This study was conducted by the Institute of Industrial Relations (IIR), University of California at Berkeley, and faculty and academic staff of the Center for Occupational and Environmental Health in northern California (COEH), University of California. The project team wishes to thank the Commission on Health and Safety and Workers' Compensation for their support and sponsorship of this study. We also thank the following persons who assisted in the project's design and implementation:

Christine Baker, Executive Officer
Irina Nemirovsky
Kirsten Strömberg
Oliva Vela
Janice Yapdiangco
Larry Swezey, Consultant

Robert Harrison, M.D., M.P.H., Clinical Professor of Medicine, UC San Francisco

Gene Darling            Leslie Nelson
Cynthia Dunn           Patrick Riley
Donna Iverson         Lorri Smith
Jessica Lage            Frozan Wahaj
Paul Mathes

We wish to thank the UC Berkeley researchers who participated on the Academic Advisory Panel for this project, the members of the Project Advisory Committee who gave us valuable information and advice on practical aspects of return-to-work efforts, the Construction Industry Task Force who informed us of problems in construction and helped us frame the focus group discussions of possible solutions, the many individuals and organizations that helped us identify and recruit the focus group participants, and the participants in the five focus groups who devoted considerable time and energy to this project.

For many injured workers with permanent disabilities, workers' compensation benefits alone are insufficient to replace lost wages. Returning to work in sustained employment, therefore, is probably the best way for injured workers to avoid significant financial losses. In addition, scientific evidence shows that returning to medically suitable modified-duty work aids healing and recovery. Many obstacles, however, hinder successful and sustained return-to-work, including communication problems and financial disincentives of important stakeholders in the workers' compensation system.

This study examines perspectives and insights from five interest groups and strategies suggested by the study participants to overcome problems that hinder return-to-work in California. Focus groups of injured workers, claims administrators, union representatives, management representatives, and health care providers were conducted to discuss

medical practices, employer programs and policies, and workers' compensation claims programs that can help injured workers return to long-term, sustained employment. The participants also discussed problems that make it difficult for injured workers to return to work and possible methods to overcome those problems.

The focus group findings revealed widespread distrust of others' motives and blaming of others for injured workers not being able to return to long-term, sustained employment. These feelings and beliefs appear to pervade the workers' compensation community.

Participants in the focus groups identified "best practices" of treating physicians, employers, and claims administrators that they believed help injured workers return to sustained employment. Participants in three of the groups said that it is important that treating physicians know how to write useful medical reports and formulate clear and specific work restrictions. However, no other specific practice—of treating physicians, employers, or claims administrators—was identified as beneficial by participants in most or all of the groups. Participants either disagreed about some practices, or they did not have a chance to comment on practices identified by participants in the other groups.

Participants also expressed views about overall problems in the workers' compensation system that hinder return-to-work, and they offered ideas on strategies to overcome some of the problems. Education—for workers, employers, treating physicians, and unions—was one approach that was suggested by participants in all of the focus groups. Cultural, attitudinal, economic, and legal problems were also discussed, but no commonly favored strategy emerged for dealing with those kinds of problems.

The project team recommends that the Commission consider undertaking further discussions in the workers' compensation community and further applied research to follow up on this study. These recommended activities are listed below and discussed more fully later in this report.

To help ameliorate some of the blame and distrust in the system and to improve our understanding of what can be expected of persons who provide important services to injured workers and employers, it is recommended that informational materials about these providers of services be developed. The materials would describe the providers' roles and responsibilities, their training, how they are paid, and how they are regulated. The

Commission could establish a cooperative, multipartite task force to assist in developing these materials.

Previous research has documented the serious losses experienced by many injured workers and the disrespectful treatment they face in trying to navigate the workers' compensation system. This study also shows that injured workers often face suspicion and negative stereotyping, which can hinder recovery. It is recommended that the Commission develop methods and plan activities to promote respectful treatment of injured workers. This could be accomplished in consultation with the task force described above.

C. Model Practices of Treating Physicians, Employers, and Claims Administrators

It is recommended that the Commission develop a set of model practices of treating physicians, employers, and claims administrators that are based on ethical "codes of conduct" and, where possible, evidence-based standards of care. As a starting point, the Commission could consider some of the "best practices" that were identified by participants in the focus groups. The Commission could develop the model programs in consultation with the task force described above. In addition, the Commission could establish and consult with an academic advisory body possessing expertise in the relevant fields of business, health, and law.

The focus group participants and members of the Project Advisory Committee have begun to identify possible strategies to overcome system-wide problems that prevent injured workers from returning to long-term, sustained employment. Education was one approach that was suggested by participants in all of the focus groups. In addition, some of the participants made recommendations to reduce delays in medical treatment and create incentives for employers to accommodate injured employees. It is recommended that the Commission hold follow-up meetings to evaluate the participants' suggestions, identify feasible and desirable strategies, and plan specific activities to improve methods for helping injured workers return to sustained employment. Discussions could be held with the task force described above.

Getting back to work may be the best way for injured workers to avoid financial losses, because for many workers, the benefits in the California workers' compensation system are insufficient to replace lost wages. Workers with permanent partial disabilities experience losses exceeding 30% of the after-tax income that they would have earned over a five-year period if uninjured. This is true for workers from both insured and self-insured companies. For many, losses are expected to continue beyond five years after injury.

The greatest losses occur when the disabled worker loses his or her job and cannot find work that pays as much as the worker was paid previously, or cannot find any work at all. For example, the RAND Institute has found that two-and-a-half years after injury, unemployment among permanently partially disabled workers who were injured at insured companies in 1993 was 16.9% greater than if they had not been injured, and it was 13.6% greater among those who were injured at self-insured companies. After five years, unemployment was 8.9% and 14.4% greater for permanently partially disabled workers from insured and self-insured companies, respectively.

These losses might be preventable. There is some research evidence and much practical experience to indicate that if workers can participate in early return-to-work programs that offer transitional jobs medically suited to their injuries, these workers will recover faster and more completely and have a better chance of keeping their jobs than if they stay home while recovering. In addition, where injuries occurred as a result of inherently unsafe conditions, permanent modifications may be necessary to ensure that workers are not reinjured. Employer programs that accommodate and support injured employees increase the likelihood that the employees will return to work.

