A work-related injury or illness often results in time away from work. Workers’ compensation covers a part of the economic loss until (unless) a return to work is achieved.
A safe,
early and durable return-to-work (RTW) outcome is the stated goal of many
workers’ compensation programs, but few track or publicly report this important
performance indicator. Those publicly reporting a return-to-work measure have
various definitions, calculation methods and time frames. Comparing outcomes is
further complicated by differences in industrial mix, demographic differences,
and systemic features of the workers’ compensation schemes.
The good
news is that most workers do return to work following a
work-related injury or illness. How RTW outcomes are reported in the US, Canada
and Australia provide insights, but interpretation is tricky. Each approach has
its own purpose with advantages, disadvantages and limitations. Understanding
what a RTW measure is describing requires an examination of the methodology, definitions,
and timing applied in the data analysis.
RTW
Scenarios and Measurement
The RTW
trajectory for work injuries is not always linear and even. Following the
injury, an accepted workers’ compensation wage-loss claim will pay temporary
total disability (TTD) or temporary partial disability (TPD) entitlements until
the worker’s condition ceases to be temporary, or employment earnings (actual
or deemed) exceed temporary benefits payable.
Consider
three simple RTW scenarios (there are many other scenarios):
1.
Injury-TTD-TPD (not working)- Full RTW at no
loss of earnings at 20 weeks
2. Injury-TTD-TPD
with partial RTW reduced hours at 20 weeks -Full RTW at no loss of earnings at
30 weeks
3.
Injury-TTD-TPD with RTW full hours at
temporarily reduced earnings (full-time light duties/alternate job) at 20 week
benefits payable – RTW regular job at 30 weeks.
Each
scenario results in a return-to-work outcome. In the first case, a full return
to work at 20 weeks; in the second, there is a partial return to work at 20
weeks. In the third case, there is a
full-time RTW at 20 weeks in terms of hours, but a loss of earnings while the
condition is still temporary. How these
cases will be considered depends on the RTW measurement design.
Definitions
of a case, RTW status and durability as well as the timing of the evaluation
will yield different and not necessarily comparable measures of RTW outcomes.
Each
measurement approach requires decisions about time frames and those choices
have consequences. A choice to consider the population of accepted time-loss
claims in a give calendar year will necessarily require the passage of time to
allow for claims to develop. An injury
resulting in time loss beginning in December can’t be assessed against a 6
month RTW milestone until at least half a year following the injury. To measure
the RTW outcomes of a cohort of claims from a given year may require waiting a
year or two in order to determine some ultimate result, particularly if the
measure is intended to reflect sustained RTW.
As noted, a partial RTW (partial hours or reduced
earnings while still TPD) may be included or excluded from consideration
depending on the case definition and measurement approach. Counting TPD cases
as successful RTW may overstate successful outcomes, but counting such cases as
non-RTW ignores the value and success of stay-at-work and early RTW programs.
The
durability of a RTW outcome may or may not be reflected in the RTW measures
published. Durability depends on the definition. Three weeks, 30 days, or three
calendar quarters of sustained employment after the last RTW are sometimes used
for these purposes. If the RTW outcome measurement is based on current
employment status, the timing of the measurement is also critical.
In survey
or interview methods, a pair of survey or interview questions may be used: “Did
you return to work?” and “Are you working now?” may be used to differentiate
return to work outcomes and infer durability. The timing of these questions can
also impact the result. If measured too soon after an RTW, the response may not
reflect a sustained employment outcome; if measured long after the initial RTW,
the result may reflect changes in other health or economic circumstances not
related to the injury.
In
designing a measure or interpreting a published RTW statistic (and its
limitations), an understanding of the underlying choices and case decisions are
essential.
National
RTW Measures
The
following examples illustrate different approaches to measuring RTW outcomes. One
relies completely on administrative data; others ask workers directly about
their RTW outcomes; and one blends claims data with interview responses
As you
review the following examples, consider the purpose and limitations of each
approach.
While each
example reports on a set of jurisdictions, direct comparison across studies is
not possible.
