Most injured workers recover from injury, but some do not. The failures are more interesting. But it is hard to find a useful analysis of why recovery fails. Anecdotes don’t help. As the saying goes, the plural of anecdotes is not data. 

I was lucky to find an analysis of recovery failures that had been prepared with a good knowledge of the pertinent research, combined with years of experience in talking with and reading the files of injured workers who failed to recover. Jennifer Christian, a physician and president of Webility.md, prepared an analysis in 2015 entitled, “Gaps that create work disability (lucky and unlucky people)."

Christian refined and compressed into this short document a wealth of information gathered over some four decades of treating, reviewing and reading about injured workers. She walks a pair of workers, Lucky and Unlucky, through three phases of a potentially disabling injury episode, showing how specific events in each phase can increase or decrease the odds of recovery failure.

Baseline: Everyone is working

The first phase occurs while both Lucky and Unlucky are still at their jobs. Christian has found over the years that workers with little formal education, especially those with learning disabilities or who don’t speak English, have a more difficult time recovering from injury. 

My own estimate is that 20% of injured workers are foreign born; survey data suggests that half or more of these individuals have poor English proficiency. Those who live in resource-poor rural areas or communities affected by economic blight and persistently high unemployment rates are also adversely placed to recover well. So also for those that lack marketable skills or who have criminal records.

Christian cited the Adverse Childhood Experiences (ACE) Study, which was first conducted in the 1990s and has been steadily updated. The ACE study findings have been filtering into the workers’ compensation community over the past five years, maybe largely by chronic pain specialists motivated to learn why some of their patients succeed and other don’t in pain programs.

ACEs include (per the Centers for Disease Control) verbal, physical, or sexual abuse, as well as family dysfunction such as incarcerated, mentally ill, or substance-abusing family member; domestic violence; or absence of a parent because of divorce or separation. Phone surveys reported that over half of people interviewed had at least one ACE. Ms. Lucky has no ACEs, or perhaps just one.

Ms. Unlucky has several ACEs, as do between 10% to 14% of the American population, according to a six-state survey conducted by the Centers for Disease Control.

Researchers propose a key threshold of four ACEs. At and beyond that threshold, adult behavioral problems such as alcoholism, drug abuse, sexual promiscuity, absenteeism, and job problems are multiples higher than for those with no ACE. Self-reported poor health, medically-unexplained symptoms and  several types of serious health problems such as obesity, heart, lung, and liver disease are more frequent, also.

Christian opines that ACE survivors often have “weak or undeveloped coping skills, low resiliency, and life skills – in part because their own parents weren’t able to teach it to them and in part because of the opinions they have formed about how the world works.”

Destabilization: Change in health

Ms. Lucky incurs a relatively mild health condition. Ms. Unlucky suffers an amputation, cancer, or other condition that seriously cuts back her functional ability. But there are other more subtle ways their fortunes diverge. Ms. Lucky has access to affordable health care delivered by skilled clinicians, while Ms. Unlucky can’t access affordable healthcare and is cared for indifferently.

The employer of Ms. Lucky is probably large and certainly adept at responding to her condition (whether mild or serious), complies with the letter and spirit of federal and state absence and disability protections, and offers a lot of voluntary supportive services such as an employee assistance program. Ms. Unlucky’s employer is probably small, and therefore not required to comply with absence and disability laws, and does not know how to reach out and assist. Ms. Lucky has paid sick leave; Ms. Unlucky, like 40% of workers, doesn’t.

A key distinction between the two employers is, per Christian, in how they lean into, or avoid, programs designed to get employees back to work. She doesn’t specifically mention but she implies that Ms. Unlucky’s employer does little or nothing about coordinating with medical providers in return-to-work planning.

Ms. Lucky’s employer knows how to transition its employees while still recovering from injury into temporary assignments. It also knows how to accommodate workers with modest permanent functional impairments. Ms. Unlucky’s employer throws it hands up. It has neither motivation nor skill for these tasks, and its workers’ comp insurer fails to offer practical help in the form of an ergonomic advisor.

Job loss

In this phase, even Ms. Lucky cannot return to work at her former employer. How well does vocational training and placement work? For Ms. Lucky, vocational rehab resources are easily accessible and her counselor is dedicated and smart. She regains employment with little or no use of any safety net other than a disability benefit program, such as workers’ comp or a private long-term disability plan. Ms. Unlucky never really connects with vocational rehab. The insurer involved pushes her to settle her claim and pushes her onto Social Security Disability Income and other safety net services.

Ms and Mr. Unlucky likely account for many of the young and middle-aged people in America who have dropped out of the workforce. The share of adults of working age has been declining since 1990. What role does the workers’ comp system have to keep injured workers within the workforce? That’s rarely discussed. But we can be aware that for some workers, the dice don’t fall favorably.

Peter Rousmaniere is a consultant for workers' compensation claims administrators and vendors and a veteran observer of workers' compensation industry trends.