April 20, 2018

Guest Post: Mark Pew on “The Intersection of Medicine and Disability” from NWCDC

By Mark Pew, Senior Vice President, PRIUM, a division of Genex Services

Las Vegas, CA – At the 2017 #NWCDConf in Las Vegas on December 7, Dr. Marcos Iglesias (Chief Medical Officer for Broadspire) presented his perspective on the intersection of medicine and disability but it might not have been what attendees expected. Though the terms “impairment” and “disability” are often mistakenly used interchangeably, in his opinion they are two completely different concepts.

Disability addresses a lack of function in an administrative or legal arena, its definition can change per payer (workers’ compensation, Social Security Disability [SSDI], U.S Department of Veterans Affairs) and by jurisdiction, and is a subjective opinion. Impairment is a medical term that defines a deviation from wholeness and is objectively measureable. Doctors do not determine disability. Doctors do determine impairment, usually in two ways: limitation, a way to measure what they cannot do; restriction, a judgment call on what they should not do based on risk. While impairment might lead to disability, that is not a guaranteed progression. To some degree, disability could be considered a mentality while impairment is the reality. Unfortunately, disability appears to be an epidemic, especially in light of these statistics:

  • 1 billion individuals, 13 percent of the world population, are considered disabled
  • 57 million Americans are disabled (using the broadest definition)
  • 1 in 20 adults of a working age are not working due to disability
  • 60-80 percent of lost work days attributed to medical conditions in the United States involved time off from work that as not really required by the condition itself…in other words, needless disability
  • In 1961, the most common reason for disability was cardiovascular (25.7 percent)
  • In 2011, the most common reason for disability was musculoskeletal (33.8 percent)

Through our work at PRIUM, we’re constantly concerned with issues of disability and impairment as we collaborate in getting injured workers back to function. In that process, we have noticed that medications such as opioid painkillers can contribute to disability and impairment and, as such, must be properly managed.

A return to function – reducing impairment (and thereby disability) – is also the paramount goal for a clinician. But an equally important goal is reducing worklessness – a fairly new term that is broader than unemployment as it includes people who are economically inactive (including those who are sick and disabled).

An inability to work not only impacts a sense of belonging and achievement but also doubles the chance of poor health, doubles mental health issues and increases six-fold the possibility of suicide. Possibly contrary to popular opinion, return to work (RTW) is not just important to the employer. It’s equally important to the patient (injured worker) due to the psychological and physical health consequences that can occur with delayed recovery and postponed RTW. So a doctor should always ask: Am I doing harm if I say they can’t work?

Patient advocacy is a trendy buzzword and a somewhat unwritten expectation for doctors with the advent of patient satisfaction surveys and value-based care. All that being said, the response to this survey question included in Dr. Iglesias’ presentation was staggering:

Are you willing to exaggerate clinical data to help a patient you think deserves disability benefits? 44 percent said yes, 56 percent said no.

Attempting to label this as “compassion” or “fraud” is fruitless. What’s really at issue here is whether it’s the right decision in terms of reducing impairment and returning function in the long run. In fact, this objective might be better served by not giving the patient what they may want (a higher disability rating and being out of work).

Both doctors and patients need to understand the difference between disability and impairment, focus on a return to function and work, and realize that might require treatment choices that are not easy. For PRIUM, one example is carefully monitoring when injured workers should be weaned off opioid painkillers.

Sometimes the doctor can balance all of that themselves, while other times they might need help from a medication safety program, case manager or a supportive family member. “Short-term pain for long-term gain” is not just a football training camp adage but a means for pushing beyond the mentality of “disability” and the reality of “impairment.” Because in the real world, regardless of the definitions, neither the doctor nor patient want those words to describe the outcome.

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