Medical Care Spending and Labor Market Outcomes: Evidence from Workers' Compensation Reforms.

Medical care represents an important component of workers' compensation benefits with the potential to improve health and post-injury labor outcomes, but little is known about the relationship between medical care spending and the labor outcomes of injured workers. We exploit the 2003--2004 California workers' compensation reforms which reduced medical spending disproportionately for workers incurring low back injuries. We link administrative claims data to earnings records for injured workers and their uninjured coworkers. We find that workers with low back injuries experienced a 7.6 percent post-reform decline in medical care, and an 8.1 percent drop in post-injury earnings relative to other injured workers.

National Disability Insurance Scheme, health, hospitals and adults with intellectual disability.

Preventable poor health outcomes for adults with intellectual disability in health settings have been known about for years. Subsequent analysis and the sorts of reasonable adjustments required in health and disability support settings to address these health gaps are well described, but have not really been embedded in practice in any significant way in either setting. As far as health is concerned, implementation of the National Disability Insurance Scheme (NDIS, the Scheme) affords an opportunity to recognise individual needs of people with intellectual disability to provide reasonable and necessary functional support for access to mainstream health services, to build capacity of mainstream health providers to supply services and to increase individual capacity to access services. Together these strands have potential to transform health outcomes. Success of the Scheme, however, rests on as yet incompletely defined operational interaction between NDIS and mainstream health services and inherently involves the disability sector. This interaction is especially relevant for adults with intellectual disability, known high users of hospitals and for whom hospital outcomes are particularly poor and preventable. Keys to better hospital outcomes are first, the receiving of quality person-centred healthcare from physicians and hospitals taking into account significance of intellectual disability and second, formulation of organised quality functional supports during hospitalisation. Achieving these require sophisticated engagement between consumers, the National Disability Insurance Agency, Commonwealth, State and Territory government leaders, senior hospital and disability administrators, NDIS service providers and clinicians and involves cross fertilisation of values, sharing of operational policies and procedures, determination of boundaries of fiscal responsibility for functional supports in hospital.

[Trends of work force participation of patients with rheumatic diseases : results from German social insurance data and the national database of the German collaborative arthritis centers]. / Trends der Erwerbstätigkeit von Rheumakranken : Ergebnisse aus Sozialversicherungsdaten und Kerndokumentation der Rheumazentren in Deutschland.

Positive therapeutic effects on the work force participation derived from international clinical trials may not be directly transferable to the community based care in Germany. Therefore recent changes of data regarding sick leave (SL), work disability pension (WDP) and employment from the social insurance and from the national database of the German collaborative arthritis centers were analyzed covering a time period of at least 10 years. Health insurance data showed a steeper decline in the average duration of SL caused by rheumatoid arthritis (RA), ankylosing spondylitis (AS) and systemic lupus erythematosus (SLE) compared with all other diseases. In RA patients from the collaborative arthritis centers the mean duration of SL was much more reduced than the average duration of SL for members of the compulsory health insurance. The proportion of gainfully employed RA patients in collaborative arthritis centers has particularly increased in women. According to data from the pension insurance fund less incident cases of WDP due to RA, AS, and SLE have been observed than WDP caused by all other diseases. Thus different nationwide data show positive changes of the work force participation of individuals suffering from inflammatory rheumatic diseases in Germany.

Genetic and environmental contributions to long-term sick leave and disability pension: a population-based study of young adult Norwegian twins.

