g.day. The last lecture. I hate being the last lecturer. People are tired, many haven’t sat in a classroom for 30 years. Ready to go home, unless there’s an after conference open bar. Some people have to catch rides and leave half way through – which as a lecturer – you never know if its because your presentation is lousy or simply a reflection of a child needing to be picked up at daycare. So , and I’ve never done this before, if you know you’re going to leave, I must ask you to move to the back now – that way I won’t be disturbed nor will you disturb other attendees. Now, of course if people start leaving from the front, I know I’m in trouble. If you stay, I think it will be worthwhile.
A little bit about BA,where we adopted this approach about 5 years ago.. While thought of as an Atlantic Canadian Company, we’re a major player in the ON and QC market. Muskoka, Mount Tremblant. Wherever there is a phone, there’s a BA ee within 100km. We’re not in the big metropolises, we’re in small towns. Our programs need to address the often virtual reality of our workforce. Tough, for a number of reasons, BA does not support telework. A decade ago we were operators placing long distance calls, now we’re remotely setting up internets. Generous benefits.
Everyone focuses on direct costs, but you don’t wake up one day too depressed to work! direct cost are only a small piece of total cost! As an employer, we need to look at TOTAL COST. No good closing an sdb or wcb claim if the ee does not rtw productive!
Some questions to ponder.
How does one become disabled? Who decides to go see the doctor, who decides that they are too ill to work?
This is the President of ABIME. Writing in the MEDICAL disability asdvisor.
Not just for MUDS, but headache, URIs, IHD…the decision on work is made by pt!
Not a medica
And if you don’t believe me, believe stats canada – because statistics can’t lie!Being in a Union doesn’t make you ill!
Lets stop focusing on the factor in red, and start looking at the others!
Opportunity to address issues affecting performance/attendance; ideally before there is a problem.
Start young and recur – employees for life.Unlike MIs or Gallbladder – sudden show up, get treated and move on; spiral in/out over months or year. Opportunity for early recognition and enhanced treatment.
Disability Management: Accept and Assist
“Accept and Assist”.
Matthew Burnstein, MD, MCFP, MRO
Chief Medical Officer – Bell Aliant
Feb 13th, 2014
• Understand Total Cost and the Drivers of
• Weakness in the Traditional Approach to
• Time for a Paradigm Shift?
• A New Model
• Study the results
• Lessons Learned
Bell Aliant Regional Communications
• 7000 union and non union members (>60% unionized)
• 6 provinces, widely dispersed
• Customer care workers, field technicians, engineers, marketing
and sales, finance, support services
• TV, internet, home security systems and phones – ever-changing
• Former monopoly
• <2% staff turnover
• In house team of Health and Wellness (H&W) professionals
• Self insured for short term disability- up to 1 yr at full salary
• Unlimited incidental absence at 100% pay
TOTAL COSTS OF DISABILITY
(INDIRECT COSTS ARE
2.5-3.5 X DIRECT
Increased stress for colleagues
Lost Sales Opportunities
Paperwork / Reporting
Cost to Employee and their Family!
What’s behind the high rates of
We’ve never been healthier,
never lived as long,
never had such great medical knowledge,
yet, as a society,
we’ve never been so disabled.
How does an individual end up
An Individual with a complaint
Patient with an illness,
who becomes a
Claimant with a disability.
In most cases, the evolution is driven by the individual,
not by the illness or the physician.
Does the medical model explain disability?
• “The experience of disability is more related to
society’s willingness to accommodate and
individual motivation than any underlying
impairment or limitation. Our narrow concepts of
health and disability limit our potential.
• Over the years, I have been impressed by the
relative lack of correlation between impairment
and disability….Much of disability results from
learned experiences, lack of adaptive skills and
reinforcements from physicians, family
members, attorneys, employers and others.
• We can no longer accept this societal illness;
the costs are too enormous”.
Dr Chris Brigham
Preface the MDAs
Only a small fraction of medically excused days off work is
medically required – meaning work of any kind is medically
contraindicated. The remaining days off work result from a
variety of non-medical factors such as administrative delays
of treatment and specialty referral, lack of transitional work,
ineffective communications, lax management, and logistical
problems. These days off are based on non-medical decisions
and are either discretionary or clearly unnecessary.
