Back With a Vengence

By Robert J. Grossman Aug 1, 2001
Back With a Vengence by Robert Grossman HR Magazine, August 2001
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Recent data confirms what some people have been complaining about for yearsgoing to work is a back breaking endeavor. Case in point: When Liberty Mutual Insurance, the nations largest workers compensation insurance carrier, recently reassessed an analysis of the economic impact of workplace injuries, no one in the occupational health and safety field was surprised to learn that back injuries are employers costliest and most frequent nemesis.

Back problems cost employers an estimated $50 billion per year in direct workers compensation costs alone, according to experts. And employers spend an additional $50 billion on indirect costssuch as finding and training substitute workers, and running work-hardening (physical conditioning) and reduced-work programs that help ease employees back into their jobs, experts estimate.

Such dramatic figures dont include less obvious costs associated with back maladies. For example, back problems are the leading cause of wrongful termination claims filed under the Americans with Disabilities Act (ADA), according to the Equal Employment Opportunity Commission (EEOC).

Additionally, back problems cause dramatic decreases in workplace productivity that may be difficult to trace. For example, employers lose thousands of workdays each year from workers whose back problems arent dramatic enough to warrant a sick day or a workers comp claim, but are serious enough to limit their productivity and efficiency, says Alan Hedge, professor in the Department of Design and Environmental Analysis at Cornell University in Ithaca, N.Y. If you just look at lost work time, its the tip of the iceberg, he adds. When youre hurting at work youre not as effective.

James Hummer, president of Whole Health Management, a Cleveland, Ohio-based company that operates on-site clinics and fitness centers for corporate clients, refers to such ineffective attendance as presenteeism. He explains it this way: Im on the job, not feeling good and functioning less than optimally.

HR in the Middle

Until the Bush administration pulled the plug on the Occupational Safety and Health Administrations (OSHA) ergonomics regulations early this year, the federal government was poised to attack workplace injuries with a strong dose of mandatory ergonomics. Now with OSHA defanged, the ergonomics movement must rely on employers voluntary commitments. That puts HR in the center of the action.

The withdrawal of the standards will spur employers to relax their financial commitment to safetywhich will turn up the heat on HR, predicts Jim McGlothlin, professor of ergonomics at Purdue University in West Lafayette, Ind., and a former official at the National Institute of Occupational Safety and Health (NIOSH).

More injuries will be reported because we have killed the mechanism for addressing the causes, he says. Guess who gets hit with all the problems without the resources to handle them? HR is in the middle of a nasty sandwich.

One ingredient of that sandwich is rising health care costs, which are prompting employers to find new ways of cutting expenses. In response, various experts are pitching the following money-saving solutions:

  • Trainers tout their ability to educate workers so they will avoid back injuries.
  • Physical therapists promise strengthening and work-hardening regimens, guaranteed to cut costs.
  • Osteopaths and chiropractors claim their cost-effective medical interventions can cut medical outlays for workers comp.
  • Ergonomists and safety engineers promise work-site engineering adjustments that will return three dollars for every one you spend.
  • Insurance carriers guarantee lower experience rates if you tackle problem jobs with ergonomic solutions and aggressive work-hardening and back-to-work programs.

The question for HR: How do you choose wisely from among these options, all of which are guaranteed to reduce outlays?

The answer: Any combination of options might prove effective for your workplace. But before making a choice, it helps to know something about the causes of back problems.

Medical Mystery

Surprisingly, there is a lack of fundamental agreement about the causes of workplace back problems. Some experts point out that scientific studies have not proven that training, exercise or altered work design will prevent back problems. Whether you do something or nothing, workers will experience back maladies, they say.

No one really knows what causes back pain, agrees Stover Snook, certified professional ergonomist (CPE) and lecturer on ergonomics at the Harvard School of Public Health. There is no known cause for up to 85 percent of low back pain. We dont even know where the pain comes from--muscles, discs, ligaments--we simply don't know.

There are, of course, many opinions about the cause of back pain, but there is little supportive scientific data, Snook says. Every practitioner will be glad to tell you exactly whats causing it. The physician will tell you its a muscle strain. The surgeon will tell you its a disc. The chiropractor will tell you its misalignment. The physical therapist will tell you its muscle weakness. The psychiatrist will tell you its in your head. Everyone has a different story, but no one has the data to prove it.

