Joint Replacements, a Baby Boomer’s Story
Fred Schott: So, let me kick off what will be the first of at least a monthly series of regular posts on mental health:
Last week was the first anniversary of The Day Everything Changed: March 12, 2020. (See the beginning of my blog post where I talk about why that date was what historians call a “hinge moment.”)
As is often the case when we’ve achieved a historic milestone, I find myself thinking about how things changed in contrast to the “Before Time.” And when I think specifically about how the coronavirus pandemic affected the world of absence, disability, and income-replacement within which the Council for Disability Awareness’s member companies operate, I keep on coming back to what I’ve learned through following the ongoing results of the U.S. Census Bureau’s Household Pulse Survey.
Shortly after the HPS launched last spring, CDA member-company representatives who sit on our research committee agreed it would be worthwhile to follow survey results for two areas of particular concern to their stakeholders: the pandemic’s impact on (a) adult Americans’ mental health, and (b) their ongoing access to necessary medical care.
Since then, I’ve been looking at the Census Bureau’s regular (weekly through last July; bi-weekly since then) survey updates and analyzing their detailed public use files to identify noteworthy trends.
Trends from the Household Pulse Survey
I’ve shared my observations on LinkedIn (follow this link for a complete list of my posts). If I had to boil them all down to a handful of key points, here’s what I’d say
- It’s no exaggeration to say mental health has become a huge issue during the pandemic. Thirty four to 42 percent of adult Americans reported symptoms of anxiety or depression over the course of the survey. By contrast, in 2019, it was only 11 percent.
- The pandemic caused a huge number of people to either delay or forego getting necessary medical care. Through July, almost half (around 45 percent) of HPS respondents said they either delayed or didn’t get necessary medical care during the previous four weeks. More recently, that percentage is down—but at around almost one in three, it’s still startlingly high.
From a disability and absence management perspective, these two points taken together would lead you to conclude that in the wake of the pandemic,
(a) there would be a lot more disability claims where anxiety or depression is either the primary diagnosis or at least a significant co-morbidity, and
(b) as a result of delayed or foregone care, the number of claims associated with physical conditions such as musculoskeletal disorders or cancer would, at least in the short-term, go down (because, for example, people aren’t having knee or hip replacement surgery, or the chemotherapy that would otherwise possibly take them out of work for a while).
Last summer, I attended a webinar where one of the presenters (who was affiliated with a third-party administrator of corporate leave of absence and short-term disability plans) presented evidence that this was exactly what was happening with one of her clients. I wrote about that in a LinkedIn post, which I invite you to read.
Interestingly enough, I haven’t seen any comparable case-study information since then. Just as nature abhors a vacuum, my mind can’t stand not knowing about something. So in my efforts to fill my knowledge void, I turned to business colleague Ian Bridgman, executive director of The Claim Lab, one of The CDA’s member companies.
Uncovering Mental Health Trends in Disability Claims
Ian: Well Fred, I hear your concern! Yes, we are seeing insurers whose short-term disability volumes are up appreciably, and their actuaries are on the edge of their seats waiting for their long-term disability termination tables to ‘overflow’!
We have been encouraging our clients to collect better data, so we can have something interesting to work with. One of the big difficulties in collecting mental health information is that much of it is anecdotal (case notes, claim managers’ interpretations, etc.) and not measured on a consistent scale. This is why we use questionnaires to collect consistent and measurable information in hard data so we can feed analytical models.
Fred: Interesting! What trends are you seeing in that data?
Ian: Looking at STD claims data, we are seeing much higher scores for depression and anxiety (as a co-morbidity, not the primary diagnosis) right at the outset of the claim than we have seen before. This is opposed to mental health issues starting off moderately and then building gradually as depression kicks in with prolonged duration.
The claim scenario is: An employee files a STD claim with a report of a rotator cuff problem, but the claimant also hates their job, the employer is not taking COVID precautions, and the claimant is very anxious!
