and multivariate statistical methods were used to analyze the effects of managed care on medical and disability costs.

RESULTS

The mean unadjusted medical cost per injury ($587) for the managed care group was 21.5% lower (P = 0.06) than for the FFS group ($748). Adjustment for differences in worker and firm-level characteristics through multivariate analysis had little effect on the unadjusted results, except that the difference in costs between managed care and FFS groups became statistically significant (P<0.01). The major cost differences were for outpatient surgery (cost per surgery) and ancillary services (pharmacy, x-ray, physical therapy, and all other costs). In addition, disability costs, particularly percent on time loss and time-loss cost per injury, were significantly lower (P<0.01) in the managed care group.

CONCLUSIONS

The results from the MCP suggest that substantial savings in workers' compensation medical and disability costs may be realized using the type of managed care intervention designed for this study. Delivering occupational health services through managed care arrangements whose design is based on an integrated, occupational health-centered delivery model may offer a viable approach for improving delivery systems, reducing costs and encouraging greater attention to disability prevention.