Canada: The
“Off Temporary Wage-loss Benefits” milestone approach
Administratively,
the days or weeks of benefit paid are precisely and easily counted. Calculating
an “off temporary wage-loss benefits rate” is often used as a proxy for a
return-to-work rate.
The
Association of Workers’ Compensation Boards of Canada (AWCBC) takes this
approach. Each jurisdiction reports the percentage of time-loss claims “off
wage-loss benefits” at specific milestones (30, 60, 90, 120, 180, and 360 day).
Let’s focus
on Key Statistical Measure (KSM) 25.5, Percentage of Wage-Loss Claims off
Wage-Loss Benefits at 180 days. The KSM is described as follows:
Intent of Measure
·
To be a proxy of return to work. To measure
how soon injured workers leave the [temporary] wage-loss compensation system
permanently.
Definition
·
Percentage of Total Lost Time Claims (KSM #2)
that have received their last day of wage-loss benefits 180 days after the
injury. The last day of wage-loss benefits is determined at December 31 of the
year following the reference year.
Calculation
·
Formula:P180 = C (D≤180) ÷ LTC,
where:
- D = The difference, in days, between the
injury date and the last date for which an injured worker received any
wage-loss benefits [emphasis added]. The last date of benefits is
determined on December 31 of the year following the reference year. One-day
medical visits or appointments can be excluded when determining the last
date of benefits
- C(D≤180)
= The number of claims for which the difference D is smaller or equal to
180 = Total Lost Time Claims (KSM #2).
- Caveat
- This
is not a return to work measure although it can be seen as a proxy.
Injured workers may stop receiving wage-loss benefits for a number of
reasons other than returning to work. Also note that the measure makes no
distinction with regards to what happens between the injury and the last
day of wage-loss benefits. For instance, a worker that has temporarily
returned to work before experiencing an aggravation is treated the same
as if the wage-loss benefits never stopped. All aggravations or claim
reopenings that occur after December 31 of the year following the
reference year are not accounted for.
The data
reported in this study come from the individual jurisdictions. AWCBC advises, “The KSM 25s (25.1 to 25.6)
are requested by AWCBC at a later date compared to all the other KSMs. When
boards submit their KSM 25s we publish it after each CFO has approved their
board's submission…we don't look at the case details…”. \
This
approach relies heavily on individual jurisdictions’ coding and adherence to
the AWCBC definitions.
The 2022 Canadian
result shows 88.21% of claims received their last time-loss disability payment
within 180 days of injury. The results range from about 81% in Nova Scotia to
over 94% in Manitoba.
Policy
issues account for some of this variability. Nova Socia, for example, has a
waiting period; short duration claims typically have 100% RTW rates after their
very brief absences. The exclusion of these claims depresses the RTW rate at
this milestone.
The
administrative simplicity (using the full population of claims and objective
payment data) makes this approach attractive, however, the results are not normalized
across jurisdictions and do not directly measure RTW outcomes or account for
successful partial returns to work. This retrospective approach necessitates a
significant lag for the cohort of claims to develop.
Australia: The
“RTW survey” approach
Asking the
injured worker is a more direct method of determining RTW outcomes. When
coupled with individual claims data, this approach opens the possibility of
deeper analysis. On the other hand, the costs of contacting and interviewing
are high. Unlike the previous administrative data/full population approach,
this method requires a sampling strategy.
Australia’s
National RTW Strategy tracks its progress through two headline measures: Returned
to Work Rate (ever return to work) and the Current Return to Work Rate (currently
working at time of survey). Sample size varies by jurisdiction and aggregates
to about 5000 respondents. The stratified samples from each jurisdiction are
selected from all cases with at least one day off work reported to the WC
insurer (or authority) in a defined period (for example, February 1, 2019 to
January 31, 2021). Interviewers (83) collect data by direct contact. This
approach provides consistency or application across jurisdictions.
The
population includes both premium-paying and self-insured organizations. The
sampling strategy included stratification techniques to strengthen
representativeness of the sample. Results reflect weighting for factors
including age and injury type (for example, psychological vs. others).
A full
description of the most recent survey methodology is available at https://www.safeworkaustralia.gov.au/sites/default/files/2022-02/NRTW%20Methodological%20Report.pdf.