Just as the causes of back problems are enigmatic, so are the solutions. Treatment varies from bed rest to exercise to manipulation, from medication to heat to cold, from traction to acupuncture to injections to surgery, Snook says. You name it, its been tried. Which is better? It doesnt make much difference who you go to or what kind of treatment you get, he says. The outcomes are about the same: 75 percent of people recover from acute low back pain within two weeks, and 90 percent recover within six weekswith or without treatment, and regardless of the type of treatment.

The fact that back pain tends to come and go on its ownas if brought on by gremlins within the bodymakes it almost impossible to ascertain whether a particular action sped up recovery. Snook quotes Voltaire from almost 200 years ago: The art of medicine consists of amusing the patient while nature cures the disease.

Given that there is no clear best manner for treating back problems, employers are probably best served by steering employees to the least expensive alternatives possibleespecially since medical outlays alone will total 40 percent of all workers comp costs this year, according to the Workers Compensation Project for the National Academy of Social Insurance.

The chiropractor and the orthopedic surgeon tend to be the highest cost per case, says Snook. The chiropractor sees them once a week for an extended period; the surgeon only once, but at a very high fee. Least expensive is the general practitioner, who prescribes some pills and perhaps exercises. Who picks up the tab? The employer; either through workers comp or health care premiums.

In a small percentage of casesperhaps 5 percent or lessemployees will require more serious treatment or examinations. If its impeding their ability to work, they need to see someone to make sure its not a rare diagnosislike a compression fracture or cancer that has metastasized to the spine, says Tom Hales, occupational physician, Centers for Disease Control in Cincinnati, Ohio.

Start with Audits

With the tremendous costs of back problems and the apparent lack of effective solutions, prevention is the name of the game for employers.

Many prevention efforts focus first on the work and how it is performed. This is where employers will reap their quickest rewards, experts say. But they shouldnt stop there, suggest the experiences of employers that have successfully reduced lost time and other expenses associated with back injuries.

Employers should be leery of quick fixes, such as the once highly touted back belts. You get manufacturers who are promoting back belts and companies buying them as quick fixes, says Marjorie Werrell, president of ERGOWORKS Consulting in Gaithersburg, Md. Ergo gizmos give ergonomics a bad name. Just because it has the label doesnt mean its ergonomics. Ergonomics is the interaction of the individual with the workplace, with the equipment and the design of the equipment. You have to consider the totality. So handing out a back belt and brushing it off as your ergonomics program is not adequate.

Attempting the wrong solutions can be costly as well as ineffective, adds Brent Clark, a partner at the law firm of Seyfarth, Shaw, Fairweather & Geraldson in Chicago. I would start with an analysis of the job, look at the injury history and figure where I am getting my injuries. Then I would prioritize.

Carriers such as Liberty Mutual, and consulting and engineering firms offer workplace audits and follow-up as a first step in workplace safety. An audit can run from one day to two weeks, and usually generates suggestions for safety improvements or job re-design.

Although precise data is not readily available, participants claim such audits cut workers comp costs when they turn the spotlight on workplace safety. The cost of an audit depends on the number of jobs and functions examined.

Some employers avoid audits because they fear recommendations for costly changes. Over 50 percent of our clients will readily admit it was their big fear that we would give them a huge laundry list of what theyd have to do and purchase, says Werrell. A large portion are surprised that they can have a functional ergonomics program without breaking the bank.

Werrell recalls a worksite where employees suffered strains from pushing and pulling carts. When we measured the force of people pushing and pulling them, the force was twice that of well-maintained carts, she says. They set up a wheel-maintenance program at minimal costs, and injuries dropped off.

On-the-Job Injuries 

Finding simple techniques for cutting workplace injuries is crucial because workers comp is one of the single biggest costs associated with back problems. Sixteen percent of all workers comp claims involve the back, adding up to 30 percent of the total costs of all workers comp claims, says Karl Jacobson, senior vice president, the Loss Prevention Department at Liberty Mutual in Boston.

And most of that money will go to a small percentage of workers comp recipients.

