Evolution or Revolution? 

Much of what I have read in the workers’ compensation space about the killing of United Healthcare CEO, Brian Thompson, is focused on beefing up security.  I understand that is a natural and necessary response, but I want to take a closer look at the frustration that is widely felt within healthcare – and workers’ comp - that the systems often don’t respond to patient and injured worker needs.   

I think the most telling realization that came from that tragic murder was that the healthcare system is broken, due in large part to the fact that it is a system that has developed without any clear overall plan or end goal.  I think the same can be said of workers’ comp.  It is very much a patchwork of different methods and different plans that have evolved in pursuit of bringing equity to the Grand Bargain while guarding against abuse and fraud.  In some cases, the guarding against fraud and abuse can interfere in the provision of legitimate care.  The question is whether it will take some evolution or revolution to consistently provide the services that workers are promised under the Grand Bargain.  

From my vantage point - as a person who was seriously injured and recovered - I found that my recovery experience lacked the information and guidance needed to help me recover as quickly as possible.  In a wider sense, this resonates with the often-heard feeling that the system is unresponsive to the needs of the injured.  That often metastasizes into anger, and we have seen where that leads in the worst-case scenario in New York City.  

How did it come to be this way?   

Why so many options; self-insured, fully insured, non-subscriber, monopolistic, with a host of administrators and providers in the mix.    

Why so much concern at convention after convention about examining why the system costs so much and is sometimes so ineffective? 

Certainly, there are a lot of ways to fulfill the employer’s end of the bargain, but a brief review of the evolution of workers’ comp is telling with regard to “how did it come to be this way?”  Said another way, “Why does the Grand Bargain not seem to be a bargain at all?” 

The design of the "Grand Bargain" in workers’ compensation was not the work of a single individual but the result of evolving ideas, legislative efforts, and advocacy from multiple stakeholders during the late 19th and early 20th centuries.  

The initial concept for workers’ compensation laws emerged in Germany in 1884.  Germany enacted the first modern workers’ compensation law as part of broader social welfare reforms. These reforms aimed to address the challenges of industrialization while countering the appeal of socialist movements. 

In the U.S. in the early 1900s, the Progressive Era saw social reformers, labor unions, and legal scholars advocate for a fairer system to address the rising tide of workplace injuries caused by industrialization. 

Labor unions were critical in advocating for the rights of injured workers. They pushed for systems that would eliminate the financial and legal burdens placed on workers injured on the job. 

Employers, particularly those in high-risk industries like manufacturing and mining, recognized the financial risks of the existing tort system. Many supported workers’ compensation laws as a way to avoid unpredictable litigation and gain financial stability through structured insurance systems. 

State legislatures were responsible for crafting and passing workers’ compensation laws, tailored to the needs of their constituencies. Wisconsin’s 1911 law became the model for other states, with New York, California, and others quickly adopting similar frameworks. 

The core problem with the workers’ compensation system in the United States is its struggle to balance the interests of employers, employees, insurers, and medical providers while effectively addressing workplace injuries and illnesses. While the system was originally designed as a no-fault framework offering guaranteed benefits to workers in exchange for immunity from lawsuits for employers, several systemic issues have emerged over time, undermining its effectiveness. These problems include inconsistent benefits, cost-cutting measures, inefficiencies, and inequities that impact injured workers’ access to adequate care and financial support. 

Of that group of challenges, I find cost-cutting measures and inefficiencies to be the most concerning issues - from the perspective of the injured worker.  My experience taught me that patient education and patient engagement were key to my effort to get better faster and stay better longer.  What I am observing at convention after convention is that the importance of those aspects of helping the injured worker have been either misunderstood or overlooked as a certain route to greater efficiency and cost-saving. 

A recent study by IntegerHealth in the monopolistic state of Ohio revealed that injured workers who didn’t face delays in receiving benefits and medical treatments due to bureaucratic hurdles got better faster creating significant cost savings.  Interestingly, there were greater upfront (input costs) to achieve those cost efficiencies (outcomes). 

Almost every person who contributed to my book, The Optimized Patient, reported that there was also a significant mindset component to being physically injured, made worse when you are away from your friends in the workplace community and the financial uncertainty about being away from work.  Workers’ compensation systems often fail to address the psychological impacts of workplace injuries, such as depression, anxiety, or post-traumatic stress disorder (PTSD). 

Increasingly, commentary on the workers’ compensation system suggests the core problem lies in its fragmentation, cost-cutting focus, and inability to adapt to the evolving nature of work and injury. While the system provides critical protections, its inequities and inefficiencies prevent it from fully serving the needs of injured workers. Moreover, the failure of workers’ comp to recognize and address that the worker is the wildcard in the recovery process prevents the industry from taking a comprehensive and well-planned approach to patient education and patient engagement. 

My contribution to the evolution of workers’ comp is addressing the fact that education about the four pillars of recovery - mindset, nutrition, activity and rest - should be part of injured worker recovery strategies that, as yet, are minimally adopted.  The value of education and engagement to optimize patients for the speediest recovery may prove to be a revolutionary idea whose time has come.  

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