Tag Archives: well-being

Stigma’s Huge Role in Mental Health Care

The role of stigma for people who are in need of mental health treatment is both profound and devastating. According to a 2011 study by the Association for Psychological Science, only 60% of people diagnosed with mental health problems reported receiving treatment. That means 40% of the millions of people in the U.S. who need professional help are getting no treatment whatsoever. Social stigma, myths and stereotypes play a huge role in limiting both access to care and discouraging people from pursuing mental health treatment. The problem is multifaceted and complex and has a wide-reaching effects on people’s education, employment, health, well-being and relationships.

There are many forms of stigma and stereotypes. First, there is a widespread public perception that people with mental illness are dangerous, unpredictable and responsible for their own illness and not deserving of compassion and care. As a result, people in need of help are excluded from jobs, education and much-needed social interaction.

This problem also plays out in the professional medical setting, where negative stereotypes often lead medical providers to be less likely to focus on the patient rather than the disease and to not place the needed focus on recovery and referral for needed consultation and care.

Stigma in society and lack of awareness among medical providers also contributes to what is known as self-stigma. That is: People in need of help believe these stereotypes themselves and develop low self-esteem, which results in denial, attempts to hide problems, alcohol and drug abuse and a sense of hopelessness — they feel they are unable to recover, so why try? These are the people who make up the 40% not seeking treatment and consultation.

Stigma results in a double problem for many people. They have real underlying symptoms, which lead to an actual disability, while myths and misconceptions lead to stereotypes and prejudice. Too often, people turn against themselves. Depression, for example, has been referred to by mental health professionals as “rage turned inward.” This can lead to fear of rejection, isolation and hostile behavior. The result often is that the needed health care system is replaced by the criminal justice system.

How many people incarcerated today have an underlying untreated mental health condition? My guess is most, if not all. These are the people who did not pursue potential life opportunities for themselves but rather pursued illegal drugs or crime out of a sense of low-self-esteem and hopelessness. The overall result is both devastating to them and society as a whole.

Underlying mental health issues also have a huge impact on both healthcare and disability costs for private and public employers, health and disability insurers and both Medicare and Medicaid and the Social Security disability system (SSDI). How many people collecting private or public disability have an underlying, undiagnosed mental health problem? Nobody really knows, but many disability experts believe the number is staggering. The resulting costs to employers, insurers and taxpayers of untreated or undiagnosed mental health issues is in the billions of dollars.

In 2003, I helped conduct an unpublished study for a major U.S. corporation regarding its active employees out of work on full disability with a primary diagnosis of depression. The analysis cross-referenced these employees’ disability claim data with their health insurance data base. It was found that 80% of the primary treating providers in the healthcare benefit side had no mention whatsoever of a primary or secondary diagnosis of depression. This means that their primary treating provider or “family doctor” was either unaware of the underlying mental health issues or failed to acknowledge or consider the possibility.

What was not able to be studied in this research was how many workers out on disability or workers compensation for a “bad back” really had an underlying mental health issue. The study did determine the No. 1 and 2 co-morbidities for employees out on disability for depression was musculoskeletal conditions and gastrointestinal conditions. The overwhelming number of medical providers treating and submitting claims for these co-morbidities (80%) had no mention of an underlying mental health issue despite the fact that their patient was out of work on full disability with a primary diagnosis of depression. The healthcare and disability costs of these employees out on full disability with a primary diagnosis of depression was staggering and in the millions just to this U.S. corporation. Because this large employer was self-insured for healthcare, disability and workers’ compensation these costs go directly to its bottom line. These costs are then indirectly passed on to corporate customers and the general public purchasing the company’s products and needed services.

What needs to be done to address underlying and untreated mental health conditions?

I do not believe any new federal legislation is required at this time. The Affordable Care Act (ACA), the Americans with Disabilities Act (ADA) and the Mental Health Parity Act are all in place to help people receive needed mental healthcare access. There is no reason people should not seek professional help that they need.