Numerous obstacles, however, hinder successful and sustained return-to-work. These may include communication problems and financial disincentives. For example, employers, claims administrators, and treating physicians are not required to take proactive steps to return a newly-injured worker to suitable transitional work. As a result:

• Treating physicians are often not informed about the injured worker's job or different jobs that could be assigned or offered to the worker while recovering.

• Employers are often not informed about specific changes that could or should be made in the workplace to accommodate the injured worker and prevent reinjury.

• Injured workers are often not informed about steps, if any, that can or will be taken to help the worker return to work.

Instead, there may be tendencies either: (1) to keep an injured worker entirely off work while recovering to avoid the possibility of aggravating the injury and help the employer avoid the cost of temporary accommodations; (2) to immediately release an injured worker to full duty to help the employer avoid the cost of temporary disability indemnity payments; or (3) to terminate the injured worker's employment.

It is not until an injured worker has been off work on temporary total disability benefits for 90 days that the employer, the claims administrator, and the treating physician are required to take specific steps designed to return the worker to work, either through placement with the same employer or through vocational rehabilitation services. Many researchers believe that efforts must be taken much earlier than 90 days, by both the employer and the health care provider, in order to prevent long-term disability.

Because of the serious physical, financial, and personal problems confronting workers with permanent disability, the Commission on Health and Safety and Workers' Compensation has recommended continuing efforts by the workers' compensation community to promote injured workers' prompt return to work in sustained employment. This project was designed to assist the Commission and the workers' compensation community in achieving this goal. In addition, this project was designed to complement the quantitative studies on return-to-work being conducted for the Commission by the RAND Institute.

The primary objective of this project was to collect in-depth, qualitative data about experiences and insights regarding three major areas of activity that can help injured workers return to long-term, sustained employment:

• Medical practices
• Employer policies
• Workers' compensation claims programs

The data were collected through a series of five focus groups. During the original design of this project, it was anticipated that most of the information and insights would revolve around events occurring soon after an occupational injury, including efforts to ensure prompt return-to-work. Therefore, this project focused explicitly on collecting perspectives and insights from the five interest groups who are involved in the earliest stages of a claim: (a) injured workers, (b) claims administrators, (c) union representatives, (d) management representatives, and (e) health care providers.

Other objectives of the project were to analyze how existing laws and regulations governing workers' compensation vocational rehabilitation benefits may affect return-to-work outcomes (to the extent uncovered in the focus group sessions), formulate practical messages that could be included in educational materials to promote positive return-to-work outcomes, and help identify further types of research needed to attain the Commission's goal of helping injured workers return to sustained employment.

The members of the project team were as follows:

1. John Frank, M.D., M.Sc., investigator. Dr. Frank is a family physician and an epidemiologist. While managing the project, Dr. Frank was an adjunct professor at UC Berkeley's School of Public Health and a professor of public health sciences at the University of Toronto. In addition, he co-founded the Institute for Work & Health in Toronto, Canada.

2. Juliann Sum, J.D., M.S., investigator and project coordinator. Ms. Sum is an attorney and an industrial hygienist. Since 1994, Ms. Sum has coordinated Commission-sponsored research and educational projects based at the Institute of Industrial Relations and the Labor Occupational Health Program, UC Berkeley. In previous positions, Ms. Sum worked for a labor union to create and administer an occupational health program and represented insurers in complex insurance coverage litigation.

3. Julia Faucett, R.N., Ph.D., F.A.A.N., project consultant. Dr. Faucett is a nurse and an associate professor, and the director of the Occupational and Environmental Health Nursing Program at the School of Nursing, UC San Francisco.

4. Laura Stock, M.P.H., project consultant. Ms. Stock is a health educator and an associate director of the Labor Occupational Health Program, UC Berkeley's School of Public Health.

Prior to the start of this project, the project team helped plan and conduct a meeting with the Commission's Construction Industry Task Force on February 16, 2000. At this meeting, representatives from labor and management discussed return-to-work problems and issues that are of particular concern in the construction industry in California. The participants then brainstormed on potential solutions. During the meeting, ideas were organized into the following categories: (1) informational and educational solutions, (2) cultural and attitudinal solutions, and (3) economic and legal solutions.

An advisory committee was formed to enable the project team to obtain advisory input from organizations and persons with practical experience in workers' compensation and return-to-work issues. To form this committee, the team assisted the Commission in selecting and inviting members of the workers' compensation community.

The first meeting of the advisory committee was held on March 31, 2000. Twenty-three persons attended, including representatives from the claims industry, employers, labor, community legal services, applicants' attorneys, injured workers, the Department of Industrial Relations, the Division of Workers' Compensation, and the Industrial Medical Council. At this meeting, the participants reviewed the overall scope and activities of the project. They also reviewed the ideas discussed by the Construction Industry Task Force and further discussed and elaborated on problems and solutions that might be applicable in a broad range of industries. Finally, the participants were invited to advise on methods to recruit participants for the focus group sessions.

Ideas generated in the meetings of the Construction Industry Task Force and the Project Advisory Committee were used in the data collection, as described in the next section of this report.

This project was designed as an exploratory study, to obtain preliminary information on important issues and concerns regarding injured workers' prospects for future, long-term employment, as viewed by some of the main participants in the California workers' compensation system.

The project team convened five focus groups of study participants. The participants were grouped with other persons who had similar roles in the workers' compensation system to encourage freer expression of opinions and ideas. Each group discussed their experiences, perspectives, insights, and opinions regarding different efforts—both successful and unsuccessful—for returning injured workers to sustained employment. They also discussed major barriers they have observed in trying to return, or trying to help injured workers return, to sustained employment. Finally, they discussed possible solutions to overcome those barriers.

This study used focus groups to obtain data on experiences, insights, and barriers to long-term, sustained employment for injured workers. Focus group research is used to collect in-depth qualitative data that closely reflect the perceptions, feelings, and manner of thinking of the participants. This contrasts with written questionnaires that often seek limited answers to closed-ended questions to generate data that can be analyzed quantitatively. Focus group data are subjected to rigorous review and analysis following specific guidelines and accepted research procedures.

Focus groups are an important research method used in applied social research, especially in the health field. Researchers have used focus groups, for example, to learn about attitudes, beliefs, and practices related to birth control use in economically developing countries, declines in fertility following modernization, parents' educational preferences for young boys and young girls, and support of aging parents by adult children. Public agencies and nonprofit organizations have used focus groups to increase the effectiveness of their programs. In California, for example, a focus group study was recently conducted to understand parents' views toward state programs that offer health coverage for children in low- and moderate-income families.

