Measuring RTW outcomes in Workers’ Compensation: Part 1 – National Approaches

 

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’ published RTW data. 

 

[This post was prepared as a resource for DMCCT- Evaluating DM Programs & Assessing RTW Processes, Pacific Coast University for Workplace Health Sciences]

Why is Ontario's WSIB phasing out its LMR program?

A few weeks ago, Ontario’s WSIB announced a major change in direction for its Labour Market Re-entry (LMR) program [roughly equivalent to WorkSafeBC's Vocational Rehabilitation Services].  The change will phase out the use of external providers and create a new Work Reintegration Program inside the WSIB. 

First a little background.  Back in 1997,  Ontario moved to a ‘self-reliance’ model; most employers were mandatorily required to accommodate an injured worker in a return to work with the accident employer.  The legislation also imposed a duty on the worker to cooperate toward this end.  For workers who could not return to their accident employer, the LMR program became the option.  The LMR program was to be delivered in the community by external professionals so in 1998, the internal disability case management and vocational rehabilitation functions of the WSIB for cases that could not return to their accident employer were outsourced.

In 2009, WSIB contracted an outside consulting agency to conduct an audit of the LMR and other Return-to-Work (RTW) services.  The report recommended changes to the program to make it more consistent with the leading practices of other jurisdictions (including WorkSafeBC).  This report, stakeholder consultations and a value for money audit showed that the re-training programs were not having the desired effect.  The lack of a link between re-training programs [employability] and effective labour market re-entry [employment] was identified as one root cause.  The absence of direct WSIB involvement in LMR actually hindered return to work and the effectiveness of LMR programs. 

The solution?  WSIB will phase out its use of external providers and will establish an internal role for ‘Work Reintegration Professionals’ who will actively “provide injured workers with a sound assessment and, if needed, high-quality, credible training that will -- to the best of the WSIB’s ability -- equip them for return to work.”  Clearly, the move is toward achieving better RTW outcomes and higher wage replacements for injured workers.

The new Work Reintegration Program is expected to be fully in place by the end of 2010.  According to the WSIB,

The new Work Reintegration approach will support:

• Increased simplicity of communication and co-ordination of services between WSIB and workers,


• Increased clarity of accountability,


• Greater assurance of workers getting the service they need, when they need it,


• Increased consistency of services provided in similar circumstances, and


• Improved management of expectations and a reasonable level of investment within clear cost parameters.

You can read background on all this on the WSIB website .

How do you measuer return to work success?

Over the weekend, I received an email from Australia seeking information regarding return to work (RTW) programs and outcomes in North America. One question asked was regarding the percentage of injured workers who RTW. One might think there was a simple, common measure that would allow direct comparison across all workers’ compensation jurisdictions. In reality, however, there are few jurisdiction using the same method to measure RTW success.

The vast majority of injured workers who file workers’ compensation claims in BC and elsewhere experience a successful RTW. What percentage and how durable a return depend on the population being studied, the denominator uses and how RTW is defined. It also depends on the law and economy in the jurisdiction under study.

Many jurisdictions suggest they achieve 85-90% RTW for time-loss injuries. Most injured workers RTW with their accident employers anyway so the high percentage may not indicate anything about the effectiveness of the law, policy or program in a particular jurisdiction.

The 2008/09 Australia & New Zealand Return to Work Monitor examines these questions in detail. Using a common survey methodology that samples from the population of claims with “10 days or more compensation (including any excess) paid”, the reported statistics are among the most comparable around. The ‘employer excess’ refers to an employer deductible where the employer is responsible for paying wage loss benefits and medical costs up to certain limits. This is a common, (although not standardized) provision in Australia. Most jurisdictions in this study have legislation that requires the accident employer to return an injured worker to employment.

The Monitor reports on both ‘durable’ and ‘non-durable’ RTW. The results are summarized in that report as follows:

The RTW rate showed steady improvement between 2002/03 (83%) and 2005/06 (87%) returning to pre 2000 levels (mid 80%). There has been no further improvement, with the 2008/09 national RTW rate similar to all previous years (83%). The durable RTW rate has gradually declined over the last four years, with a lower durable RTW rate being recorded in 2008/09 (72%) to 2007/08 (75%).