As in most complex public health issues, the answer lies in awareness, education, outreach and research dollars. Educating the public is a very difficult task. As we have learned the hard way with overall prejudices, urban myths and misinformation in society, in general educating people can take generations. Medical authorities in leading medical schools and institutions have also stated that documented research and best practices based on evidence-based medicine can take 20 years to filter down to local medical practices, if ever.

People suffering with underlying mental health issues don’t have 20 years to wait for proper referral and treatment. Medical professionals on the front line need to be educated today to ask the right questions with their patients about potential underlying mental health issues and help reassure people that the overwhelming majority of mental health issues can be diagnosed and successfully treated.

As a society we can no longer allow people to hurt themselves or others when treatment is readily available for people who need help because of genetic and other environmental causes that are no fault of their own. How many of our major problems such prejudice and gun violence have a root cause in untreated mental health issues? Maybe all of them.

Obesity as Disease: A Profound Change

The obesity rate in the U.S. has doubled in the past 15 years. More than 50% of the population is overweight, with a BMI (body mass index) between 25 and 30, and 30% have a BMI greater than 30 and are considered obese. Less than 20% of the population is at a healthy weight, with a BMI less than 25.

On June 16, 2013, the American Medical Association voted to declare obesity a disease rather than a comorbidity factor, a decision that will affect 78 million adults. The U.S. Department of Health and Human Services said the costs to U.S. businesses related to obesity exceed $13 billion each year. With the pending implementation of ICD (International Classification of Diseases) 10 codes, the reclassification of obesity is is fast becoming a reality and will dramatically affect workers’ compensation and cases related to the American Disability Act and amendments.

Before the AMA’s obesity reclassification, ICD-9 code 278 related to obesity-related medical complications rather than to obesity. The new ICD-10 coding system now identifies obesity as a disease, which needs to be addressed medically. Obesity can now become a secondary claim, and injured workers will be considered obese if they gain weight because of medications, cannot maintain a level of fitness because of a work-related injury or if their BMI exceeds 30. The conditions are all now considered work-related and must be treated as such.

The problem of obesity for employers is not confined to workers’ compensation. The Americans with Disability Act Amendment of 2008 allows for a broader scope of protection for disabilities. The classification of obesity as a disease now places an injured worker in a protected class pursuant to the ADA amendment. In fact, litigation in this area has already started. A federal district court ruled in April 2014 that obesity itself may be a disability and will be allowed to move forward under the ADA (Joseph Whittaker v. America’s Car-Mart, Eastern District of Missouri).

Obesity as an impairment

Severe obesity is a physical impairment. A sales manager of a used car dealership was terminated for requesting accommodation and won $128,000. He was considered disabled, and the essential function of the job was walking, so he was terminated without reasonable accommodation.

The judge ruled that obesity is an accepted disability and allowed him to pursue his claim against his employer. This could have substantial impact for employers as injured workers could more easily argue that their obesity is a permanent condition that impedes their ability to return to work, as opposed to a temporary life choice that can be reversed.

The Equal Employment Opportunities Commission (EEOC) has recently chimed in on obesity. According to the EEOC, severe [or morbid] obesity body weight, of more than 100% over the norm, qualifies as impairment under the ADA without proof of an underlying physiological disorder. In the last year, we have seen an increasing number of EEOC-driven obesity-related lawsuits. Federal district courts support the EEOC’s position that an employee does not have to prove an underlying condition, especially in cases where there is evidence that the employer perceived the employee’s obesity as a disability or otherwise expressed prejudice against the employee for being obese.

Workers’ compensation claims are automatically reported to CMS Medicare with a diagnosis. When the new ICD-10 codes take effect, an obesity diagnosis will be included in the claim and will require co-digital payments, future medical care or continued treatment by Medicare.

There is good news on the horizon. Reporting of a claim only happens if there is a change in condition not primarily for obesity. It is recommended that baseline testing for musculoskeletal conditions be conducted at the time of hiring and on the existing workforce. In the event of a work-related injury, if a second test is conducted that reveals no change in condition, it results in no reportable claim and no obesity issue. In the event of ADA issues, the baseline can serve to determine pre-injury condition or the need for accommodations.

