BY PETER BRYAN AND JANET WALKER
“Everyone Goes Home” should include eliminating on-duty and incident-related injuries, not just tragic fire service fatalities. If we really want to reduce injuries, there are many ways to do so. Increasing firefighter safety is everyone’s responsibility; reducing workers’ compensation injuries should be also.
Most fire agencies will experience increases in firefighter injuries, workers’ compensation injuries, and the expenses necessary to treat these injuries and administer the program.
Is it feasible to reduce the injury rate and the costs at the same time? Can the fire service improve the treatment of employee injuries in the same way it strives to improve the treatment of injured and ill patients?
Below are several components of such a program that the Rancho Cucamonga (CA) Fire Protection District has implemented, including an employee wellness program designed to improve firefighter wellness, expedite injury treatment, and reduce workers’ compensation costs.
The district and its employee organizations, the Rancho Cucamonga Professional Firefighters Local 2274, and Fire Support Services (which represents the nonsafety personnel), have agreed to and implemented a signed policy that mandates employee participation in a district fitness program. While on duty, each shift employee must participate at least 30 minutes each day, and each daytime employee must participate at least two hours per week during a Monday through Thursday work schedule. Participation includes a variety of fitness programs, starting with walking for at least 30 minutes up to and including cardiovascular and stretching/strengthening exercises. Facilities are provided at each station as well as at the City Hall administrative offices.
Injury Treatment Guidelines
Heart attack. The district developed the Heart Attack Symptoms Guideline allowing for consistent medical diagnosis and emergency treatment for employees when symptoms develop on and off duty. The guideline is also used by occupational medical facilities, emergency departments, and supervisors.
On experiencing symptoms of a heart attack, on or off duty, the employee seeks immediate emergency medical treatment and advises his battalion chief. If it is determined that the conditions are not heart related, the employee may be released back to work or to his own personal physician for follow-up. The treating physician makes the determination in consultation with the district’s management staff.
As soon as possible, the employee takes the emergency department report to Concentra, the district’s 24-hour occupational medical facility, or to a predesignated physician whom the district has accepted for the employee’s primary care, for follow-up to determine whether the symptoms are job-related. The treating physician also makes this determination in consultation with the district management staff.
Unless contraindicated or unless the employee has undergone one recently (generally in the past year), the employee undergoes a treadmill test. Generally, the district’s third party administrator (TPA) assigns a cardiologist to the patient’s case; this doctor forwards the treadmill test results to the occupational medical facility or to the treating physician to immediately treat the employee.
The cardiologist or treating physician, if appropriate, examines the treadmill results. At that point, the treating physician will direct the employee to return to work and also seek personal physician treatment if needed. Otherwise, the medical facility will designate the employee “medically unfit for duty” and refer him back to a cardiologist. A diagnosis that symptoms are heart-related must be confirmed before a workers’ compensation claim can be accepted.
Musculoskeletal injuries. The Musculoskeletal Injury Guideline is similar to that for heart attacks but addresses musculoskeletal system injuries, which account for most firefighter injuries. On-duty injuries are almost always documented immediately to ensure speedy treatment. Occasionally, with some on-duty and most off-duty injuries, a team that includes a district representative, the district risk manager, and the TPA must determine whether the injury is job related.
Magnetic resonance imaging (MRI) is conducted on the next day following a reported musculoskeletal injury unless it is contraindicated by the treating physician. Generally, the MRI can be scheduled for the following day when the employee sees the treating physician for the initial medical examination. If the MRI is inconclusive and an immediate diagnosis cannot be determined, additional MRIs will be performed daily or as often as is practical to provide the treating physician with a diagnostic tool. The district has significantly reduced the time between injury and treatment or surgery and thus shortened the timeline between the injury and the employee’s return to work. After seeking initial physician treatment for injury, the employee returns to the treating physician within 72 hours after the injury for a reevaluation, which provides for immediate diagnosis and rapid treatment in most cases.
National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments (2007), provides medical screening standards for nearly all medical conditions that district employees have experienced; the district has used them beginning with NFPA 1582, 2003 edition. The medical standards have allowed much more consistency in reviewing an applicant’s medical status for preemployment screening and for determining an employee’s fitness to return to work. NFPA 1582 applies to on- and off-duty (personal) injuries and provides employees with definite information on when and how they can return to work, reducing much of the previous delay, which benefits employees and the district. In addition, the district has met and conducted Essential Job Functions evaluations for fire captain and fire engineer; they have been used extensively in a manner similar to that for NFPA 1582.
Case Review Procedure
The district has implemented a “constant case review and update” procedure that involves weekly or biweekly conference calls with its risk manager and the TPA. During these conferences, participants review the current status of active employee injury cases, ensuring that treatment is moving along as quickly as possible and that individual cases do not become “inactive” because of delays in receiving reports, obtaining medical appointments, completing medical reviews, and so forth. Also, this timely review ensures that the employee receives the best possible treatment, another mutual benefit for the employee and employer.
