Keeping down the high costs of workers' compensation by redefining first aid
Employers are required to record certain injuries and illnesses under the OSHA recordkeeping regulation and to adhere to certain other requirements under workers' compensation law. The two laws have separate functions: Workers' compensation is designed to compensate injured or ill workers, whereas the Occupational Safety and Health Act is designed to prevent injuries and illnesses and to create a body of information to improve understanding of their causes. Thus, certain injuries and illnesses may be reportable under state workers' compensation law but not under the OSHA recordkeeping rule and vice versa. The two things that OSHA's reporting requirements for injury and illness have in common with state workers' compensation reporting requirements is that electrical contracting firms want to decrease the number of both.
In an effort to exclude less serious injuries from its data, in 2002 OSHA started no longer requiring the reporting of first aid treatment cases under its recordkeeping rule. Only injuries that result in loss of consciousness, or require medical treatment, time off work, restriction of work, lost time, or transfer to another job are now reported. Likewise, when an employee is treated under an employer's first aid program, rarely is it necessary for the employee to file a workers' compensation claim. The fact is, most employers pay for first aid programs out-of-pocket to avoid entanglements with insurance and deductibles and to buoy their safety records.
The average price of a workers' compensation claim varies by state, reports the National Council on Compensation Insurance (NCCI), Boca Raton, Fla., with New York leading all 50 states from 2002 to 2003 with an average workers' compensation cost total of $19,000. In a recent study, the agency also found that workers' compensation pays more to treat comparable injuries than group health insurance plans — and that's just the cost of the medical expenses. Indirect costs — loss of productivity and quality from time off work and the costs of hiring and training replacement workers, as well as retraining permanently partially disabled workers for other jobs — usually exceed the direct costs by as much as five times. Some of these costs can be alleviated by implementing a company first aid program.
Yet, for most people, first aid refers to treatment administered immediately after an injury occurs and at the location where it occurred, consisting of a one-time, short-term treatment that requires little technology or training to administer. For those bound by specific federal and state regulations for medical treatment for employees, though, first aid treatment can be a means of cutting through some serious red tape to the advantage of both the employer and employee.
Evidence of MSDs
Because of the progressive nature of soft-tissue damage, or musculoskeletal disorders (MSDs), this type of injury seems to be the perfect match for trial treatment as first aid.
In 2003, OSHA considered modifying the form employers use to record workplace injuries and illnesses to include a separate column for MSDs. However, the agency concluded that the separate column would not improve its recordkeeping abilities. Therefore, when reporting these types of injuries, employers continue to check the column for “injury” or “all other illness,” depending on the circumstances of the case.
The stance OSHA takes on repetitive motion injury/illness conditions is that they should be treated in the same way as any other condition. Unlike other conditions and injuries, however, MSDs caused by repetitive motion present when an employee admits to experiencing pain and are not due to a specific incident or accident. Therefore, the key to treating MSD injuries off the grid, so to speak, is to encourage workers to report when they are experiencing early onset symptoms, such as tingling, numbness, and tightness in the hands, fingers, or forearms. At this stage, the condition is OSHA-classified as a “discomfort,” not an “injury,” and can be treated outside of the traditional occupational medicine route.
This might mean having to change your workers' perceptions about what constitutes health. “These are issues that cause the person discomfort but aren't taking them out of their jobs,” says Dr. Grove Higgins, doctor of chiropractic medicine at Champion Health, Colorado Springs, Colo. “Most people wait until they have a situation where they have either so much pain that they don't want to work or they have dysfunction so they can't work.”
Higgins sees this most in his work with tradespeople. “Their livelihood is tied to their activity, so a lot of them don't seek help because they think it's normal,” he says. “A lot of them push it off onto aging, which is a bad excuse as well.”
Therefore, it's imperative that HR representatives and safety personnel have an open-door policy when it comes to talking to employees about chronic pain conditions. In order to qualify as first aid, the condition must be treated before it progresses to the point of being an OSHA-recordable injury — or where it's necessary for the worker to file a compensation claim to pay for days off work and medical treatment. “Once the person becomes injured, it costs the company money, and it also causes the person to be out of their job,” says Higgins. “It's bad for both ends of the system in the long term.”
“The standard way of doing medical cases isn't always the best thing for the employee,” says Bill Tuten, safety manager for Berwick Electric, Colorado Springs, Colo. “All too often, once workers are referred to worker's comp, they lose time on the job, and they don't necessarily get better,” he says.
For the last two years, employees of Berwick Electric who have come to Tuten with MSDs have been treated in a first aid capacity by providers of Active Release Technique (ART), a movement-based diagnostic tool and massage technique. When caught early, most MSDs take between three and four ART treatments, on average, to resolve the case. Tuten estimates this has saved his company around $75,000.
