From a Biopsychosocial Model to a Biopsychosocial-Political Model
With the biopsychosocial model [13] as a framework we studied the contribution of medical, psychological, social (occupational), and compensation policy variables to explain the differences between six countries in sustainable RTW among LBP claimants. This study showed that occupational back pain disability is more of a socio political than a medical problem. Cross-country differences in applied work interventions and eligibility criteria for long-term disability benefits contributed to the observed differences in RTW-rates. Work interventions and less strict compensation policies to be eligible for long-term (partial) benefits, contributed to sustainable RTW.
Comparison with Other Studies
To date, in a few studies the effect of compensation policy variables is described. Cassidy et al. [21] showed that a system change from a ‘tort’ insurance system to a ‘no fault’ system in Saskatchewan, Canada, was associated with a decrease in the incidence and duration of claims and with faster recovery of those with whiplash injuries. Similar results were found for those with LBP and mild brain injuries [22, 23].
Another example is a replication of a study in a different compensation system, e.g. studies evaluating the Sherbrooke model in Canada and the Netherlands [24, 25]. Despite the different socio-political context, the effectiveness of work interventions on RTW after LBP in the Canadian study was to a large extent replicated in the Dutch study.
In former studies on this multinational cohort study it was shown that work interventions were effective on RTW in LBP claimants, whereas medical interventions were in general not effective in the participating countries [17, 18]. This study adds that it shows that the large cross country differences in RTW were mainly explained by differences in applied work interventions in the cohorts. In addition, it showed that compensation policy variables independently explained part of these differences in RTW.
Strengths
It is stated that new methodology in health policy research, e.g. multinational cohort studies, is strongly needed to allow evidence based policy development [26]. To date, the influence of a compensation policy change on outcomes has been studied in only one before-after design in one jurisdiction of Canada [21–23]. In contrast to the multinational cohort design, before-after designs are more susceptible to bias: compensation policy changes frequently coincide with and cannot always be disentangled from other socioeconomic or political changes. In addition, due to the multinational design the external validity of the findings of the present study is larger than in studies conducted in one state or country. Because compensation policy variables cannot be studied in randomised controlled studies, a multinational cohort design seems the best option in health policy research. Therefore, this study and its methodology are a unique contribution to the evidence base in the field of back pain and health policy research.
Weaknesses
The observational design is a strength as well as a limitation of this study. The (demographic) differences at baseline between the national cohorts might have led to bias. We attempted to limit this bias by adding these demographic characteristics to the biopsychosocial and compensation policy variables in the explaining model. Baseline differences in demographic characteristics appeared to have no important contribution to the differences in sustainable RTW. Although we did not find any relevant interaction effects between compensation policy variables and the work interventions, the effect of compensation policy variables could be determined (partially) by other unknown variables that coincide or highly correlate with the studied compensation policy variables. Finally, the compensation policy variables we studied were previously defined by the members of all national research teams [16] and dichotomised for this analysis on a theoretical basis. It was assumed by the panel that these compensation policy variables have an influence on differences in RTW between countries in RTW. This assumption was, however, not based on any previous research, due to a lack of health policy research in this field. Hence, it might be that relevant compensation policy variables were not included in the present study.
Policy Implications
In many countries, e.g. in the USA, disability policies after shorter-term sickness are focussed on strict medical and occupational requirements to be eligible for long-term disability benefits and/or for work interventions. Frequently, the physicians’ role in these countries is to assess these requirements for receiving ‘compensation for the injury’ or access to care [27]. However, to distinguish full from partial and permanent from temporary disability is notoriously difficult and causes confusion and injustice [8]. A recent qualitative study showed that such policies directed on judging the eligibility for claims, do not stimulate claimants to return to work [28]. In addition, these policies could induce claimants to adopt a ‘sick role’ to prove their pain is real [27].
In few countries, like the Netherlands, disability policies are primarily based on reintegration measures with no or few medical or occupational requirements for entitlement to long-term and partial benefits and occupational rehabilitation. The rationale of these policies is that less disagreement between claimants, employers and insurers creates a safe and secure workplace environment for RTW without risk of losing benefits. This could explain the high rate of work interventions and success in preventing work disability due to LBP in the Netherlands [29]. This rationale is also recently supported by the OECD: People do not return to work if they risk the loss of their benefits and risk denial of access to (occupational) health care; this contributes to very low outflow rates from disability benefits [8].
The main implication of our study is that a policy change is needed to encourage more work interventions supported by less strict compensation policy policies for entitlement to long-term and partial disability benefits. In order to achieve such a policy change, a collaborative action is needed by politicians and stakeholders at the workplace [30–32]. Hadler formulated it recently as the ‘important legacy from the twentieth century’s debacle with back injury’: “Even more important than a workplace that is comfortable when workers are well and accommodating when they are ill, is a workplace that appreciates each individual’s humanity: the need to be valued, the need to feel secure, the need for some autonomy, and the need to see a future. ‘Human capital’ deserves no less” [9].