Funding and Administration
The district participates with six other fire and local government agencies in a Joint Powers Authority (JPA) to share the administrative costs of the JPA and third-party administrator. This JPA is a “banking” system in which each agency is responsible for its own costs. Several other “pooled” systems in California were evaluated but were determined not to be feasible for the district. One of the greatest benefits has been the development of the Medical Provider Network (MPN), which includes more than 5,800 physicians in a very large geographic area. By developing the MPN through the JPA, each agency has saved time and effort. The large geographic area benefits employees by placing treating physicians closer to their residences.
Immediate diagnosis, rapid and effective treatment, and the prompt return to preinjury physical condition are imperative for the employee and the department. Not all physicians can support these goals for a variety of reasons, including evaluation and treatment delays, unfamiliarity with a firefighter’s essential job functions, and poor coordination with specialists. Proper and timely reporting and submission of paperwork are also critical to facilitating treatment and recovery. Physicians who have demonstrated an inability to provide timely and appropriate care, coordination with specialists, and the required documentation are considered “unfavorable.” Following a careful and complete review of past experience with such physicians, the TPA/MPN will remove them from the network.
Compromise and release is being used more often to relieve the district of long-term future medical treatment costs in cases where there may not be any treatment or surgery ever performed.
Cases in which employees who retire under a regular service retirement (RSR) and then later file for an industrial disability retirement (IDR) are reviewed closely. Those without conclusive medical proof to support approval of an IDR are generally denied.
Quarterly litigated case reviews have been conducted with the JPA’s legal counsel to expedite the resolution of these cases. During the past four years, litigated cases have been reduced from 14 to six, a 57-percent reduction.
The district has developed two modified duty programs in which the treating physician releases the employee to partial duty. The modified duty is also available to employees who sustain an off-duty injury and want to avoid using their sick time before returning to regular work assignments.
In one program, the employee performs business fire inspections normally assigned to engine and truck company members. This modified duty broadens these employees’ fire service knowledge and, more importantly, reduces the inspection workload for company members.
In a second modified duty program, under staff personnel supervision, the employee is involved in developing and revising operational policies and special programs covering such areas as the purchase of new apparatus, equipment, and supplies. Both modified-duty programs generally enjoy reasonable participation because the employee sees the benefit and has a higher participatory presence and ownership in these programs.
Rancho Cucamonga Experience
Believing that it is feasible to improve the program for our employees and program administrators and reduce the cost to our citizens and taxpayers, the district began a five-year program to do just that. We have only begun to compile data on our experience over the past five years, analyzing the number and severity of injuries and cost, which is an indicator of the number and severity combined.
We developed a five-year plan and implemented a new proactive treatment philosophy to improve employee wellness and injury treatment.
The number of injuries “Incurred but Not Received” (i.e., those for which a claim has been accepted but the full and actual cost of the claim has not yet been determined) with estimated costs of $25,000 or more have generally been relatively few. This indicates less severe injuries to employees, thus fulfilling the “Everyone Goes Home” objective (Table 1).
Initial financial analysis is showing promising results in cost reduction. Workers’ compensation budget costs for the past few years have been reduced, which has provided additional revenues for adding paramedic personnel and apparatus (Table 1).
|Figure 1. Number of Workers’ Compensation Claims, 2001-2008|
Although the number of workers’ compensation claims (Figure 1) has fluctuated since 2000, the total cost of claims (Figure 2) has been decreasing and the cost per claim has significantly reduced. Although the number of injuries will likely fluctuate, the severity may be a better indicator of whether an employee wellness program is making a difference.
|Figure 2. Workers’ Compensation Claims Costs, 2000-2008|
Two other factors can be used to determine the injuries and workers’ compensation trends. The Experience Modification Factor provides a measure of the member’s experience compared to the overall experience of the JPA, and the Composite Funding Rate is the total cost of insurance per $1,000 of payroll. These factors are used to guide risk managers and third-party administrators toward determining the insurance rate. Although these indicators are only recently being used, they have shown promise toward reducing injuries and lowering costs (Table 1).
PETER BRYAN is chief of the Rancho Cucamonga (CA) Fire Protection District, which provides full-service fire, EMS, hazardous materials, technical rescue, and wildland urban interface services. He has also served as the chief of the Monrovia (CA) Fire Department and the Norco (CA) Fire Department during his 36 years of fire service.
JANET WALKER is a management analyst II for the Rancho Cucamonga (CA) Fire Protection District and is responsible for budget preparation, administration, management, and analysis. A district employee since 2000, she has also worked for the cities of Upland and Hesperia and the U.S. Army Corps of Engineers.