What does this mean to employers?

Obesity is now considered a physical impairment that may affect an employees’ ability to perform their jobs and receive special accommodations pursuant to the ADA.

An increasingly unhealthy workforce will pose many challenges for employers in the next few years. Those that can effectively improve the health and well-being of their employee population will have a significant advantage in reducing work comp claim costs, health and welfare benefits and retaining skilled workers.

Recent studies

In a four-year study conducted by Johns Hopkins with an N value of 7,690, 85% of the injured workers studied were classified as obese. In a Duke University study involving 11,728 participants, researchers revealed that employees with a BMI greater than 40 had 11.65 claims per 100 workers, and the average claim costs were $51,010. Employees with a BMI less than 25 had 5.8 claims per 100 workers, with average claim costs of $7,503. This study found that disability costs associated with obesity are seven times higher than for those with a BMI less than 30.

A National Institute of Health study with 42,000 participants found that work-related injuries for employees with a BMI between 25 and 30 had a 15% increase in injuries, and those with a BMI higher than 30 had an increase in work-related injuries of 48%.

The connection between obesity and on the job injuries is clear and extremely costly for employers. Many employers have struggled with justifying the cost of instituting wellness programs just on the basic ROI calculations. They were limiting the potential return on investment solely to the reduction in health insurance costs rather than including the costs on the workers’ comp side of the equation and the potential for lost business opportunities because of injury rates that do not meet customer performance expectations. Another key point is that many wellness programs do not include a focus on treating chronic disease that may cause workers to be more likely to be injured and prolong the recovery period.

Customer-driven safety expectations

There are many potential customers (governments, military, energy, construction) who require that their service providers, contractors and business partners meet specific safety performance requirements as measured by OSHA statistics (recordable incident rates) and National Council on Compensation Insurance (NCCI) rating (experience modifiers) and, in some cases, a full review by 3rd party organizations such as ISNet World.

Working for the best customers often requires that your company’s safety record be in the top 25th percentile to even qualify to bid. To be a world-class company with a world-class safety record requires an integrated approach to accident and injury prevention.

Challenges of an aging workforce

The Bureau of Labor Statistics projects that the labor force will increase by 12.8 million by 2020. The number of workers between ages 16 and 24 will decline 14%, and the number of workers ages 25 to 54 will increase by only 1.9%. The overall share of the labor force for 25- to 54-year-olds will decline from 68% to 65%. The number of workers 55 and older is projected to grow by 28%, or 5.5 times the rate of growth in the overall labor force.

Employers must recognize the challenge that an aging workforce will bring and begin to prepare their workforce for longer careers. A healthy and physically fit 55-year-old worker is more capable and less likely to be injured than a 35-year-old worker who is considered obese.

Treating chronic disease

Employers who want a healthy work force must recognize and treat chronic disease. Many companies have biometric testing programs (health risk assessments) and track healthcare expenditures through their various providers (brokers and insurance carriers).

The results are quite disappointing. On average, only 39% of employees participate in biometric screenings even when they are provided free of charge. For those employees who do participate and who are identified with high biometric risk (blood pressure, glucose, BMI, cholesterol), fewer than 20% treat or even manage these diseases.

This makes these employees much more susceptible to injury and significantly lengthens the disability period. The resulting financial impact on employers can be devastating.

Conclusion

Best-in-class safety results will require a combined approach to reduce injuries and to accommodate new classes of disability such as obesity. It is important that employers focus on improving the health and well-being of their workforce while creating well-developed job descriptions, identifying the essential functions, assessing physical assessments and designing job demands to fall within the declining capabilities of the American workers. It is important for an employer to only accept claims that arise out of the course and scope of employment. This is especially true with the reclassification of obesity as a disease. Baseline testing will play an essential role in separating work-related injuries from pre-existing conditions in this changing environment.