In a focus group, the interactions in the group increase the participants' candor, probe the thinking behind participants' opinions, and uncover concerns below the surface that were not apparent to researchers beforehand. In other words, focus groups generate data that would be much less accessible without the interaction of the group. Therefore, rather than merely providing data on whether a person is satisfied with a particular program, focus groups also provide specific information on why the person is satisfied or dissatisfied and how the program could be improved.

The moderator of a focus group facilitates interaction between the participants by presenting questions in a neutral manner and by refocusing the discussion when irrelevant topics are introduced. The key to obtaining data effectively lies in the interaction of the group members with each other. The moderator uses questions that are open-ended to allow flexibility in the group discussion. The questions and discussion guide, however, are planned carefully in advance to achieve a proper balance between open discourse and focusing on relevant topics.

Prior to undertaking any activities to recruit focus group participants, the project team obtained approval from the UC Berkeley Committee for the Protection of Human Subjects, as required by federal law, on detailed procedures for identifying and recruiting participants, obtaining informed consent, and protecting participants' identities. Participants gave written consent for the use of data that they provided and were promised that their participation and individual data would be kept confidential within the extent of law.

1. Injured Workers

Injured workers were recruited through state Division of Workers' Compensation Information & Assistance offices, labor unions, law firms that represent injured workers, and injured-worker support groups. Flyers were prepared to recruit injured worker volunteers to participate in a group discussion on working after a job injury and be paid a $50.00 stipend. Each of the organizations made the flyers available to interested persons. Individuals who called us were enrolled on a first-come, first-served basis.

The final group who participated included 11 injured workers. The workers had been employed in the following industries at the time of injury: (a) six had worked in business, health, educational, social, or engineering services industries; (b) three had worked in public administration; (c) one had worked in the transportation industry; and (d) one had worked in the insurance industry. Their injuries included repetitive stress injuries of the arm or hand, back and neck injuries, knee injuries, and head injuries.

2. Claims Administrators

Claims administrators were initially recruited by Commission staff. Letters were sent to 12 claims administrators who had expressed interest in participating in Commission projects, inviting them to participate in the focus group session. Eight of these claims administrators either were able to participate, or referred us to another person who could participate. The final group who participated included eight claims administrators: (a) four from insurance companies; (b) two from self-insured, self-administered employers; (c) one from a third-party administrator for self-insured employers; and (d) one from a joint powers authority.

3. Union Representatives

Union representatives were initially recruited by Commission staff. Letters were sent to 10 union representatives who were either members of the project advisory committee or members of a labor advisory board for UC Berkeley's Labor Occupational Health Program, inviting them to participate in the focus group session. Five of these union representatives either were able to participate, or referred us to another person who could participate. The project team then recruited additional union representatives who were either recommended by the California Labor Federation, AFL-CIO, or had previously worked on projects with UC Berkeley's Labor Occupational Health Program. Of these additional persons, four were able to participate, or referred us to another person who could participate.

The final group who participated included nine union representatives: (a) four from unions representing workers in hotel, recreational, health, educational and other service industries, including some in the public sector; (b) two from unions representing workers in food and transportation equipment manufacturing industries; (c) one from a union representing workers in the construction industry; (d) one from a union representing workers in the transportation industry; and (e) one from a union representing workers in the communications industry.

4. Management Representatives

Commission staff sent letters to 13 employer representatives who had expressed interest in participating in Commission projects, asking for their assistance in recruiting persons in management who are in a position to offer or assign work that an occupationally injured employee can do safely, and who supervise the work. Seven of these representatives either were themselves able to participate, or referred us to another person or persons who could participate.

The final group who participated included eight management representatives: (a) five from food, computer equipment, and other manufacturing industries; and (b) three from hotel, health, or educational services industries. We had hoped to recruit managers from small, medium, and large employers. However, except for one participant who was from a multi-employer organization, small employers were not represented in the group.

5. Health Care Providers

The focus group of health care providers was conducted last. In the four previous sessions, focus group participants believed that the performance and effectiveness of the treating physician depends on whether the physician was selected by the worker or the worker's attorney, on the one hand, or by the employer or employer's claims administrator, on the other. In addition, for purposes of selecting the focus group participants, project advisors and members of the project team believed that nurse practitioners and physical therapists, who cannot be designated as treating physicians in the workers' compensation system, play an important role in return-to-work efforts.

Quantitative data were not available showing either the proportions of different professions and specialties that are involved in providing health care in workers' compensation in California, or the proportions of treating physicians who are selected by workers, their attorneys, employers, or claims administrators. Therefore, the project team sought to recruit approximately equal numbers of health care providers commonly selected by workers or applicants' attorneys on the one hand, and those commonly selected by employers or claims administrators on the other. We also set aside two slots for nurses or nurse practitioners and one for a physical therapist.

Based on the above criteria, Commission staff sent letters to organizations representing injured workers, applicants' attorneys, employers, and claims administrators, asking them to recommend health care providers who are "treating physicians" in the California workers' compensation system, as defined in the workers' compensation system. (The statutory definition of "physician" in workers' compensation includes medical doctors, doctors of osteopathy, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractors.) Commission staff sent letters to statewide organizations representing occupational health nurses and physical therapists, asking for their assistance in recruiting those types of health care providers. In addition, the project team requested names of physical therapists from a physical therapist member of our Academic Advisory Panel.

As a result of these efforts, more than 70 health care providers were recommended to us. We sent letters to those providers inviting them to enroll in the focus group session. The providers who called us were enrolled on a first-come, first-served basis, within the categories previously established for the composition of the group. The final group who participated comprised seven health care providers: (a) four "treating physicians" recommended by injured workers or applicants' attorneys (a psychologist, a chiropractor, a medical doctor specializing in physical medicine and rehabilitation, and a psychiatrist); (b) one "treating physician" recommended by employers or claims administrators (an orthopedic surgeon); (c) one family nurse practitioner who works at an occupational health clinic under contract with employers; and (d) one physical therapist who treats injured workers through consultation or referral from physicians.

Approximately two to four weeks prior to each focus group session, the project team mailed a letter to each participant confirming enrollment and explaining the purpose and nature of the session, a consent form that had been approved by UC Berkeley's Committee for the Protection of Human Subjects, driving directions, and a map. Follow-up telephone calls were also made to confirm attendance and answer any questions the participants might have.