More commonly, a report on RTW will be designed to meet the needs and data of a single jurisdiction. For example, a report out of the Texas Department of Insurance Workers’ Compensation Research and Evaluation Group in November 2008 reported on ‘initial’ RTW rates. The research found 74% -78% of claims (injury year 2004-06) had an initial RTW within two quarters post injury. This climbed to around 83%-88% by four quarters and topped out at 90-93% by 12 quarters (the longest category studied). These results have to be taken in the context of the unique Texan workers’ compensation context. For a variety of reasons, it is likely the study population in Texas is more severely injured than in the Australian & New Zealand Monitor’s data.

There is no standard for measuring RTW in Canada. Many jurisdictions in Canada have mandatory reinstatement laws that require an employer to return an injured worker to employment (although BC does not have such a provision). All have some form of RTW program.

New Brunswick 2008 Report to Stakeholders states:

Ninety-six percent of injured workers who lost time from work returned to employment or their pre-employment status following their injury. Two percent were not employed immediately following their claim closure, and 2% were fully disabled and incapable of employment.

At WorkSafeBC, RTW is not just another program; it is an integral part of our strategy and linked directly to the goal of improving satisfaction, accessibility and public confidence. While most workers return to their accident employer, the focus of BC’s vocational rehabilitation efforts is on those who face significant barriers in achieving a successful RTW.

A key indicator of RTW success for WorkSafeBC is the percentage of cases referred to Vocational Rehabilitation assistance who achieve a successful outcome. Measured as a percentage of all closed cases, the results have been as high as 81.7% in 2008. Although the current economic conditions in the province are likely to result in a lower level, the importance of RTW will not diminish.

We know from research that work is good for health and well-being. Regardless of how an agency decides to measure RTW, supporting every injured worker to achieve a safe and durable RTW is and should continue to be a priority for every workers’ compensation system.

Workers' Compensation: Recovery and Return to Work (RTW)

In my view, Prevention and Rehabilitation/Return-to-Work are the two main pillars of workers’ compensation; the ‘compensation’ part is just what we do after prevention fails and before the worker returns to work.

I view the early, safe and durable return-to-work (RTW) of an injured worker as the hallmark of a successful health outcome for an injured worker. Many workers and employers are under the mistaken impression that RTW should only occur after the worker is ‘back to normal’ or ‘100% recovered’.

To help correct this impression, I often use this recovery curve diagram to depict how the workers’ compensation system works. It shows the level of health functioning (H0)the worker has prior to the work-related injury and depicts the sudden, drastic drop in health function caused by the injury. During the initial post-injury period, the worker is Totally Temporarily Disabled(TTD). As the worker recovers, there will be a point where the worker is no longer TTD but is Temporarily Partially Disabled, (TPD). During this phase of the recovery curve, many workers actually return to work. As any practitioner of Disability Management will tell you, returning to work can be an effective therapy. For many workers, the demands of their regular jobs may be met at a level of health functioning lower than (H0). This makes sense since few jobs require a worker to be at the peak of their functional health capacity to adequately and safely perform their duties.

Recovery continues until the worker reaches a medical ‘plateau’ or what some call ‘maximal medical improvement’. Most compensation systems require that temporary disability payments cease once the worker’s condition plateaus but in practice about 90% of workers return to work prior to that point.

If the worker has permanently lost some functioning, (an amputation of the hand, for example) the worker will never return to the pre-injury level (H0). A new maximal level of health functioning will be established (H1). Conceptually, the difference between H0 and H1 is a permanent functional impairment. Depending on the workers’ compensation system, this impairment may result in a permanent partial impairment based on function or translated into a Permanent Partial Disability (PPD). As long as the level of health functioning is above the requirements for the worker’s particular job, the worker can RTW; if there are parts of the job that demand more than the current level, job modifications or other strategies (like providing lifting devices, restricted duties, or shorter shifts) may allow the worker to RTW during TTD).
RTW to the accident employer is usually the best alternative. Some systems (Ontario and Victoria Australia are two examples) require employers to take injured workers back into employment while others (British Columbia and Washington State for example) do not have such ‘mandatory reinstatement’ provisions in their legislation.

Promoting early, safe, and durable return-to-work is a priority for most workers’ compensation systems. WorkSafeVictoria recently posted videos for workers, employers and agents that continue that jurisdiction’s long-standing tradition of encouraging RTW. These videos are worth a view.