Nationally,
the 2021 “ever” RTW rate was 91.6 %. The “current” RTW rate at time of surve
was 81.4%. This broadly speaks to the issue of durability of a RTW outcome.
Note the
variation in outcomes by jurisdiction. Seacare, reports a much lower RTW rates
(76.3% ever, 62.3% current) than Comcare (95.6% ever, 87.6% current). Comcare
covers employees of the Australian Government and certain large national
companies that are self-insured under federal legislation, while Seacare
specifically covers seafaring employees working on prescribed ships engaged in
interstate or international trade or commerce within the Australian maritime
industry. The jurisdictional injury and recovery profiles differ significantly
and are reflected in the RTW rates.
Design
makes the outcome measures meaningful, particularly for individual
jurisdictions over time. There are challenges in follow up and the “lag”
between current practice and measuring impacts of policy changes.
United
States: The “Outcome Interview and Data
Analysis” approach
The US
workers’ compensation landscape lacks a national RTW outcome report. The
Workers’ Compensation Research Institute (WCRI) has conducted a series of
studies “Comparing Outcomes for Workers” using the data from structured
interviews and claims records for more than a dozen states. [Comparing Outcomes
for Workers, 2019 Interviews. Bogdan Savych and Vennela Thumula. January 2020.
WC-20-17 to WC-20-20]
The series
focuses on:
Recovery of
physical health and functioning
Return to
work
Earnings
recovery
Access to
medical care
Satisfaction
with medical care
In this
study, the RTW outcome is defined as the corollary of the previous two studies.
The percentage of claims “never” returning to work or failing to achieve a
sustained one-month RTW are measured from stratified samples normalized for
each jurisdiction in the study series.
This is a “members
only” or “for purchase” series, however, a publicly posted WCRI.net video provides
some results for the Connecticut version of the study.
The
interviews took place three years after injury (2019). Again , this approach provides consistency of
application across jurisdictions.
The results
from the Connecticut version of the series displayed in the video show similar
results across studied jurisdiction. Between 9% (Indiana) and 18%
(Pennsylvania) “never returned to work” or never sustained a return to work for
at least a month. This “never RTW” measure implies an “ever RTW” rate of
between 82% and 93% using comparable data among the states included in the
analysis.
The
analysis shows the median state result as 10% never RTW [90% ever RTW] and 14%
never RTW or not at least a month sustained [86% RTW or sustained at least 1
month].
The
inclusion of claims data allows for further statistical analysis. For example,
the median time between injury and the first sustained RTW was between 7 weeks (Florida)
and 12 (Pennsylvania) weeks post injury.
The
analysis provides policymakers and stakeholders comparative data to assess
performance and improve systems. Through rigorous study design and application
of advanced statistical methods, each participating jurisdiction receives a
study allowing for outcomes to be directly compared relative to any state’s
individual performance. Differences and similarities in outcomes can better
inform policy decisions.
This
approach also has its drawbacks. Rigorous design and interview protocols
provide comparability, but there can be wide differences in when interviews
take place among participating states. The number of states participating in
the study is also limited. The design requires significant time for claims to
develop then be surveyed and the results analyzed. Policy and economic impacts
may not be reflected quickly or evenly across included states.
(Full
disclosure, I have acted as a technical reviewer for WCRI on this series).
Summary Comment
There is no
“right way” to measure RTW outcomes. For national or group studies, the design
often reflects compromises in setting objectives and achieving comparable data
sets. Note the timeframes for RTW outcome studies necessarily lag changes in
policy, practice and economic conditions. Rigorous definitions for cases and
common application of techniques across jurisdictions take time and effort.
National or
group results may be useful for policy decisions, however, the priorities of
individual jurisdictions may differ significantly. In the next post we will
look at several state/provincial approaches to measuring RTW outcomes.
In the next
post, we will look at individual jurisdictions’ publisher RTW data.
[This post
was prepared as a resource for DMCCT- Evaluating DM Programs & Assessing
RTW Processes, Pacific Coast University for Workplace Health Sciences]