Liberty Mutual, the leading workers comp insurer in the United States, writes 10 percent of the business. According to Barbara Webster, researcher at the Liberty Mutual Center for Disability Research in Hopkinton, Mass., 15 percent of workers comp recipients accounted for 89 percent of Liberty Mutuals total workers comp costs. This same group missed a month or more of work; 5 percent of those on workers comp missed more than a year. By contrast, 75 percent of the individuals collecting workers comp from Liberty Mutual missed one week of work or less.

Experts agree that reducing the number of these long-term cases is the best way to cut workers comp costs. The conundrum for HR is to learn why some people in pain dont complain at all; why others complain, are treated and get better quickly; and why others linger on, soaking up resources.

Only 10 percent of workers with work-related back pain seek compensation, says Hales of the Centers for Disease Control. Since everyone gets it and everyone gets better, the question is what cases cause people to have disability?

Causation: Conflicting Theories

Eliminating injuries is a no-brainer, say ergonomists such as Purdues Jim McGlothlin. Go after the problem at the root, he advises. Engineering is the ticket, the long-range solution. And remember the 80/20 rule: Eighty percent of the costs are from 20 percent of the workforce. So start where the injury occurs; take care of the highest risk jobs first and work your way down.

Neglect engineering and job design at your peril, McGlothlin says. If your job is lifting 100-pound bags of seed off the ground and putting them into a cart, youre lifting 49 pounds more than the NIOSH lifting standards suggest. When you blow out your back, they send you to HR where they try to manage the problemput you on work restriction for a few weeks, send you to a physical therapist.

But thats only a short-term solution, he says. Then you go back to the job and hurt yourself again. Only difference is this time you never come back. Ninety percent of those who hurt themselves a second time never return to work. HR winds up with a liability problemcash settlements, workers comp. Its a huge headache, and youve failed to treat the problem at the source.

But not everyone shares McGlothlins view.

The link between a job and reported injuries is tenuous, says Nortin M. Hadler, professor of medicine and microbiology/immunology at the University of North Carolina. He is the leading critic of what he calls medicalizing back problemscategorizing back pain acquired at work as an injury and paying for medical treatment only if the pain can be positively linked to the job.

Hadler says psychosocial factors, not the job itself, are accurate predictors of who will claim an injury. Contented workers in stable, caring settings are less likely to claim injuries.

If theres any hazard to your back at work, it pales in comparison to the social issues that influence your health, he says. Facilities with low complaint rates are more likely to be staffed with supervisors who empathize and nurture, managers who show genuine concern for workers, who understand how multivariate the challenges of going to work are.

To support his theory, Hadler cites a recent ergonomics study focused on workers sorting parcels at a number of different UPS hubs. Jobs at some hubs were targeted for ergonomic interventions, others were not. There is not even a hint of an association between physical task demands and the likelihood of recorded disabling back pain, Hadler observes.

Then why do most ergonomics programs report savings? Hadler attributes it to the Hawthorne Effect, the theory that any change will improve workplace performanceat least for a while. Cornell Universitys Hedge counters: Companies that implement an ergonomics program will see decreases in injuries. Every study shows injuries go down and costs go down over a period of time. To the extent that we minimize the risk, we will make things better.

Hadlers psychosocial factors are absolute nonsense, Hedge says. Psychosocial factors is a garbage term that suggests its all in peoples head.

Even conceding some merit to psychological factors, Hedge says, its folly to start with them in mind.

Always look for the simplest explanation first, he says. Psychosocial explanations are not the simplest. I look at the work situation first. Change the physical causes and youll get results.

But Hadler is not easily dismissed, health and safety experts concede.

You cant explain Hadler away, says Ted Courtney, associate director of Liberty Mutuals Research Center for Safety and Health. Hes an important voice, a balancer. He keeps the situation from being that ergonomics is always the answer.

Either potential solutionanalyzing the physical functions of a job or ensuring that employee relations, morale and management are handled correctlyfalls squarely on HR's shoulders.

Ergonomics and the Bottom Line

McGlothlin says most large employers are committed to ergonomics programs, but middle-size and small organizations have been slower to climb on board. Often, smaller firms fear the cost of making their workplaces ergonomically sound. But the financial case for investing in safety is compelling.

Over 80 percent of the injuries we see in the workplace can be eliminated and we can get return on investment, McGlothlin says. For every dollar you invest in ergonomics, youll get a three dollar return.