Each session was designed to last two hours. To maximize the focus, relevance, and usefulness of the discussions, for each session a five- to six-page guide was prepared that contained introductory information about the project, basic ground rules regarding the confidential and voluntary nature of the discussions, introductory questions to help the participants and the members of the project team become acquainted with each other and better understand each others' comments, and "key" questions to guide the discussions into the main subject areas of this project. The biggest challenge was to balance the need to obtain information regarded as relevant to this project (by making the questions sufficiently specific) against the need to discover what issues were the most relevant to the participants in the particular session (by making the questions sufficiently open-ended).

The key questions were prepared based on the primary objective that had been established in the original design of this project. Background information and definitions were then prepared for each key question, to enable the moderator to explain the scope, meaning, and direction of the questions. Additional questions called "probes" were also prepared, to enable the moderator to stimulate responses or to steer discussions that might be too general or that stray from the questions. Some of the probes were based on ideas and knowledge gained in the advisory meetings that were held in the planning phases (described above). In addition, outlines and other information to guide the discussions were prepared and displayed on flip chart paper and given out as handouts during the sessions.

The questions, explanations, probes, and other materials were designed and modified for each session, depending on the roles and experiences of the participants in the particular session and on information obtained in preceding focus group sessions. Thus, each guide was carefully drafted, revised, and redrafted by the members of the project team. The key questions asked in each of the five sessions are given in the Appendix.

Each session lasted two hours, and the sessions were audiotaped. The project coordinator (Juliann Sum) moderated the sessions, using the discussion guides and accompanying information presented on flip charts and in handouts. Other researchers on the project team took notes and asked pertinent questions during the sessions. Project assistants collected signed consent forms, operated the recording equipment, and helped with setting up equipment and materials for the sessions.

The audiotapes of the five sessions were transcribed. Originally, the project team had planned to conduct only abridged transcriptions of the sessions. However, after early results showed major differences in perspectives and unexpected nuances between the different groups on many important issues, the team decided to fully transcribe all of the sessions to allow more precise analysis of both differences and commonalities.

The project team reviewed the content of the sessions to gain an understanding of the full range of themes, issues, and concerns that were uncovered in the sessions. Based on the initial review, subject-matter codes were developed to organize the data.

The transcripts were then coded (indexed and cross-indexed) by the project coordinator according to the subject-matter codes and rearranged physically for further analysis and organization of the data. The analysis relied on both review of the rearranged transcript data and review of the team members' notes and recollections regarding the content of the discussions and the intensity of emotions of the participants.

A.	Recurring Themes	16
	1.  Blame and Distrust of Others' Motives	16
	a.  Injured Workers' Motives and Actions	16
	b.  Employers' Motives and Actions	17
	c.  Unions' Motives and Actions	17
	d.  Claims Administrators' Motives and Actions	18
	e.  Applicants' Attorneys' Motives and Actions	19
	f.  Treating Physicians' Motives and Actions	20
	g.  Rehabilitation Counselors' Motives and Actions	22
	2.  The Imbalance of Power Against the Injured Worker	23
	3. Complexities, Conflicts, and Disputes	24
B.	Views Regarding Practices and Programs of Treating Physicians, Employers and Claims Administrators	25
	1.  Treating Physicians' Practices	25
	a. Understanding the Workers' Compensation System	26
	b. Communicating with the Injured Worker	27
	(1) Listening to the Injured Worker	27
	(2) Informing and Educating the Injured Worker	29
	(3) Establishing Trust with the Injured Worker	30
	c.  Communicating with the Employer and the Claims Administrator	30
	(1) Learning About the Workplace	31
	(2) Determining When an Injured Worker Can Return to Work	32
	2. Employers' Policies and Programs	33
	a. Policies and Programs Regarded As Desirable	33
	(1) Design of Programs To Help Ensure Transitional or Permanent Return-to-Work	33
	(2) Coordination and Communication in Individual Cases	35
	b. Problems and Challenges	38
	(1) Lack of Necessary Accommodations While Recovering	38
	(2) Lack of Permanent, Alternate Work	41
	(3) Employer Not Contacting the Treating Physician	41
	(4) Workers Being Discouraged from Reporting Injuries	42
	(5) Discrimination in Employment	42
	(6) Conflictual Relationships Between Employer and Employee	43
	(7) Influence over Types of Medical Treatment	43
	(8) Lack of Knowledge About How To Deal with Work Injuries	44
	(9) Finding Meaningful Work for Injured Workers	44
	(10) Co-Workers' Attitudes	45
	c. Methods Used To Overcome Problems	46
	(1) Education About the Return-to-Work Process	46
	(2) Financial Incentives To Reduce Time Off Work	46
	(3) Elimination of Incentives To Not Report Injuries	47
	3. Claims Administrators' Programs	47
	a. Programs Regarded As Desirable	48
	(1) Educating and Guiding the Employer	48
	(2) Identifying Preferred Health Care Providers	49
	(3) Managing Cases	49
	b. Problems	52
	(1) Delays in Accepting a Claim	52
	(2) Delays in Sending Records or Communicating with the Treating Physician	52
	(3) Refusal To Authorize Necessary Treatment	53
	(4) Lack of Familiarity with the Medical Issues in a Case	54
C.	Strategies Suggested by Participants To Overcome Problems in the System	55
	1. Educational Needs	55
	a. Workers' Educational Needs	55
	b. Employers' Educational Needs	56
	c. Treating Physicians' Educational Needs	57
	d. Unions' Educational Needs	57
	2. Cultural, Attitudinal, and Organizational Issues	57
	a. Employer's Responsibility to Injured Employee	57
	b. Goal of Returning to Same Employer	58
	c. Quality of Jobs Offered to Injured Workers	58
	d. Employment Relationships	58
	e. Negative Attitudes Towards Injured Workers	59
	3. Economic Factors	59
	a. Injured Worker's Disincentives To Report Injuries	59
	b. Inadequate Incentives for Employers To Accommodate Injured Workers	59
	c. Injured Workers' Difficulties in Changing Occupations	60
	4. Legal Systems	60
	a. Imbalance of Power	60
	b. Complexity and Confusion	60
	c. Role of the Treating Physician	61
	d. Delays in Medical Treatment	61
	e. Applicants' Attorneys Fees	62
	f. Permanent Disability (PD) Benefits	62
	g. Temporary Disability (TD) Benefits	63
	h. Nondiscrimination Law in Workers' Compensation	63
	i. Medical Confidentiality Statute	63
	j. Multiple Legal Systems	63
	k. State and Federal Disability Laws	64

 

This study has examined perspectives, insights, and opinions about medical practices, employer policies and programs, and workers' compensation claims programs that can help injured workers return to long-term, sustained employment. The focus group findings are organized into three categories:

A. "Recurring Themes" covers issues and concerns that were common in all five focus groups.

B. "Views Regarding Practices and Programs of Treating Physicians, Employers, and Claims Administrators" describes participants' perspectives on specific aspects of those practices and programs.