Although exclusion from the workforce due to long-term sick leave (LTSL) and disability pension (DP) is a major problem in many Western countries, the etiology of LTSL and DP is not well understood. These phenomena have a strong association as most patients receiving DP have first been on LTSL. However, only a few of those on LTSL end up with DP. The present study aimed to investigate the common and specific genetic and environmental risk factors for LTSL and DP. The present study utilizes a population-based sample of 7,710 young adult twins from the Norwegian Institute of Public Health Twin Panel, which has been linked to the Historical-Event Database (FD-Trygd; 1998-2008). Univariate and bivariate twin models were fitted to determine to what degree genetic and environmental factors contribute to variation in LTSL and DP. The estimated heritabilities of LTSL and DP were 0.49 and 0.66, respectively. There was no evidence for shared environmental or sex-specific factors. The phenotypic-, genetic-, and non-familial environmental correlations between the variables were 0.86, 0.82, and 0.94, respectively. Our results indicate that familial transmission of LTSL and DP is due to genetic and not environmental factors. The risk factors contributing to LTSL and DP were mainly shared, suggesting that what increases risk for LTSL also increases risk for DP. However, a non-negligible part of the genetic variance was not shared between the variables, which may contribute to explaining why some progress from LTSL to DP, whereas others return to work.

Young adults on disability benefits in 7 countries.

BACKGROUND: This article, based on a study by the Swedish Social Insurance Inspectorate, describes the development of young adults receiving disability benefits due to reduced working capability, and the disability benefit systems in seven European countries; Denmark, Finland, Iceland, Norway, the Netherlands, Sweden, and the UK. This comparative study mainly uses Sweden as a benchmark. METHODS: Apart from a documentary and legal data collection and analysis, 26 semi-structured interviews were conducted with representatives of the responsible ministries and authorities in the studied countries. In addition, national and European data was collected. RESULTS: There is an increasing trend of young adults, aged 19-29, on disability benefits in all studied countries. The most common diagnosis group among young adults on disability benefits is mental and behavioural disorders, ranging from 58% in the UK to 80% in Denmark. CONCLUSIONS: The comparison of the different disability benefit systems shows that there are relatively large national differences in terms of rules and regulations, the handling of disability benefit cases, and offered rehabilitation activities and other measures to support young adults on disability benefits to strengthen their working capability, and hence enable them to approach the labour market in the future. However, it is clear that these countries face similar challenges, and therefore there could be a lot to learn from European exchange of experiences and expertise in this area. This article identifies a number of measures of special interest to study and discusses further with regard to the further development of the Swedish system for disability benefits for young adults.

Heightened vulnerabilities and better care for all: disability and end-of-life care.

OBJECTIVE: The purpose of this study was to assess the extent to which vulnerability was present or heightened as a result of either disability or end-of-life policies, or both, when people with disabilities face end of life. METHOD: People with disabilities and policy makers from four Canadian provinces and at the federal level were interviewed or participated in focus groups to identify interactions between disability policies and end-of-life policies. Relevant policy documents in each jurisdiction were also analyzed. Key theme analysis was used on transcripts and policy documents. Fact sheets identifying five key issues were developed and shared in the four provinces with policy makers and people with disabilities. RESULTS: Examples of heightened vulnerability are evident in discontinuity from formal healthcare providers with knowledge of conditions and impairments, separation from informal care providers and support systems, and lack of coordination with and gaps in disability-related supports. When policies seek to increase the dignity, autonomy, and capacity of all individuals, including those who experience heightened vulnerability, they can mitigate or lessen some of the vulnerability. SIGNIFICANCE OF RESULTS: Specific policies addressing access to community-based palliative care, coordination between long-standing formal care providers and new care providers, and support and respect for informal care providers, can redress these heightened vulnerabilities. The interactions between disability and end-of-life policies can be used to create inclusive end-of-life policies, resulting in better end-of-life care for all people, including people with disabilities.

The growth in applications for Social Security Disability Insurance: a spillover effect from workers' compensation.

We investigate the determinants of application for Social Security Disability Insurance (DI) benefits in approximately 45 jurisdictions between 1981 and 1999. We reproduce findings of previous studies of the determinants of DI application then test the additional influence of changes to workers' compensation program benefits and rules on DI application rates. Our findings indicate that the programs are interrelated: When workers' compensation benefits declined and eligibility rules tightened in the 1990s, the DI application rate increased.

Regional trends in awards of incapacity benefit by cause.