To date, 10 employees have been under the care of an ART provider, which has prevented two or three surgeries and the accompanying disability and indemnity costs, as well as the costs of having workers on modified duty anywhere from six weeks to six months. “I've had cases before that, had I known about ART, I know we could've saved tens of thousands of dollars,” Tuten says.
Berwick's first ART candidate presented with a strain on his right arm from pulling data wire. Not wanting to initiate a workers' compensation claim, the injured employee first went to his primary care provider, who referred him to another doctor, who referred him to a neurologist. The diagnosis was nerve damage in the right arm, anywhere from the wrist to the shoulder. The prescribed course of action was exploratory surgery to locate the exact point of the damage. Not wanting time off work for a possible lengthy recovery, the employee finally came to Tuten for help. Tuten recommended ART. “After the very first treatment he was pain-free and regained full use of his arm,” Tuten says.
The employee was treated four more times, still on a first aid basis, and hasn't had another problem with his arm. “You're talking about a very serious surgery that actually could have damaged him further and possibly caused him to lose part of the use of his right arm,” Tuten says. “He lost very little work.”
However, not every MSD can be healed by this technique. Two of Tuten's employees were referred to the traditional occupational medicine system for surgery.
How ART really differs from other treatment providers is that it works as both a treatment for chronic conditions in workers' comp scenarios as well as first aid. “We have two different types of ways to render care,” says Tulio Pena, director of corporate programs for ART, Colorado Springs, Colo. “In many cases, the individuals present once their conditions are more severe, and they've entered the work comp system. But what a lot of corporations have started to do over the last year is use our onsite care program, where we deliver therapy directly to corporations to catch aches, pains, and discomforts before they become OSHA-recordable injuries and cost the corporation from the work comp standpoint.”
To that end, some of the clinic's doctors and therapists work part-time for a few hours a week in offices on company grounds, saving employees valuable travel time. But office visits aren't possible for every company, particularly electrical contractors where most of the employees are on job sites. “In our industry, you've got anywhere from four or five guys on one job site to 150 guys on another,” says Tuten, noting that in this case, employees do have to take the time to visit the ART clinic in their areas.
Another service ART provides its clients are in-house presentations on injury prevention and stretching techniques. “The prevention part is actually the most simple part,” says Higgins, a full-body provider of ART. “Because the job is so repetitive, just being able to do things outside of what they do typically helps.”
Higgins advises workers on making motions with their hands that are opposite of their daily tasks. “Say the person is turning a screwdriver or gripping a pair of pliers a lot. In that case, a very simple thing to do would be to do a five- to 10-second stretch where the employee is doing the opposite of what the task requires,” he says. “For example, when workers find themselves grasping all day, they should take a break for a quick stretch where they keep the elbows straight, pull the fingers back, and extend the wrist in order to stretch the forearm.”
Five to 10 seconds of stretching every 15 or 20 minutes may be enough to relieve most aches and pains and prevent scar tissue. “Just giving their bodies a different experience so they don't have this continual repetitive motion is enough,” Higgins says.
But unless the stretching exercises are mandated as medical treatment, it can be difficult to enforce them on the job site. Unless required by a general contractor or a client, the exercises are entirely voluntary.
A safety manager worth his salt tries everything to encourage employees to participate in the program. “They need to put a bump in the road for it,” says Higgins, who has witnessed managers finally getting the idea of a more active treatment program on his onsite visits. “It's changing the way they do things,” he says.
In the past, it seemed that safety managers took a more passive approach to ergonomics and MSD prevention and treatment. “They'd give one seminar and expect everybody to adopt it,” Higgins says. “There was no backing it up.”
Higgins credits the presence of the ART providers in the actual companies as a way of keeping workers involved in the program. “We're there all the time so they know they can get seen because the company wants them to be seen,” he says. “After they've seen us, we give them skills to keep themselves well. They learn these skills, and they're reinforced continually.”
As part of his first aid program, Tuten hangs posters illustrating the different exercises in common areas on job sites. He also includes occasional reminders in his workers' paycheck envelopes.
Still, some best efforts can't beat human nature. “I see people do it once in a while,” Tuten says. “Whenever I make my safety audits, I talk to the guys about stretching, and not too many are against it. What their issue is most of the time is that they forget or they only think about it until they get a kink in their back or shoulder.”
As an active member of the American Society of Safety Engineers, Tuten tries to spread the word about using first aid treatment in general, as well as ART's specific program.