C. "Strategies Suggested by Participants To Overcome Problems in the System" summarizes participants' overall views on problems and their underlying causes, along with their ideas about how to tackle some of those problems.

In this section of the report, quotes are provided to illustrate each of the themes in the participants' own words. This report does not show all of the comments that were made.

This subsection of the report gives an overview of the major themes that emerged in the five focus groups: (1) blame and distrust of others' motives; (2) the imbalance of power against the injured worker; and (3) complexities, conflicts, and disputes. Later subsections describe the participant' experiences and perspectives on particular practices, policies, and programs and their suggested strategies to tackle problems in the system.

One theme that pervaded the sessions was distrust of other persons' and organizations' motives. Participants felt that financial incentives drive the actions of others, as opposed to a concern for the long-term employability of injured workers. As might be expected, many of these views differed sharply across the five focus groups.

Most of the participants also felt that others' selfish motives resulted in actions that prevent injured workers from returning to sustained employment, by either worsening the workers' injuries (e.g., requiring the worker to return to work prematurely), hindering recovery (e.g., refusing necessary treatment), or not allowing the workers to return to work while recovering. The participants did not identify practices, policies, or programs of their own organizations that hindered injured workers returning to work or to sustained employment.

Examples of the participants' varied and conflicting views are given below.

a. Injured Workers' Motives and Actions

Claims administrator and management representative participants believed that some injured workers seek to have more work restrictions specified than necessary, or try to stay off work entirely:

" . . . it really depends on that employee. If that employee does not want to be at work, they can maneuver themselves out."

—management representative

"The [employees] know that the more they . . . lie that they can't do something, the more they know they're going to get [in permanent disability benefits]." —management representative

 

b. Employers' Motives and Actions

Injured worker and union representative participants believed that some employers try to bring back injured employees as soon as possible in order to avoid paying for temporary disability benefits, and that some refuse to bring back injured employees in order to avoid paying for necessary accommodations:

" . . . if an employee is hurt, and they need a week off . . . the employer is going to face a full charge for the workers' comp claim. So that's the motivation. The motivation is not to get the employee back to work." —union representative

" . . . twice my doctor has asked for accommodations for me and twice

. . . I mean I have letters from my boss, and she said, `No, we're not going to provide it because we don't have to,' . . . Absolutely no regard for me." —injured worker

 

c. Unions' Motives and Actions

One injured worker participant expressed distrust of unions' motives and their seeming lack of interest in helping members who are injured:

"My experience with the union, and with all unions actually, is that interest in the individual is very small. . . . in my experience, unions are always interested in sharp raises, even when workers express that that is not their major concern. Those kind of issues that make the unions stronger are the main interests, and really, when I was a shop steward, I had very little support in helping individuals. " —injured worker

One management representative participant felt that the union representing their employees actively prevents injured employees from returning to work:

" . . . our union wouldn't let any modified worker out on the floor. . . . our union's kind of ugly. So they feel that when a person is injured at work, they feel that it is solely the responsibility of [company] and [parent company] to make sure that that person is well taken care of . . . the union feels that, because it was our fault they're injured, we need to take them under our wing, and then that job that they're bidder-holder to needs to be divvied up amongst other people and given the overtime, or another person brought in, that could possibly be on layoff. . . . " —management representative

 

d. Claims Administrators' Motives and Actions

Injured worker, health care provider, and union representative participants believed that claims administrators delay and deny claims and withhold payment for necessary medical treatment in order to save money:

"The insurance companies—their main job is to spend as little as they can. . . . " —injured worker

" . . . we're not going to get away from the fact that insurance companies want to keep the money no matter what. . . . as many people as I do consultations for, the same insurance companies when I'm treating a patient will deny my care or put it on delay. . . . `If you know I'm telling you the truth. . . . ' they'll say, `We're sorry, at this point in time the exposure is too great, so we're going to try—hopefully it will go away.'" —health care provider

" . . . They are denying things that are so plain and straightforward, medically sensible, that it makes me believe that there is a defense strategy, having to do with starving out workers and making proper care more difficult." —health care provider

"I've heard . . . that the insurance companies are actually rewarded for denying or delaying. . . . they . . . get a bonus for how much money is not spent on injured workers." —injured worker

 

e. Applicants' Attorneys' Motives and Actions

Claims administrator and management representative participants believed that applicants' attorneys select treating physicians who will keep their clients off work, and that they do this to maximize their own fees (which are based on their clients' award or settlement of permanent disability benefits):

" . . . once an employee gets an attorney, then it changes the whole goal for the outcome of the claim. The goal is no longer return the person to work, meaningful employment anywhere. . . . The applicant's attorney will guide that claim in such a manner that they get the largest PD, which means the most money that they put in their pockets." —management representative

" . . . the adversarial role has come from the attorney, who is holding the person back. . . . in order to get the greater reward, [the worker must] stay away from the job. . . . " —management representative

" . . . the longer the TTD you have, the more likely you're going to escalate the amount of PD. And to look at some of these really bad cases, we absolutely see trends like this, where it seems like a straightforward injury, an attorney gets involved and refers to the usual doctor for that attorney. And then you have symptom migration to different body parts, you have exotic diagnosis of RSD, of psychiatric components. . . . I am more angry at the attorney as to what it does to the injured worker, because it takes over that person's life. Their life then becomes the claim, and all they get at the end of the day is the PD, and we all know that while it's expensive for us, in a person's life, that’s not much money. And then the attorney is escalating his fee because he gets that larger chunk of PD money from the injured worker. . . . All they care about is getting a higher award at the end of the day. . . . I'm not saying all attorneys are this way, I'm just saying that there are a lot of them who are. They have an understanding that once the employee is back in the workplace with his co-workers, he's got to be getting better and it’s less likely that he going to be that disabled. And if he has no disability, guess what? He gets no payment." —claims administrator