Participants in the disability benefits system seem largely
unaware that so much disability is not medically required.
Absence from work is “excused” and benefits are generally
awarded based on a physician’s decision confirming that a
medical condition exists. This implies that a diagnosis creates
ACOEM Guideline on Preventing Needless
Work Disability by Helping People Stay Employed
• “Disability is a complicated psychosocial
problem that extends beyond the sole question
of illness or injury. Many factors contribute to
the complexity of the problem.
• They include, but are not limited to an
individual’s values and beliefs; the role of
illness in the individual’s childhood..; the
specific symbolic meaning of illness or injury to
the individual; the individual’s relationship with
his employer; economic issues; workplace
accommodations made available by the
employer; and the employer’s
policies/practices, culture, and values”.
Dr Presley Reed
The Medical Disability Advisor 4th Ed.
Disability is not a medical concept
Defined by a contract, usually related to
Therefore, it is a legal rather than a
Influenced by non medical factors :
Employer, availability of alternate duties
Training, experience, education
Doctors are trained to treat
Physician’s Perspective On Disability Determination
• 86% of physicians believe that completing
disability forms adversely affects the
• 62% feel it represents a conflict of interest
• 56% are willing to exaggerate clinical data
to assist a deserving patient
• Physicians report a lack of confidence in their
ability to determine disability (self rated ability as
• 80% of physicians feel it would be better for
an independent group to determine disability
Journal of General Internal Medicine 1996 11(9)
Certificate of Disability
Canadian Medical Association Policy
• The CMA believes it is the employer’s
responsibility to supervise an employee who
is absent from work for a short time because
of a minor illness. The medical profession
objects to being asked to police such
• The association objects to the use of
physicians as “truant officers”.
• It is generally accepted that most minor
illnesses are self limiting and do not require
the intervention of a physician.
If illness was the cause of absenteeism, then absence rates
should be similar across communities. But they are not:
Gross Absence Rates
Trade & Commerce
5.3% (Perspectives 1999)
Unionized ees 13.2 days/yr vs Non Unionized ees 7.5 days/yr
(Stats Can 2011)
What are the reasons we miss work?
Region (NS vs AB)
Quality of Supervision
The primary determinant of work
attendance is job satisfaction:
• What makes people come to work?
– Opportunity, Desire and Ability
– Global / Environment / Organization / Personal
variables can affect those
• Who decides if working is possible?
– Decision to work is made by the individual
– The decision to offer alternate duties and provide
accommodation is made by employer
– Neither is a medical decision
And you want employees to like their work……….
“It is always more important to
know what type of person has a
disease than it is to know what
type of disease a person has.”
Disability vs Disease
• Disability and disease are distinct concepts;
diagnosis does not determine disability
• Doctors don’t know disability and are not truant
• Disability from work is determined by a multitude
of non medical factors
• While supporting the concept of early return to
work, doctors are patient advocates, and
ultimately, patients determine their ability to work
• The workplace/workplace policies must
encourage employees to remain at work (even
in the face of challenges)
• Engagement may reduce absenteeism
So, if disability is not driven
by disease, and doctors
don’t know much about
disability or the workplace,
what do we do?
How do we determine or
The first paradigm shift
Stop talking to
doctors and start
Talk to employees
• Doctors talk to their patients - they trust them and
advocate for them, but they don’t know the workplace
• Trust your employees – they are telling you the truth*
• Treat them as you’d treat a manager or a colleague
or want to be treated yourself
• They know their job and what aspects they can do
and can’t do
• Allow them flexibility to do the job
• It is their motivation which determines outcome – so
what is motivating them to come to work or keep
* Most of the time. Why treat the 99% who are honest to catch the 1%?
What’s going on?
What you see
ARE ONLY THE
Troubled or Absent Employee
“TIP OF THE ICEBERG”
What you don’t see
• Legal/ Financial
KNOWING THE SOURCE OF THE PROBLEM
ALLOWS THE CASE MANAGER TO DETERMINE A
COURSE OF ACTION
• Heart Health
The Second Paradigm Shift
• Accept them and help them
• You cannot rehabilitate someone who is busy proving they are
• Malingerer’s are rare. Anxious and overwhelmed individuals are
• Often the claimant is just in the wrong basket – needs family
leave, needs to change jobs, needs to be on administrative leave
or re-assigned while workplace conflict is addressed
• Chronic diseases are chronic/recurrent and need to be addressed
holistically (is public health up to the task?)
