Thoughts on Workmen’s Compensation
The recent hasty attempt by our California State legislature to deal with the growth of Workmen’s Comp was probably just a foretaste of the major surgery to come. Is there a way to think our way through to a solution of this growing problem? The chances are that nibbling away at the edges does not really meet our needs. Cutting back on chiropractic visits can be no more than a band aid on the problem, and probably a mistake at that. If a therapy helps, we should by all means allow it to go to completion. The real problem is permanent disability. The society simply cannot afford so many people feather-bedding on the rest of us, and perhaps we should look to the welfare reform program for a solution. Would it be possible for us to assert, as a humane and civilized society, that there should be no such thing as permanent disability? And can a dyed-in-the-wool liberal like me in good conscience propose such a thing? Allow me to make the case.
At the recent annual conference of the American Academy of Pain Management, a physician speaker stated that he categorically refuses to accept chronic pain patients who come to him in order to be declared totally disabled. I was startled to hear this, because if there is a case to be made for total disability, it would appear to be with chronic pain. We are talking about people in whom the touch-sensing neurons have been recruited into the pain system, so that mere touch is painful. It can get so severe that such people have to have to undergo general anesthesia just to have their fingernails trimmed. One would agree that such people are fairly disabled.
But there we are. He refuses to accept them as patients because they have already adopted the mind set that they are never going to get well. In all attempts to get them well, there will be a subtle sabotage at work. To all those in the health care field this phenomenon is well known. Asked how he does with a particular technique, a practitioner might say that he does very well “except for my workmen’s comp patients,” which are in a class by themselves. We have had clients quit treatment the very moment that a breakthrough in symptoms gets underway, and some have even said explicitly, “I have to stop treatment. If I felt any better than I do I could not in good conscience continue to accept my disability payments.”
We have a skewed incentive system here, just as we did with welfare. The object of life becomes one of sustaining the cash flow. The point will inevitably be reached where we have no choice as a society but to turn off the spigot. So how can this be done humanely? The answer will surprise. I propose that we strategically invest in our disabled population. We invest in order to save.
Right now we are being penny-wise and pound-foolish. We are in the midst of an incredible ascendancy of rehabilitative technologies. This has not become obvious yet because of the role of the other part of our dysfunctional system, which is the reimbursement side. The third-party payers have no incentive to produce a positive long-term outcome. They only have an incentive to minimize the immediate cash outlay. Any new techniques coming along just represent a burden to them that has not yet been budgeted. It is unwelcome. In truth, there is as much pathology in the system as there is in the patient.
Suppose we divided the population of the disabled into those who wish to be well, and those who wish to be declared totally disabled. The latter would henceforth get only palliative care and sustenance. Their “rehabilitation” would end, and with it their therapy shopping. The rehabilitative resources would, however, be lavished on the former, in the expectation of the most efficient recovery path and restoration of personal productivity. Here the system should be biased in favor of “yes.” If the disabled person finds the therapy worthwhile, we should try to accommodate. Many therapies are synergistic, and the sometimes fragile will to recover must be nurtured at all costs. These people should not be made to run a gauntlet of resistance in order to get well. In return for this societal generosity, however, they would have to be willing to accept any productive role upon their recovery, even if it means a career change.
Let me indicate what is possible: One major category of disability is minor traumatic brain injury. (There is actually nothing minor about it, just that it does not involve skull fracture.) Modern rehabilitative methods have shown that it is possible to restore more than 80% of such totally disabled head injured to better than 80% of the level of function pre-injury. More than 60% of such people are back in the working world within months. Another example is addictions. Recent reports have shown an 85% success in the recovery of homeless crack addicts in Houston, Texas, where success meant not only relapse prevention, but return to sheltered status and to productive engagement—a paying job. This would have been unheard of two years ago.
A third major category is Post-traumatic Stress Disorder. This might involve people who witnessed a bank robbery at close hand, who were personally threatened with death or injury, or who work too long in the emergency room or children’s cancer ward. With modern methods, some 95% symptom recovery is now routinely possible with PTSD. On average, these recovery technologies would take no more than a few months, and cost no more than the average middle class person spends on his car in a year. Our society cannot be aware of these rehabilitative possibilities, on the one hand, and deny them to our disabled in good conscience, on the other.
PTSD opens the door to a discussion of mental illness in general. Most
mental illness is episodic, and we increasingly know how to abort the
episodes and put people back on track. For example, we now know how to
bring people out of a suicidal episode within a single therapeutic session.
And finally, there is chronic pain, for which it has been found that if
we are not stingy with the remedies, we can be very helpful. We may not
banish the pain, but we may well banish suffering, so that the person
can get on with life.
Can we then shrink the category of totally disabled to virtual insignificance?
I believe that we can, even in those cases where rehabilitation is out
of the question. As an example, take the case of “locked-in syndrome,”
where a person is no longer able to move any voluntary muscle at all.
One could scarcely think of a better example of a totally disabled person.
What job could he possibly do? As it happens, research in Germany by Niels
Birbaumer has shown that such a person can communicate with the outside
world via his brain activity, which he can learn to manipulate consciously
through feedback. So, this person could become a security guard at a bank,
for example. The bank security monitors would be routed via Internet to
his hotel---sorry, hospital room---and he could spend all day watching
the monitors. He would signal the alarm with his brain when necessary.
Most likely he himself could not be more pleased to finally have a useful
role.
In this manner, a constructive role could be devised for nearly every disabled person. They would then end up paying for their own care, and thus de-ballast the system. In effect, my proposal would entirely reverse the tendencies of the current model. We should be almost profligate in paying to get people well if they want to be well, and we should be most parsimonious when it comes to long-term care. Essentially no one should fall a burden to the state for the rest of life without in some way paying their dues if they are able. And with modern technologies, we can enable almost anybody to be productive in some fashion.
Siegfried Othmer, Ph.D.
November, 2003
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