Management representative participants believed that applicants' attorneys, by their actions, prevent injured workers from returning to sustained employment:

" . . . the [employee] that obtains an attorney, the ulterior motive there to drag out the TTD as long as possible—six, seven years—till push comes to shove, to vocational rehab, interruption of voc rehab three to four different times. And that person . . . (A) does not come back to the original employer, (B) very rarely ever does get a real, normal job again." —management representative

 

f. Treating Physicians' Motives and Actions

Claims administrator and management representative participants believed that worker-selected treating physicians try to please workers who want to stay off work in order keep the worker coming back as a patient:

" . . . family practice doctors. . . . they have a different relationship to the injured worker, and some of them, how do I say this, don’t often have backbone. If the injured worker wants to be off for a couple of weeks for other reasons, they are going to accommodate that. And they will kind of sign off on what the injured worker wants versus talking about return-to-work. . . . It’s a relationship-based issue and how the doctor works with his patients." —claims administrator

 

Claims administrator and management representative participants believed that attorney-selected treating physicians try to please the attorney in order to get more referrals from the attorney:

" . . . if you are referred by the applicant's attorney to . . . be the treating physician or treating provider, you know what to write. You're in it for the money." —management representative

" . . . sometimes a case will fall into litigation and the change in treating physician has another angle and that angle might be more geared towards the ultimate outcome of permanent disability. . . . Those docs typically are not very focused on return-to-work. . . . It's often the opposite." —claims administrator

" . . . this little social circle of attorneys and physicians will get this employee coming back to this doctor. . . . the doctor and attorney are, I don't want to say in collusion, but in reality that's what it is. They can milk the system forever. The employee, in many cases, is basically innocent. Once they're into that system, the attorneys and doctors play them back and forth, and that person will be out there for five, six, seven years. . . . Meanwhile everyone else is getting rich." —management representative

In contrast, union representative participants believed that employer-selected treating physicians try to please employers who want to avoid paying for temporary disability benefits while the worker is recovering:

" . . . that's the name of the game. Is that the employer's doctor? It's not the employee's doctor, it's the employer's doctor, and their goal is, regardless of how badly they're injured, if they can walk out of that doctor's office, they can go back to work and perform some duty, no matter how demeaning it may be. . . . " —union representative

"There are employer doctors who'll send somebody back with a crutch to climb a ladder. I have seen it. I can give you any number of examples of folks being sent back to work too early."

—union representative

One union representative participant felt that employer-selected physicians, by their actions, cause workers' injuries to worsen:

"Nothing is worse than sending a worker back to work when they're not fully healed, fully cleared. Invariably there's going to be a reinjury. I've just seen that repeatedly. . . . I've seen it too often."

—union representative

Health care provider participants believed that a particular health maintenance organization is only concerned about pleasing the employers that it contracts with for treatment of nonoccupational injuries and illnesses, and is not very concerned about the wellbeing of occupationally injured workers:

"[HMO] is obscene [in] workers' comp. . . . as a health provider. [HMO]—who do they contract with? Their money doesn't come from their patients. . . . They are abusive to people that come in with psychological workers' comp injuries. . . . It's incredible. . . . I see the people—the occ med guy won't give them any time off work. And they will never give them any mental health treatment. And it's very clear who they are concerned about." —health care provider

 

g. Rehabilitation Counselors' Motives and Actions

Injured worker participants believed that rehabilitation counselors try to please the claims administrators who select them, rather than really help the injured worker:

" . . . voc rehab counselors [could advocate for us] if they were not allowed to get their clients from the insurance companies."

—injured worker

"The voc rehab . . . they seem like they didn't want to help me too much, and so it was like, okay, they're going to get a large sum of my money. . . . I had seen how much that they didn't do, and I still had to pay for it, I was like, `I got taken in!'" —injured worker

 

2. The Imbalance of Power Against the Injured Worker

Injured worker, union representative, and health care provider participants felt that the system as a whole is unfair to injured workers:

"Everybody gets a little chunk of the pie except us. . . . we have a little mafia here. It's all connected, and the only person who is alone is the worker." —injured worker

" . . . if the power balance was more equal. . . . the power balance is not— the injured worker goes into this company system and just gets swallowed up." —union representative

" . . . the system . . . it's entrenched and defended with big guns." —health care provider

"I think there's a process . . . that actually impedes healing and return to work. . . . There's kind of a victimization process . . . and it's just a matter of who's encouraging the process. You can have a workers' comp attorney who will encourage you to be a victim. Your employer, by pushing too hard, is encouraging you to feel victimized. . . . there needs to be a balance of power. . . . when you're the sick person, and `All these people are coming at me and I don't know what the process is and no one is trying to help me,' you're making the person more ill. You're impeding the return-to-work process by doing this."

—union representative

Injured worker, union representative, and health care provider participants felt that some employers do not respect or care about their injured employees and that they have the power to get rid of these employees rather than accommodate them:

"Their attitude is, `Everything for management. Death to workers.' . . . Basically, their attitude is that we don't have to do anything—make us." —injured worker

"The only thing that causes them to accommodate is respect and concern. There's no profit in that." —injured worker

"I have so many workers that come to me and say, `I've worked for 30 years for this [employer]. I'm injured. I can no longer go back and do my job.' And I have to say, `And they don't owe you a goddamn thing.' . . . There's something—and I agree with the workers—there's something wrong with that. You have no responsibility as an employer. . . . I really empathize with workers. . . . it's just not fair."

—union representative

"Some employers' paradigm is that any injured worker is a liability . . . `We don't want them back.'" —health care provider

 

3. Complexities, Conflicts, and Disputes

Claims administrator participants felt that complexities in the system foster distrust and hostility, which hinder return-to-work efforts:

"No one's trusting anyone, because it has become a very complicated, litigious system, and therefore, the injured worker hires an attorney because he thinks he has to. Well, the attorney never really has time to talk to him, so he never really gets an understanding of what's going on. Then, he starts getting all these benefit notices that sound very legalistic, and scare him half to death, and he's getting one a day practically. He doesn't know what that's about. So, he starts getting angry. He gets angry at the claims administrator, he starts getting angry at his employer, . . . so it's a very complicated, complex system." —claims administrator

Management representative participants felt that because of the complexity of the system, return-to-work gets forgotten by everyone:

" . . . it's become too complicated, all this grandfathering in: `Well, if the injury occurred in '92 or before, and if it's '93, then in '96 we go this way. . . . " "I think it gets so complex that return-to-work gets forgotten." "It gets forgotten by everyone."