BACKGROUND: Since the early 1990s, rates of incapacity benefit (IB) in Britain for musculoskeletal complaints have declined, and they have been overtaken by mental and behavioural disorders as the main reason for award of IB. AIMS: To explore reasons for this change. METHODS: Using data supplied by the Department for Work and Pensions, we analysed trends in the ratio of new IB awards for mental and behavioural disorders to those for musculoskeletal disorders during 1997-2007 by Government region. RESULTS: In Great Britain overall, the above ratio more than doubled over the study period, as a consequence of falling numbers of new awards for musculoskeletal disorders. The extent to which the ratio increased was smallest in London (50%) and South-East England (56%), and was progressively larger in more northerly regions (>150% in North-East England and Scotland). CONCLUSIONS: The differences in trends between regions seem too large to be explained by differential changes in working conditions, patterns of employment or the rigour with which claims were assessed. An alternative explanation could be that the main driver for the trends has been culturally determined changes in health beliefs and expectations, and that these cultural changes began in London and the South-East, only later spreading to other parts of Britain.

What can we learn from analyzing historical data on social security entitlements?

We use data from Social Security administrative records to examine the lifetime patterns of initial entitlement to retired-worker and Disability Insurance (DI) benefits across cohorts born in different years. Breaking out age-at-entitlement patterns for different birth-year cohorts reveals close adherence in entitlement ages to changes in program rules, such as increasing the full retirement age. The proportion of a cohort that becomes newly entitled to DI benefits rises noticeably during recessions and at ages 50 and 55, and cumulative entitlement rate patterns show that more recent cohorts rely increasingly on DI benefits in their late 30s and 40s.

[Whiplash in insurance medicine: lessons for physicians]. / Whiplash in de verzekeringsgeneeskunde.

The number of employees applying for a labour disability benefit due to whiplash has gradually decreased during the last 25 years in the Netherlands. The total number of applicants seems to stabilise around 30% of the number around the turn of the century. This is surprising given that the professional standards for social insurance physicians emphasise the importance of rehabilitation, while courts hardly ever judge in favour of benefit claimants. We investigate the underlying reasons for the changing statistics and make a recommendation on how social insurance physicians can best approach a claimant.

Healthcare provision in amyotrophic lateral sclerosis: procedures, queries and pitfalls in Germany and Poland.

There are a number of physical restrictions that develop in the course of amyotrophic lateral sclerosis (ALS). While loss of speech and motor control may be partially compensated by the support of assistive devices, swallowing difficulty and respiratory insufficiency require medical interventions (percutaneous endoscopic gastrostomy, noninvasive, and invasive ventilation). Based on the data collected within the NEEDSinALS study, we found major differences in personal satisfaction with the financing, healthcare provision, medical infrastructure, and regulations of German and Polish ALS patients, despite minor differences in economic burden caused by the disease. In order to explain this phenomenon, we thoroughly reviewed the legal basis, structure and organization of the healthcare systems in Germany and Poland to determine the range of obstacles in the everyday lives of patients and their caregivers that are attempting to attain an assistive device or care after the start of medical interventions.

Mental health as a reason for claiming incapacity benefit--a comparison of national and local trends.

BACKGROUND: Getting incapacity benefit (IB) claimants into work has become a focus for policy makers. Strategies to help this group depend on an understanding of the reasons for claiming benefit at a local level where variations from a national strategy may be needed. METHODS: Data supplied by the Department for Work and Pensions (DWP) was analysed to establish reasons for claiming benefit in Scotland and Glasgow between 2000 and 2007. RESULTS: There has been a continuing rise in mental health diagnosis and a corresponding fall in musculoskeletal diagnosis during this period. More people were claiming because of mental health problems in Glasgow than in Scotland. Also those with a poor employment history (credits-only claimants) are more likely to claim IB because of a mental health problem. This study has shown a breakdown into 25 categories those claiming IB because of a mental health problem. CONCLUSION: DWP data can be used to provide important insights into the trends in reasons for claiming IB, in particular those claiming because of mental health problems. This study also highlighted the growing importance of problems caused by alcohol and drug-abuse claimants, a subset of the mental health category. DWP data should be used at a local as well as a national level to guide and evaluate interventions to help this vulnerable group.