• Whatever the barrier or reason for being off work, the outcome is
better, and total cost reduced, if you support the employee and
work through the issues
The Third Paradigm Shift: think long term
• Employees are there for the long term, so you
need to think long-term
• An injured/ill employee who could be at work,
but chooses not to rtw, generates a greater
loss to the organization over the long term
than the “extra” few weeks of sick leave. They
• Presenteeism costs more than absenteeism
• Forcing an employee to rtw when they feel
they are “unfit” will cost the employer money
Tools to Assist the Shift: Health Assessment
A complement to, not a replacement for, a discussion between
manager and employee.
Health Assessment Type
When to use
•Medical issues impacting attendance
•Level 3-Attendance Support
•Persistent Ergonomic Issues
Return to Work
•Assess fitness to return to work from LTD,
Administrative Leaves, etc. (used
Train Managers to Identify Employees at Risk
• How to help employees stay at work
– Identify employees who is having difficulties, as early as
• Absence is a predictable event
– How to predict absences?
• Know the workplace / know the people and know when
action is necessary
Tools to Assist Shift:
• Triggered when there is a demonstrated history of being over the average
for the department for absence or not meeting performance targets
• Absence is absence
–– it’s not why you missed work, it’s that you missed work (assumed
• The reasons for the absences/poor performance determine the help
• Early identification is key.
• No fault, no blame but the absences/performance is an issue
–What can you do? What can we do?
Transitional Return To Work
• Focus on ability not inability
• Manager and employee (+/- health services)
• Part of corporate culture - it should be expected
(and employer should be prepared with
• Time limited – it’s a transition not a move
• Progressive (but flexible)
• Must be safe (for ee, co-workers, public)
• Goal is rehabilitation – it cannot be punitive
• Work must have meaning
• Workplace must be welcoming
Bell Aliant is Committed to Early and
Safe RTW (as is the Union!)
• 28.12 It is agreed that the rehabilitation of
sick and injured employees is a priority. The
Company and the Council will participate in
programs that will enable early and safe
return to work…The rehabilitation plan will be
based on the employee’s functional
capability, input from the employee’s existing
health care providers, and other health care
professionals as deemed necessary by the
Manager and Employee can decide on
modified duties – LRA 2008-04.
• If the employee’s restrictions are expected to last 30
days or less and the employee can be
accommodated under the terms of the collective
agreement, no action is required other than
proceeding with the accommodation request. If
however, the employee cannot be accommodated
under the terms of the collective agreement, then
medical documentation may be required. At any
time, the manager can seek input from Health and
Wellness. The manager must inform the local shop
steward of the details of the accommodation and the
Mental Health Initiative
• 1/3rd of claims, last 50-100% longer
• MH issues start young and recur
• Often months of presenteeism before absence
(opportunity to intervene)
• There are often workplace drivers and workplace
solutions! (another opportunity to intervene)
• Mental health awareness training for Leaders of
• Educational sessions, communications
• Focus on early recognition, highlight resources
Results of this Approach
Gross Absence Rate* 4.5%>4.3%>4.1%>3.6%>3.6% (2013)
SDB as % salary` 1.36%>1.28%> 1.24% >0.97% >0.99%
Denials < 1% - usually wrong basket
Grievances on denials – rare
Relationship with Union - positive
# of Health Assessments – increased (some referred by
• # of IMEs for SDB adjudication – rare
• # of IMEs for HA’s and SDB mgmnt - frequent
* Cdn GAR: Company >500 ee =4.4%;Unionized Workplace 5.3% (stats can 2011)
`SDB % of Income Cdn average 1.5% (Towers Watson)
Accept and Assist trumps Deny and Defend
Think Total Cost and think long term
Talk to employees, not doctors
Engage HR/LR/Ops in program development – make them
stakeholders/ambassadors; train mgrs/union
Don’t under estimate cultural resistance
Become health navigators – focus on Chronic Disease
Orient new employees/managers
Address presenteeism- its your next SDB claim, offer help
Performance = Attendance improvement
EE who can, but won’t participate in TRTW, is likely
disengaged and a problem beyond their SDB claim