—management representatives

Management representative participants felt that methods for rating permanent disabilities contribute to disputes, which hinder return-to-work efforts:

" . . . My estimate says that we think this claim is worth $8,000 or $9,000 dollars, using the rotten system that we got, I believe that it's worth $8,000 or $9,000. And you can get that and we’re back to work and we're going down the road. And you get an attorney who now, because we have a system that is so badly flawed that they can say, `Oh no, we can get you $45,000.' The difference between $8,000 and $45,000—no system, no injury should be that far apart in rate. No injury." —management representative

A health care provider participant felt that when a claim becomes adversarial, the relationship between employer and employee is cut off:

" . . . once it's an adversarial relationship . . . It becomes a match between the applicants' attorney and the defense attorney to line up the doctors' reports. . . . it cuts off relationships between the employer and patient, because the employer is told, `You don't contact the employee once he's got an attorney, you contact the attorney.' The employee says, `They don't care about me anymore.'" —health care provider

 

Employers, and Claims Administrators

In the focus groups, the injured worker, claims administrator, union representative, and management representative participants were asked to describe actions of treating physicians, employers, and claims administrators that they believe affect whether an injured worker will return to sustained employment. The term "treating physician" was defined as the doctor who was either designated by the injured worker prior to injury or selected by the employer, the claims administrator, the injured worker, or the worker's attorney after injury. The term "employer" was defined as the person or persons in management who are in a position to offer or assign work that an injured worker can do safely, and who supervise the work. The term "claims administrator" was defined as persons who handle workers' compensation claims for employers, either in-house, through an insurance company, through a third-party administrator, or through a joint powers authority.

The health care provider participants were asked to describe important factors that they believe affect whether an injured worker will return to sustained employment. They were also asked to describe what information and other input they find to be relevant and useful in determining: (1) when a worker can or should return to work; and (2) appropriate work restrictions.

Many of the participants believed that to be able to help injured workers return to sustained employment, treating physicians need to understand the workers' compensation system.

In addition, participants in all five groups believed that it is important for treating physicians to truly listen and communicate, but views differed widely as to whom the physician should work with or believe—the injured worker on the one hand, or the employer or claims administrator on the other:

• Injured worker and health care provider participants felt that correct diagnosis and proper treatment are essential to helping injured workers return to sustained employment, and some of these participants said that the treating physician must listen to the injured worker and believe the worker's reports of pain in order to arrive at a correct diagnosis. Injured worker participants therefore felt that the physicians whom they or their attorneys selected were more effective in treating the workers' injuries than the physicians selected by their employer or claims administrator. In contrast, management representative participants felt that treating physicians should not always believe injured workers' reports of pain.

• Claims administrator and management representative participants felt that treating physicians should actively work with the employer or claims administrator to return the injured worker to work as soon as medically possible. In contrast, union representatives felt that when treating physicians allow themselves to be influenced the employer, the injured worker loses trust in the physician.

 

a. Understanding the Workers' Compensation System

Claims administrator, union representative, and management representative participants felt that it is important that treating physicians have an in-depth understanding of the workers' compensation system to be able to write useful medical reports and formulate clear and specific work restrictions:

" . . . I think many times the physician impedes the employee's progress and income and a whole lot of other things, because they don't know. . . . in many cases . . . our third party administrator—they have a terrible time getting the reports out of them, because they don't understand what's required." —management representative

"It's clearly going to depend upon the treating physician, and how educated they are in workers' comp and return-to-work issues. . . . as educated as the physicians are, sometimes they forget that if they are treating [in] occupational medicine, they need some kind of training . . . that teaches them when you're speaking to . . . a claims administrator or insurance carrier, that you're very specific as to what the work restrictions are." —claims administrator

 

b. Communicating with the Injured Worker

Injured worker, union representative, and health care provider participants discussed the importance of the treating physician listening to the injured worker to arrive at a proper diagnosis, establishing rapport and trust with the injured worker, and educating the worker about his or her injury and aspects of returning to work. Participants in the five groups differed, however, as to whether the treating physician should believe the worker's reports of pain and consider the worker's concerns or preferences about staying off work.

(1) Listening to the Injured Worker

Health care provider participants emphasized that is important for the treating physician to listen to the injured worker, both to establish trust and to determine how to treat the worker's injury:

" . . . be a doctor first, and examine the patient. Try and listen to what the patient is saying and find a reason for their problem. . . . " —health care provider

" . . . you listen with your ears and your body language, if you stay out of people's way, they have a huge amount of information relative to all the things that we need to know about them. Often when I'm working with the residents, and physicians, they're trained to obtain histories by asking pointed questions where they get . . . trapped into asking pointed questions early, and absolutely block the information that would flow to them naturally if they had just shut up. So, first visit, to establish trust and a relationship wanting to be a partner in this individual's recovery. I find that the best way, to shut up and listen to them, and a lot of stuff will come out of them. They'll tell you what they need, what they want, what they are afraid of." —health care provider

One health care provider participant observed that physicians' failure to listen to injured workers frequently generates dissatisfaction with medical treatment:

"I see a lot of people who have seen five doctors prior, and most prominent, single complaint that they voice about their prior medical treatment is `They didn't listen to me. They didn't listen to my complaints.'" —health care provider

Injured worker participants felt that it was important that their treating physicians believed their reports of pain and other experiences with their injuries:

" . . . the best thing my treating physician has done, and he was appointed by my attorney, was primarily that he believed me and takes my injury seriously. . . . " —injured worker

In contrast, management representative participants felt that treating physicians should not always believe what injured workers say about the pain they are experiencing:

"I've spoken with . . . a lot of good treating physicians. . . . They trust that . . . on a scale of one-to-ten, when the patient says nine-and-a-half, that they're really in that much pain. Even though, from objective standards, they couldn't possibly be at a nine-and-a-half, because they'd be passed out." —management representative

" . . . a treating physician . . . is more prone to accept . . . whatever you say you are, `I hurt, my back hurts,' you know. They don't worry too much about trying to determine objectively whether that's true or not. They will simply write down, `Back hurts.'"