Elderly poverty and Supplemental Security Income.

In the United States, poverty is generally assessed on the basis of income, as reported in the Current Population Survey's (CPS's) Annual Social and Economic Supplement (ASEC), using an official poverty standard established in the 1960s. The prevalence of receipt of means-tested transfers is underreported in the CPS, with uncertain consequences for the measurement of poverty rates by both the official standard and by using alternative "relative" measures linked to the contemporaneous income distribution. The article reports results estimating the prevalence of poverty in 2002. We complete this effort by using a version of the 2003 CPS/ASEC for which a substantial majority (76 percent) of respondents have individual records matching administrative data from the Social Security Administration on earnings and receipt of income from the Old-Age, Survivors, and Disability Insurance and Supplemental Security Income (SSI) programs. Adjustment of the CPS income data with administrative data substantially improves coverage of SSI receipt. The consequence for general poverty is sensitive to the merge procedures employed, but under both sets of merge procedures considered, the estimated poverty rate among all elderly persons and among elderly SSI recipients is substantially less than rates estimated using the unadjusted CPS. The effect of the administrative adjustment is less significant for perception of relative poverty than for absolute poverty. We emphasize the effect of these adjustments on perception of poverty among the elderly in general and elderly SSI recipients in particular.

Too sick to work, too healthy to qualify: a cross-country analysis of the effect of changes to disability benefits.

BACKGROUND: Denmark and Sweden have implemented reforms that narrowed disability benefit eligibility criteria. Such reforms in combination with increasing work demands create a pincer movement where in particular those with moderate health problems might be unable to comply with work demands, but still not qualify for permanent disability benefits, ending up with temporary means-tested or no benefits. This paper examines whether this actually happened before and after the reforms. METHODS: The Survey of Health, Ageing and Retirement in Europe (SHARE) study waves 1-2 and 4-6 in Denmark and Sweden for the age group 50-59 years (N=5384) was used to analyse changes in employment rates and benefits among people with different levels of health before, during and after disability benefit reforms. Interaction between time and health in relation to employment versus permanent or temporary benefits was used as a criterion for whether our hypotheses was confirmed. RESULTS: Overall, employment rates have increased in the age group, but only among the healthy. The OR for receiving temporary or no benefits increased from 1.25 (95% CI: 0.81 to 1.90) before to 1.73 (95% CI: 1.14 to 2.61) after policy reforms for the 29% with moderate health problems and from 2.89 (95% CI: 1.66 to 5.03) to 6.71 (95% CI: 3.94 to 11.42) among the 11% with severe health problems. The interaction between time and health was statistically significant (p<0.001). CONCLUSION: People with impaired health and workability are forced into a life with temporary means-tested or no benefits when pressed by rising work demands and stricter disability benefit eligibility criteria.

Recent developments in health insurance, life insurance, and disability insurance case law.

This survey reviews significant state and federal court decisions from 2006 and 2007 involving health, life, and disability insurance. Also reviewed is a June 2008 Supreme Court decision in the disability insurance realm, affirming that a conflict of interest exists when an ERISA plan sponsor or insurer fulfills the dual role of determining plan benefits and paying those benefits but noting that the conflict is merely one factor in considering the legality of benefit denials. In addition, this years' survey includes compelling decisions in the life and health arena, including cases addressing statutory penalties and mandated benefits, as well as some ERISA decisions of note. This year, the Texas Supreme Court held that Texas's most recent version of the prompt payment statute abolished the common law interpleader exception and allowed the prevailing adverse claimant in an interpleader action filed beyond the sixty-day statutory period to recover statutory interest and attorney fees from the insurer. Meanwhile, the Court of Appeals of New York upheld the constitutionality of a statute mandating coverage for contraceptives in those employer-sponsored health plans that offer prescription drug coverage, including those plans sponsored by faith-based social service organizations. In the ERISA context, litigants continue to fight over the standard of review with varying results. In a unique assault on the arbitrary and capricious standard of review, the Fourth Circuit found that an ERISA plan abused its discretion when it failed to apply the doctrine of contra proferentem to construe ambiguous plan terms against itself. In more hopeful news for plan insurers, the Tenth Circuit held that claimants are not entitled to review and rebut medical opinions generated during the administrative appeal of a claim denial before a final decision is reached unless such reports contain new factual information.