Stephen Gutmann, senior ergonomics specialist at 3M headquarters in St. Paul, Minn., says theres no question that ergonomics programs pay off. He cites the following formula as proof: Total your medical and indemnification costs for a back injury with your indirect costs. Divide by your profit margin. That will give you the sales your company needs to generate to cover the cost of the injury. If you have a $5,000 injury and a 10 percent profit margin, youll need $50,000 in additional sales to cover the injury cost.

It may not be quite that simple, adds attorney Brent Clark, although he does believe there are plenty of savings to be realized. Nobody knows how much we can reduce the costs, he says. It could be 50 percent or 10 percent, but theres enough low-hanging fruit still out there that we know if we address them well get reductions.

Diminishing marginal returns is the real issue, Clark continues. Many companies begin by spending wisely, then start to chase down rabbit holes. If the intervention gets down to an individual who just happens to get injured, re-engineering may not be cost effective.

Looking Long Term, Part I 

In the short term, employers have an incentive to minimize the number of accidents and injuries they report to OSHA because state workers compensation premiums are based on experience ratings. Basically, the more accidents and injuries you report, the more likely it is that your rates will increase.

When employers report a number of accidents and injuries that exceeds the average for their industries, they can wind up paying substantially higher workers comp insurance bills, says Daniel Mont, director of the Workers Compensation Project for the National Academy of Social Insurance.

At the same time, insurance companies compete for business by rewarding customers who achieve lower recordable rates.

​As a result, employers have a strong incentive to hold down the number of recordables, which means they may reward managers who reduce the number of injuries they report. The problem is, that may merely mask problems and eliminate the chance to prevent greater costs down the line. Early identification of potential injuries has proved to be an excellent way of reducing long-term and chronic problems.

If we can get someone who reports symptoms or soreness early, the chance of treating them effectively increases, the time off from work is minimized or nonexistent and you can get to the root causes in the workplace sooner, Gutmann says.

Companies such as 3M recognize this and are taking steps to change the managerial mindset. Were looking to develop alternative metrics so we can get away from managing by looking in the rearview mirrormanaging by recordables, Gutmann says. We de-emphasize performance appraisals on loss time rates or reportable injuries.

Managements commitment to a comprehensive ergonomics effort is keyeducation, medical support and job analysis and designand a system that embraces, instead of stifles, early reporting of problems, Gutmann says.

Further, 3M downplays the distinction between injuries sustained on the job and those sustained elsewhere, he says. If Sally or Bob hurt their back playing softball, you want them coming in and telling you, because if work aggravates that condition, we end up inheriting it. We want to know even if we take an OSHA recordable, because if we catch it early, treat it and prevent it from recurring, it may not even go to workers comp.

Avoiding workers comp claims isnt the primary concern at the Bureau of National Affairs (BNA), which has 1,600 employees in its Rockville, Md., and Washington, D.C., offices. BNA encourages individuals to file workers comp claims as soon as a problem occurs. Usually their problem is open and closed, says Margaret Cowles, BNA employee specialist in Washington, D.C. They go to the doctor, its worked on and then its gone. It doesnt matter that I have 50 claimswe look at the bottom line. If we get them in and out quickly weve done our job.

As a bonus, Cowles says, the company has created a caring environmentand it pays off with fewer injuries and better morale. New workers tell me they cant believe BNA cares so much about its people, she says.

On-site Clinics: Sensible Alternative

In states where employers are allowed to opt out of the workers comp system, some large employers have decided to become self-insured, thereby avoiding some of the obstacles to good health management. Some employers even invest in on-site clinics for comprehensive health and wellness services.

Some clinics are in-house operations. Others are run by outside vendors, financed on a costplus basis, which grants doctors and other clinicians time to treat patients without bean counters rushing them along.

Theres not an economic incentive to act like a factory and get people in and out, says Bruce Sherman, medical director, Clinical Quality Services, Whole Health Management, Cleveland. National data for a typical physician is 9-12 minutes per patient. In our clinics we average between 20 and 30 minutes, he says. We can bring people back to the clinic as much as necessary.

