There are times when a patient's occupational duties will delay or prevent them from recovering. These circumstances create the need for the doctor to recommend modified duty or remove the patient from work.
This can be a daily duty and is usually a simple process. Still, there are occurrences when the duty is taxing. For example, the patient may not want to or cannot afford to be away from work. The employer may not grant the patient time off, cannot or will not allow modified duty and/or may threaten to fire the patient. Insurance carriers can also chime in with their opinions.
To assist in these taxing situations, the doctor has to be familiar with several factors that can help make the process easier to manage. The factors should be considered when the situations are assessed. The factors that apply should be documented in the work orders and in the patient's clinical record.
Application of the Orders
The first rule for modified-duty and work-removal orders is that they also apply to household and recreational activities. It is hard to stop all household duties, but they must be limited in a manner similar to the work orders. It is pointless to modify a patient's work activities or remove them from work if they subsequently show up at the office describing recent home activities that could be as harmful as the occupational duties.
It is also embarrassing for the doctor to receive a call from an employer questioning why an employee who has been removed from regular duty showed up and played in the company softball game.
Periods of Time
Modified-duty and work-removal orders should have expiration dates. The recommended length of time is 30 days or less. The maximum time coincides with performing progress examinations every 30 days during the course of a patient's care. Exceptions occur when a patient has permanent impairment. Impairments can result in permanent modified-duty orders. In cases in which the patient's impairment results in disability, the patient will be unemployed and work orders will not be necessary.
Types of Modified Duty
There are several types of modified-duty assignments. The possibilities are endless, so let's discuss general categories of modifying duties.
Lifting limits is probably the most common form of duty restrictions. It is good for the doctor to be familiar with the heaviest lift a patient makes during work and how frequently they perform the lift. Both weight and frequency can be addressed.
Modified duty can be a reduction in hours. This is especially helpful for a patient who has been working a significant amount of overtime. Work time can be addressed by increasing the number of breaks during the day and working half days.
Activity restrictions. If walking irritates the patient's condition, it can be limited during the day. Bending, twisting, driving and other activities can be restricted. The activities are usually limited by stopping the activities altogether or limiting the amount of time a job requiring the activities is performed.
Posture limits can also be the subject of modified duty. Postures are also modified based on time. For example, if a patient has a disc problem, sitting should be limited.
Use of braces, supports or special protective equipment also qualifies as modified duty. Care has to be taken to make sure the patient does not have to work "against" any device used. Some devices can cause altered body mechanics and create additional problems.
Modifications can include providing a completely different set of responsibilities. In extreme cases, employees have been assigned to run the copy machine or sit in the break room reading company training manuals. This seems odd until the financial considerations (described below) are understood.
Financial Considerations
If the patient does not have a work-related injury and is removed from work, they will have to use accumulated sick and vacation time during the absence. Once this time is used, if additional time away is necessary the employer would have to agree to an unpaid leave.
If the patient has a work-related injury and is removed from work, the worker's compensation carrier will probably contact the doctor requesting the doctor consider a modified-duty assignment instead. The employer will be on-board with the request.
Worker's compensation carriers must pay patients 70-80 percent of their wages during their time off. It is referred to as "lost time." This represents the greatest expense for the carrier in most worker's compensation cases.
Insurance companies establish worker's compensation premiums on employee wages because they may have to pay wages as part of any claim. If they have to cover the patient's wages, they pass the expense on to the employer through increased premiums.
When a carrier weighs factors for a company's policy renewal, previous lost time expense usually carries more weight than previous health care expenses.
Carriers prefer modified-duty assignments over work removal so they do not have to compensate the employee. Employers prefer modified duty over work removal so their premiums do not increase. This is why assigning employees duties like running the copy machine is not uncommon. In many cases, it is cheaper for the employer to have the injured employee at work and hire a temporary employee in the patient's regular position than to have the employee off and risk premium increases.
In these situations, it is vital that the doctor keep the patient's best interest at heart and is familiar with how to properly assign modified duties.
Carriers and employers build a safety net into their policies to help regulate another aspect of work removal. Many worker's compensation policies do not begin paying employee wages until after the third missed work day. Pay begins at that point and continues until the patient has been absent for seven work days. On the eighth day, the carrier goes back and pays for the first three days.
This policy helps prevent workers from faking a minor injury in order to get a few days of paid time off. An employee may have used their vacation and sick time, and now needs time off to attend a family wedding. They could file a worker's compensation case for a mild complaint, receive a few days off with pay, and return to work if lost time were covered immediately.
The delayed coverage of lost time prevents this from being a problem for the employer. It is hard to have a minor complaint that requires seven days off.
Some will try to fake a problem or will attempt to talk the doctor into helping. A patient may say, "Doc, I think I need time off work. Can you write me a note? Can you make it about seven days, not counting Saturdays and Sundays?" If this occurs, it is obvious the patient is working the system.
The doctor's first responsibility is the patient's health and safety. Despite this, it is hard not to allow the financial circumstances and viewpoints of more than one party to influence writing work orders.
Acknowledging Missed Time vs. Removal From Work
Patients often report having missed work prior to consulting the doctor. In some cases, the patient will request a note for the missed time. The patient wants the doctor to justify their decision to stay home before receiving care. The doctor did not recommend the time off and should not backdate a work note. The best solution could be to provide a note stating, "Upon entry for care the patient reports having missed work on the following dates..."
This provides a note for the patient and does not indicate the doctor recommended the time off. In many instances, the employer sees the patient has a note signed by the doctor and accepts it without reading it closely. If it is read closely, the doctor has done what they can.
One hopes that the majority of patients requiring modified duty or removal from work will not have complicated circumstances and many of the factors discussed here will not have to be addressed. However, when the circumstances are complicated, the above information can help you formulate a plan for modified duty or work removal that benefits everyone.
When I graduated from chiropractic college in 1981 and started practice, I heard it all, and very little was positive. “You are a quack; you do not know what a subluxation is; you couldn’t get into a real health care program, so you chose the one that is slightly above a mail-order degree; you have no proof that chiropractic works; Are you really licensed?”, and so much more.
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