November 2023 – Why Biopsychosocial Matters

By Dr Les Kertay –

What’s the Problem?…

In our last column, we introduced the distinction between a biomedical approach to diagnoses and a biopsychosocial approach. We noted that some of the difficulty with current claims processes, in disability and in workers’ compensation, is that we attempt to apply a biomedical model to something that is more properly understood as a biopsychosocial phenomenon.

Much of the biomedical model’s appeal is that it is easy to understand, but as H.L. Mencken said, “To every complex problem, there’s a solution that is simple, neat, and wrong.” Humor aside, the biomedical model works when there is a clear medical problem, the diagnosis of which is well supported by objective medical findings along with symptoms that match the diagnosis. In such circumstances, we usually can identify a treatment and can predict the timeline for recovery with reasonable accuracy. In this situation, the biomedical model works for care, and in a claims context the duration will be reasonably close to what the guidelines tell us.

The problem, of course, is that these tidy diagnoses and return-to-work predictions are not what we see in many claims, especially in that subset of claims that defy our expectations and that take up a great deal of our time and attention. Think Pareto Principle, the 80/20 rule in which we find that 20% of our most difficult claims take up 80% of our management effort. At least for these claims, and perhaps for many more, building claims processes around biomedical factors, while ignoring all the other things that go into the timing of recovery and return to work, simply doesn’t work.

Enter the Biopsychosocial Model

Claims, in fact, are much better understood when we consider the nature of the people filing claims, their circumstances, and their attitudes toward work and their lives generally. Certainly, there is a biological component to the claim, but that biological component is happening to people with varying motivations, comorbid conditions, mental states, and fears about their injury and returning to work.

George Engel, a gastroenterologist with a deep interest in the non-medical factors that influenced his patient’s experience, is widely cited as having coined the term “biopsychosocial” in a 1977 paper (Engel, 1977), although the term was used earlier, and the ideas have been around for a very long time (Lugg, 2021). Perhaps the best-known formulation of the idea, variously attributed to Hippocrates (460-370 b.c.), William Osler (1849-1919), and others is the saying “It is better to know what sort of patient has a disease than to know what sort of disease a patient has.”

The Claim Lab’s data on psychosocial influences on claims experience has shown a consistent ability to identify claims that are at risk for extended duration. We can see that an employee’s relationships to managers and coworkers, financial strains, emotional distress, family situation, motivation and other factors can have a combined effect on recovery, and we have been able to quantify the degree of risk in claims.

There is No One-Size-Fits-All Solution

Unfortunately, a common misconception is that this means that delayed recovery is a “mental health” problem. It’s true that a diagnosed mental health condition can be part of a claim, either alone or as comorbid with other conditions. Diagnosed conditions such as Major Depressive Disorder typically benefit from formal mental health care. These conditions are a risk factor for delayed recovery of other conditions.

But there is more to it than that. Psychological symptoms are common: raise your hand if you’ve never been anxious and distracted at various times. Such symptoms, too, impact claims durations, and they may or may not benefit from behavioral interventions, depending on severity and frequency. Other factors such as worrying about family members, financial strain, and workplace issues also impact claims durations, but these common human experiences are neither pathological nor likely to require, or respond to, mental health treatment. 

In short, we will not solve the problem of delayed recovery by sending to therapy everyone who takes longer to return to work than available guidelines would predict. Nor will we solve the problem by simply labeling as a “mental health problem” anything that gets in the way of recovery.

Instead, we must build strategies to help claims professionals (a) better understand psychosocial factors that might impact claims, (b) develop strategies for effectively communicating with at-risk claimants, and (c) build systems that support these efforts. We need to continue to educate health professionals to better understand both the negative health consequences of unnecessary work absence, and the fact that having a terrible boss is neither a diagnosable condition nor a medical basis for a compensation claim.

Using a biopsychosocial approach to understanding claimants is complex, requires careful understanding of the individual claimant’s situation, the aggregate block of business and the capabilities of claims staff, and requires a strategy for communicating effectively with claimants, employers, and health providers. It’s not a simple solution – but it’s safe to say that what we’ve been doing is less effective than it could be. We at The Claim Lab are dedicated to helping you understand in greater depth the risk profile of claimants in your block of business, and to help you build solutions that will improve your outcomes.

If you want to discuss what this in more detail, please contact us at info@claimlab.org.