An ounce of prevention
Currently, the massage technique is the only official first aid treatment Tuten uses at his company. “There's a very strict criteria about what constitutes first aid under the OSHA recordkeeping regulation,” Tuten says (see Fourteen Components of First Aid on page 44). ART has the blessings of both its state and the federal OSHA agencies.
For the future, however, Tuten keeps an open mind about other alternatives to OSHA-regulated medical treatment. “This is a viable method to introduce into our safety programs,” Tuten says. “Surgery's not always the answer. Medication is not always the answer. I'm glad that they're here, but I think we just need to open our minds up a bit.”
Ultimately, treatment programs should never take the place of prevention. Low-cost options for injury treatment, even if it's not recorded by OSHA, still come at a higher price than no injuries at all. Currently, there is no widely accepted standard for ergonomics in the construction industry (see Toward an Ergonomic Standard for Construction: One Step Back?). Therefore, it's important for safety managers to incorporate the best advice from all sources to inspire their workers to develop safe working habits (see The Best Medicine on page 48).
“You still have to investigate why these injuries happen,” Tuten says. “You still have to do your due diligence as a professional safety individual to investigate why that person has that strain.”
Sidebar: Fourteen Components of First Aid
In the revision to its regulation, “Occupational Injury and Illness Recording and Reporting Requirements,” OSHA adopted a single, all-inclusive first aid list and explicitly stated that any treatment not on the list is considered, for recordkeeping purposes, to be medical treatment. OSHA considers the listed treatments to be first aid, regardless of the professional qualifications of the person providing the treatment. The following treatments fall within OSHA's definition of “first aid:”
Using a nonprescription medication at nonprescription strength (for medications available in both prescription and nonprescription form, a recommendation by a physician or other licensed health care professional to use a nonprescription medication at prescription strength is considered medical treatment for recordkeeping purposes).
Administering tetanus immunizations (other immunizations, such as hepatitis B vaccine or rabies vaccine, are considered medical treatment).
Cleaning, flushing, or soaking wounds on the surface of the skin.
Using wound coverings, such as bandages, Band-Aids, gauze pads, etc.; or using butterfly bandages or Steri-Strips (other wound-closing devices, such as sutures, staples, etc., are considered medical treatment).
Using hot or cold therapy.
Using any non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc. (devices with rigid stays or other systems designed to immobilize parts of the body are considered medical treatment for record-keeping purposes).
Using temporary immobilization devices while transporting an accident victim (e.g. splints, slings, neck collars, back boards, etc.).
Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister.
Using eye patches.
Removing foreign bodies from the eye using only irrigation or a cotton swab.
Removing splinters or foreign material from areas other than the eye by irrigation, tweezers, cotton swabs, or other simple means.
Using finger guards.
Using massages (physical therapy or chiropractic treatment is considered medical treatment for recordkeeping purposes).
Drinking fluids for relief of heat stress.
Sidebar: The Best Medicine
Between 1999 and 2002, more than 30% of all workers' compensation claims filed by Independent Electrical Contractors (IEC) trade association members were related to ergonomics. This amounted to more than $10 million in claims in just four years.
In the absence of a federal standard focused on ergonomics and construction, IEC, as part of its alliance with OSHA, created an Ergonomic eTool that describes common hazards electrical contractors may encounter and possible solutions for these hazards. To view the eTool, visit OSHA's Web site at www.osha.gov/SLTC/etools/electricalcontractors/index.html.
Sidebar: Toward an Ergonomic Standard for Construction: One Step Back?
In May, the Appeals Panel of the Accredited Standards Committee (ASC) of the American National Standards Institute (ANSI) rejected an appeal mounted by Alexandria, Va.-based American Subcontractors Association (ASA) and five other construction associations against ASC's A10 Committee for Construction and Demolition Operations (Subgroup A10.40) proposed ergonomics standard, “Reduction of Musculoskeletal Problems in Construction.” The appeal was based on the construction associations' belief that the science the proposed standard is based on isn't accurate or construction-specific.
“We believe it imposes some rather vague obligations without any standards by which to measure or determine what is to be measured and identified and how it's to be fixed,” says Bill Isokait, ASA senior director and counsel, government and industry relations. “We're not confident that it really is very helpful in that regard.”
The proposed standard now goes to ANSI for final approval, where the ANSI Board of Standards Review will examine the record of the standard, including the appeal.
“We believe that a consensus is possible on an ergonomic standard, but we don't think this particular standard is a very good one,” says Isokait. “There isn't a consensus among the employer groups about what these things are, how to identify them, or how to remedy them. Construction is a moving target given that responsibilities, duties, and work practices are always changing to accommodate how projects change and progress. We don't believe the standard does a very good job of recognizing that and addressing it.”