Fred, your research on the effects of depression and anxiety on the claims experience is very relevant here.
Depression and Anxiety Increase Risk of a Future Disability Leaves
Fred: Right, that’s the Journal of Occupational and Environmental Medicine[i] paper where I was one of the contributors. Using a dataset that combined both health and disability data, we found depression and anxiety increases your risk of a future disability leave—and a disability leave increases your risk of a subsequent depression and/or anxiety diagnosis. And that was pre-pandemic. I can only imagine how things will play out now and going forward. What do you think, Ian?
Ian: That’s a good question. The unfortunate habit in STD of “let the mental health claim manage itself” is unlikely to work here. And we are seeing some insurers investing heavily in behavioral health teams to focus on these claims. But what they need is a consistent measure to segment these claims effectively, so the appropriate interventions can be applied.
Let me share with you some findings from work we’ve done with our clients. In the early stages of a short-term disability claim, we use a proprietary set of tools to evaluate a claimant’s psychosocial environments. Since the COVID-19 pandemic has ramped up, we’ve noticed a major change in several key measures that relate to what you’ve been following in some of your other research:
A bit of context around these selected measures:
- MH-1 looks at a claimant’s level of anxiety and/or depression
- MH-2 is an indicator of how long the claimant has been anxious/depressed
- PHY-2 is focused on deficits in quantity and quality of sleep: The higher the score, the greater the deficit.
- And COG basically gets at challenges a claimant faces in being able to concentrate, focus, or manage complex situations: The higher the score, the greater the challenges.
As you can see from the chart, pandemic-era claimants are way more anxious and depressed; they aren’t sleeping well; and their stress and lack of sleep is significantly impacting their ability to problem-solve. That makes it way more challenging for claims managers to get them back to health, back to work, and back to life.
Fred: Wow. As Mr. Spock would say, “Fascinating!” (I know; I’m dating myself.) But, right now, if we surveyed the whole population, surely we would see an elevated level of depression and anxiety, and a need for help?
Ian: Yes, I’m sure that would be so. Everyone needs to be aware of their own levels of wellness. How to identify their own poor mental health and, importantly, what to do about it. Self-help needs to be accessible. Not everyone has the time or patience to root around in academic research papers!
The Correlation Between Sleep and Poor Mental Health
One of the data items that surprised me was sleep and the linkage we see between sleep and poor mental health. Not so much that there was a link, but the degree of the correlation. It’s all in that psychosocial data! Everyone knows that surviving on less than four hours sleep makes for a long day. Just try doing that day after day, but what can we do about it? Sleep is worthy of its own blog!
Fred: Yes, let’s do that next. But getting back to what we were just talking about—what do we do about this wave of claims where a mental health is, if not a primary diagnosis, then at least a major co-morbidity?
Canadian Employers Invest More in Psychiatric Management Programs
Ian: Ah yes, the fact remains we are seeing a much higher incidence of these severe mental health claims and they will be more complex to manage.
Maybe there is an opportunity to take a leaf out the playbook of our friends north of the border. In Canada, there is a far greater willingness to invest in psych programs to help with depression and anxiety, whether self-teach, cognitive behavioral therapy courses, or virtual consultations for more serious cases.
Whether we like it or not, all claims management comes down to cost, at some point the cost of providing these interventions will be less than the cost of maintaining prolonged long-term disability claims! Maybe some adventurous insurers will see a sales and marketing opportunity here?
Fred: Thanks, Ian. That’s a fitting call to action to close out our conversation. Let’s do this again!
[i]* Gaspar FW, Jolivet DN, Wizner K, Schott F, Dewa CS. Pre-Existing and New-Onset Depression and Anxiety Among Workers With Injury or Illness Work Leaves. J Occup Environ Med. 2020 Oct;62(10):e567-e572. doi: 10.1097/JOM.0000000000001985. PMID: 32769787; PMCID: PMC7537737.
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