—management representative

Injured worker and health care provider participants felt that it is important for the treating physician to be responsive to injured workers' needs and preferences in understanding their injuries and seeking alternative treatments:

"I will ask people, `What is it that you need done or need to know to feel settled about your injury?' And it's amazing how many times . . . [other physicians] haven't done the right test. They haven't done the one test that the patient is still concerned about. . . . it is going back to listening to the patient very carefully. Not going into doctor mode, or, `With this injury, I do that.'" —health care provider

"I went to a self-selected doctor, and the most important thing he did was he allowed me to seek out therapy that I felt was beneficial, which really improved my physical state and . . . allowed me to get to the point where I could start to even think about returning to work. . . . It also made me more proactive in terms of finding my own cures, because there was someone I would go to who would listen to me and prescribe whatever I said was working." —injured worker

Injured worker, union representative, and health care provider participants felt that it is important for the treating physician to respect injured workers' concerns and preferences about staying off work, returning to modified-duty work, or finding another job:

" . . . he decided to send me back four hours a day . . . and I think that was really important because I really had no idea what I could or could not do at that point, and he was very receptive to my feedback. . . . He was very open." —injured worker

" . . . the decision to return to work is a medical decision. But the employee has a say in it, you know. It's between you and your doctor. Do not let your employer make or influence that decision."

—union representative

" . . . the information relative to return-to-work is very, very straightforward, and that is, I ask, `Do you want to return to this job?' That's what I ask people, early on, and most especially if progress seems to be slow. . . . And when the answer comes back, `No, I really don't,' then I don't bother anymore attempting to liaison with the employer or whatever. I say, `Listen, let's get you into voc rehab, and be done with this,' and we don't go into a repeated return-to-work, fail, return-to-work, fail cycle." —health care provider

In contrast, a claims administrator participant felt that the treating physician should not always accommodate an injured worker's preference to stay off work:

" . . . family practice doctors . . . If the injured worker wants to be off for a couple of weeks for other reasons, they are going to accommodate that. And they will kind of sign off on what the injured worker wants versus talking about return-to-work." —claims administrator

(2) Informing and Educating the Injured Worker

An injured worker participant felt that the most important thing her treating physician did that will help her return to work was to educate her about her injury:

" . . . the doctor I got from my attorney . . . the most important thing he did was really educate me about my injury, and gave me a lot of information that all turned out to be true. . . . I have a good understanding of what's going on and how easy it is to get reinjured, and I am able to think of some realistic ideas for the future."

—injured worker

A claims administrator participant emphasized that physicians should educate patients as to when it is safe to return to work, even while still experiencing some pain:

"I think the physician needs to have discussions with the patient . . . letting them know that they may experience some pain, but it's nothing to be concerned about. That they can still continue to do the modified duties. . . . Years ago, I had a patient that had continuously tried to go back to work. . . . until he changed physicians, and the physician sat down him and actually had a discussion with him about certain pain that he might be experiencing that didn't mean it was going to be injuring himself, [so] he remained at work. All of the fear of . . . feeling pain was because he felt that he was causing further injury and he really wasn't." —claims administrator

Claims administrator, management representative, and health care provider participants felt that it is important that treating physicians educate injured workers about the return-to-work process and the advantages of returning to work:

" . . . he has a very good bedside manner, and he doesn't kind of feed into that `poor me' kind of thing with the patient. He tells them . . . you know, gives them a little kind of a pep talk about trying to encourage them back to work. . . ." —claim administrator

" . . . I do education, information. . . . I talk to my patients. `You're not going to get a better job than this." —health care provider

" . . . the doctors I have seen successful are the ones who are . . . communicating to those injured employees that they want to help them use the workplace as part of the treatment. . . . really working with the thought that using your work duties as part of your medical treatment and explaining that to the employee." —claims administrator

(3) Establishing Trust with the Injured Worker

Union representative participants emphasized that trust between the injured worker and treating physician is essential for successful treatment, recovery, and return-to-work:

" . . . I always ask . . . `How do you feel about your relationship?' . . . I think that's more important than if they were the best doctor in the world and you just felt terrible every time you went in there."

—union representative

" . . . if you feel like your treating physician is a traitor, you don't want to practice the treatment that he advises you, because you have lost confidence in that person, and you don't really want to go see them." —union representative

 

c. Communicating with the Employer and the Claims Administrator

Management representative and claims administrator participants discussed the importance of the treating physician working closely with employers and claims administrators to ensure that injured workers return to work as soon as medically possible, because this enables the physician to formulate specific and realistic work restrictions based on available jobs. In contrast, union representatives objected strongly to treating physicians allowing themselves to be influenced by employers or claims administrators in determining when an injured worker can return to work.

(1) Learning About the Workplace

Claims administrator, union representative, and management representative participants felt that to be able to write specific and realistic work restrictions, the treating physician must understand the physical requirements of the injured worker's regular job and other available jobs. To acquire this knowledge, some treating physicians visit the work environment or review job descriptions, photographs, or videotapes of jobs being performed. Management representative participants also felt that the treating physician must understand employers' policies on return-to-work and programs to prevent further injury or disability, and must be willing to meet and communicate with the employer about methods to help injured workers return to work:

" . . . treating doctors who are successful [with return-to-work] . . . understand the workplace the injured worker is coming back to. And some of the most successful programs are programs where the employers and the treating doctors, ahead of time, know each other and work together, and the doctors will often go into the workplace and observe the work being done so that they understand the jobs there, the physical requirements of the job. . . . There are ways of getting it done other than having the doctor physically traveling to the workplace. A lot of employers videotape their jobs, so they can show a videotape and a detailed job description to the doctor. Hopefully the doctor can then take time to sit down and look at that tape and go over it and study it." —claims administrator

" . . . when I pick these physicians, it's a requirement that they come to the facility, that they see each of these jobs. I also give them job descriptions. . . . so he knows what is involved with these positions. And so that helps him to give a very realistic set of restrictions. . . . And also too at the occ med clinic, the physical therapist . . . comes over once a quarter, and she'll take a series of digital photographs of the different jobs and the facilities as people are going through their motions. So she also has a really good idea of what the person does and what that person's limitations are. So we don't have to follow this long laundry list of restrictions like, `limited to no more lifting than one pound,' you know." —management representative

"[It is essential] that they will talk with us, that they'll communicate with . . . our case managers, that we can communicate with them . . . [and] get them on the phone. We talk about our return-to-work policy. We show them the environment. We talk about our preventative programs. We have a pretty aggressive ergonomics program we show them. We talk about what the process is, what the employees have available. So we really try to get them to understand how we approach

it always, so that even when we're calling to question, they understand why we're doing it."<