Using an adapted Delphi process to develop a survey evaluating employability assessment in total and permanent disability insurance claims.

BACKGROUND: No research has been undertaken about employability assessment of total and permanent disability (TPD) insurance claims. Employability assessment provides vocational information to life insurers to help decide claims. To determine how helpful employability assessment is, a new measure was needed to survey insurers. OBJECTIVE: To generate survey items by harnessing the knowledge and agreement of rehabilitation advisors with expertise in employability assessment. METHODS: A panel of 10 (89% of eligible Australian rehabilitation advisors) participated in an adapted three-round Delphi process. Rounds 2 and 3 were incorporated into a novel real-time card sort format. RESULTS: From 94 potential items submitted for first round qualitative analysis, 36 items in four domains-quality, content, utility, and claims-were generated. Two quantitative ranking rounds in one face-to-face session produced a 21-item prototype. The final electronic survey instrument contained 11 sections seeking insurer demographics and feedback on: external providers; employability assessment concepts, components, quality, and usefulness; functional, occupational, labor market items; and finally, cost and type. Our Delphi process was anonymous, completed in four weeks with 100% response rate and 75% agreement. More time between Rounds 2 and 3 would enhance statistical analysis. CONCLUSIONS: Our adapted Delphi methodology for survey item generation is generalizable for any panel able to meet in person.

Public social security burden of musculoskeletal diseases in Brasil-Descriptive study.

BACKGROUND: To present data on the social security burden of diseases of the musculoskeletal system and connective tissue (DSOTC) in Brasil in 2014, and evolution of these social security expenditures between 2009 and 2014. METHOD: Compilation and analysis of data on the granting of disability pensions and sickness benefits in the year 2014, available on the official website of Social Security, classified according to ICD 10. It was evaluated the evolution between 2009 and 2014, using the F test to compare the curves with the growth of the active age population (PIA). RESULTS: Among the 22 disease groups classified according to ICD-10, the DSOTC group led benefits grants in 2014, with 19% of the sickness benefits and 13.5% of the disability pensions. The main causes of sickness benefit and disability retirement were, respectively: dorsopathies (43.3% and 41.2%), soft tissue diseases (27.3% and 19.7%), osteoarthritis (7.6% % And 27.8%) and chronic inflammatory arthropathies (2.8% and 7.9%). In the evolution of the number of sickness benefits granted between 2009 and 2014, both INSS and DSOTC totals showed an increasing tendency (35.9 and 35.3%, respectively, with p = 0.000 for both). As for disability retirement, there was a 5.9% increase in the INSS total (p = 0.039), while for the DSOTC there was a decrease of 7.6% (p = 0.005). CONCLUSIONS: These data point to a progressive increase in the granting of sickness pensions and disability benefits in the country, superior to the growth of the PIA, as well as a high participation of DSOTC in these benefits.

Genetic testing and the future of disability insurance: ethics, law & policy.

Predictive genetic testing poses fundamental questions for disability insurance, a crucial resource funding basic needs when disability prevents income from work. This article, from an NIH-funded project, presents the first indepth analysis of the challenging issues: Should disability insurers be permitted to consider genetics and exclude predicted disability? May disabilities with a recognized genetic basis be excluded from coverage as pre-existing conditions? How can we assure that private insurers writing individual and group policies, employers, and public insurers deal competently and appropriately with genetic testing?