Such programs cut costs, claims Whole Health Managements president, Jim Hummer. He recalls the companys experience with one of its large clientsNASA. We had to take an integrated approach to keeping their minds and bodies in shape, says Hummer. When we did so, they found their workers comp costs went down. For a community of 2,000which included not only office staff but maintenance and small manufacturingannual out-of-pocket workers comp costs fell to under $1,000.

Looking Long Term, Part II

Workers compensation isnt the only area where employers need to take a long-term view of their employees back problems.

Back claims continue to be the No. 1 source of ADA filings. Overall, from July 1992 to September 1999, the EEOC reports that claimants filed 20,324 back-related cases16.1 percent of all disability cases brought under the ADA during the period.

In the end, few complainants actually prevail, but thats not the point. Employers have done well on this issue, but at considerable expense, says Dave Rowland, an attorney in the Chicago office of Seyfarth, Shaw. Its a good litigation strategy, good for the lawyers, but not necessarily good for the employer.

As a general rule, Rowland says, it doesnt pay to argue when a worker claims disability from a hurting back. Instead, if the person has good medical information, and it sounds like he or she has a legitimate back problem, why not consider ways that allow the person to do the job effectively and productively?

If the employee is impaired, at least potentially disabled under the ADA, the employer is obligated to attempt adjustments. Rowland says 30 percent to 40 percent of the cases can be handled by making minor job adjustments. Twenty-five percent to 30 percent of the impaired employees need time off to recuperate and then can return to their job without adjustments.

In one quarter of the cases, however, the worker is disabled for extended periods and unable to return to the existing job. These are the most difficult and costly under ADA, Rowland says. You have to consider them for available vacancy for which theyre qualified, but you dont have to bump someone else.

Avoiding such claims is becoming more difficult because it is getting tougher for employers to screen out employees with potentially bad backseven if lifting is a required part of the job. The government is chipping away at the employers ability to say Youve got to be capable to lift a certain amount to qualify for a given job, Clark says.

You cant ask about prior medical conditions of any kind, Rowland agrees. Post- offer you can ask, but you cant presume that someone with a prior back condition will have problems in the future. You can give a physical, but do you really have the guts to say I believe you wont be able to do the job without hurting yourself? To reject someone, you have to meet a stringent testthat theres a direct threat to the physical or mental well-being of the worker.

Rowland says encouraging workers to self-select out of jobs is one option for avoiding problems. Some employers show videos or take prospective workers out to the plant, so people can see for themselves how rigorous the job is and then decide on their own to opt out.

Aggressive Claims Management

In addition, HR can cut costs by being more aggressive in the way it manages claims, Rowland says. Insist on good information from the employee regarding the injury and the limitations it requires. HR tends to over-assume. Nothing under the ADA prevents you from getting further information. By asking, youre able to ferret out whether theyre lying or not.

Another tip: Follow a proactive case management approach. Dont let people who lost work get lost, Hales says. Coordinate care among medical specialists, avoid unnecessary surgery, get an individualized program for each person and keep them on it. Make sure they know theyre expected back at work.

Too often, HR lets workers languish at home without trying aggressively to get them back into the workplace, says attorney Clark. Light duty assignments can help ease workers back on board, but workload reductions should be managed carefully. You want the employee to feel somewhat awkward in the light duty job. As soon as the primary reason for their injury is removed, you want them back to their regular job.

Light duty is a solution urged by workers comp carriers, but it poses problems. Rowland recommends drafting a written policy that places limits on the length of time it will be available. More than two months is risky.

Prevent them from becoming chronically disabled, says Timothy R. Dillingham, associate professor, Department of Physical Medicine and Rehabilitation, at Johns Hopkins University in Baltimore, Md. Keep people as active as you can. If theyre getting physical therapy it has to be activeultrasound and massage doesnt work. Try to keep them working. Limited duty is better than sending them home.

Snook, at Harvards School of Public Health, may have the best advice for HR: Since low back pain is so common, and since it is so difficult to prevent, we have to begin designing jobs for people with low back painas well as for people without low back painespecially when youre dealing with an aging population. Keep them on the jobor allow them to return sooner. Thats the best possible therapy you can give your workers.

Robert J. Grossman, a contributing editor of HR Magazine, is a lawyer and a professor of management studies at Marist College in Poughkeepsie, N.Y.

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